Medium-term outcome of fundoplication after lung transplantation

Gastroesophageal reflux disease (GERD) in lung transplant recipients has gained increasing attention as a factor in allograft failure. There are few data on the impact of fundoplication on survival or lung function, and less on its effect on symptoms or quality of life. Patients undergoing fundoplication following lung transplantation from 1999 to 2005 were included in the study. Patient satisfaction, changes in GERD symptoms, and the presence of known side effects were assessed. The effect on lung function, body mass index, and rate of progression to the bronchiolitis obliterans syndrome (BOS) were recorded. Twenty-one patients (13 males), in whom reflux was confirmed on objective criteria, were included, with a mean age of 43 years (range 20-68). Time between transplantation and fundoplication was 768 days (range 145-1524). The indication for fundoplication was suspected microaspiration in 13 and symptoms of GERD in 8. There was one perioperative death, at day 17. There were three other late deaths. Fundoplication did not appear to affect progression to BOS stage 1, although it may have slowed progression to stage 2 and 3. Forced expiratory volume-1% predicted was 72.9 (20.9), 6 months prior to fundoplication and 70.4 (26.8), six months post-fundoplication, P= 0.33. Body mass index decreased significantly in the 6 months following fundoplication (23 kg/m(2) vs. 21 kg/m(2), P= 0.05). Patients were satisfied with the outcome of the fundoplication (mean satisfaction score 8.8 out of 10). Prevalence of GERD symptoms decreased significantly following surgery (11 of 14 vs. 4 of 17, P= 0.002). Fundoplication does not reverse any decline in lung function when performed at a late stage post-lung transplantation in patients with objectively confirmed GERD. It may, however, slow progression to the more advanced stages of BOS. Reflux symptoms are well controlled and patients are highly satisfied. Whether performing fundoplication early post-lung transplant in selected patients can prevent BOS and improve long-term outcomes requires formal evaluation.

The identification of differentially expressed microRNA in osteoarthritic tissue that modulate the production of TNF-alpha and MMP13

OBJECTIVE

To identify differentially expressed microRNAs (miRNAs) in human osteoarthritic (OA) cartilage and bone tissue and to determine their relevance to chondrocyte function.

METHODS

Cartilage and bone was obtained from OA patients who underwent total knee joint replacement surgery or from post-mortem patients with no previous history of OA. MiRNA expression was quantified by real-time PCR (RT-PCR). Functional pathway analysis of miRNA was performed using Ingenuity Pathway Analysis. Primary chondrocytes were isolated by collagenase digestion and transfected with miRNA mimics and miRNA inhibitors using cationic lipid. Tumour Necrosis Factor-alpha (TNF-alpha) and Matrix metalloprotease 13 (MMP13) protein levels were measured by Enzyme-Linked ImmunoSorbent Assay (ELISA).

RESULTS

In total we identified 17 miRNA that showed greater than 4-fold differential expression between OA and normal cartilage, and 30 miRNA that showed greater than 4-fold differential expression in OA bone. Functional pathway analysis of the predicted gene targets for miR-9, miR-98, which were upregulated in both OA bone and cartilage tissue, and miR-146, which was downregulated in OA cartilage, suggested that these miRNA mediate inflammatory functions and pathways. Over-expression of miR-9, miR-98 or miR-146 in isolated human chondrocytes reduced interleukin-1 beta (IL-1 beta) induced TNF-alpha production. Furthermore, inhibition and over-expression of miR-9 modulated MMP13 secretion.

CONCLUSIONS

We have identified a number of differentially expressed miRNAs in late-stage human OA cartilage and bone. Functional analysis of miR-9, miR-98 and miR-146 in primary chondrocytes suggests a role in mediating the IL-1 beta induced production of TNF-alpha. MiR-9, upregulated in OA tissue, was found to inhibit secretion of the collagen type II-targeting metalloproteinase MMP13 in isolated human chondrocytes.

Migration and stopover in a small pelagic seabird, the Manx shearwater Puffinus puffinus: insights from machine learning

The migratory movements of seabirds (especially smaller species) remain poorly understood, despite their role as harvesters of marine ecosystems on a global scale and their potential as indicators of ocean health. Here we report a successful attempt, using miniature archival light loggers (geolocators), to elucidate the migratory behaviour of the Manx shearwater Puffinus puffinus, a small (400 g) Northern Hemisphere breeding procellariform that undertakes a trans-equatorial, trans-Atlantic migration. We provide details of over-wintering areas, of previously unobserved marine stopover behaviour, and the long-distance movements of females during their pre-laying exodus. Using salt-water immersion data from a subset of loggers, we introduce a method of behaviour classification based on Bayesian machine learning techniques. We used both supervised and unsupervised machine learning to classify each bird's daily activity based on simple properties of the immersion data. We show that robust activity states emerge, characteristic of summer feeding, winter feeding and active migration. These can be used to classify probable behaviour throughout the annual cycle, highlighting the likely functional significance of stopovers as refuelling stages.

Doctor of medicine training--reflections on the UWI (Mona) experience

Postgraduate Doctor of Medicine (DM) training at the University of the West Indies (UWI) has grown in response to the need to meet the regional requirements for high quality, competent clinical specialists. The progress of these programmes are examined from historical and health manpower development perspectives. More than 600 persons have been trained through the DM programmes at UWI, Mona and 89% of them continue to provide critical services in the region. Such statistics underscore the success of the programme in meeting the Caribbean Corporation in Health (CCH), UWI and Faculty of Medical Sciences (FMS) objectives. The relevance of the programme to the Caribbean's needs is manifestly clear Curriculum changes including a mandatory research component for all DM degrees reflect the evolution of training programmes as they adjust to current expectations of modern clinical practice and new emphases on evidence-based medicine and policies. Nevertheless, challenges exist including the deterioration of the physical plant for training, availability of training posts and funding of research. Monitoring, evaluation and quality assurance of existing programmes are to be continued.

Tests and calibration of NIF neutron time of flight detectors

The National Ignition Facility (NIF) neutron time of flight (NTOF) diagnostic will measure neutron yield and ion temperature in all NIF campaigns in DD, DT, and THD(*) implosions. The NIF NTOF diagnostic is designed to measure neutron yield from 1x10(9) to 2x10(19). The NTOF consists of several detectors of varying sensitivity located on the NIF at about 5 and 20 m from the target. Production, testing, and calibration of the NIF NTOF detectors have begun at the Laboratory for Laser Energetics (LLE). Operational tests of the NTOF detectors were performed on several facilities including the OMEGA laser at LLE and the Titan laser at Lawrence Livermore National Laboratory. Neutron calibrations were carried out on the OMEGA laser. Results of the NTOF detector tests and calibration will be presented.

Complex effects of IL1A polymorphism and calpain inhibitors on interleukin 1 alpha (IL-1 alpha) mRNA levels and secretion of IL-1 alpha protein

Alleles of IL1A-889(C>T) and IL1A+4845(G>T) are in linkage disequilibrium. Interleukin 1alpha (IL-1alpha) is produced as a precursor protein and cleaved at positions 117-118 by calpain, generating a mature protein for export. IL1A+4845 affects amino acids expressed at position 114 and hence may modulate calpain-mediated cleavage. We sought evidence for this mechanism in intact cells. Blood leukocytes from heterozygous donors released more IL-1alpha protein than cells from IL1A(1,1) donors, while release from IL1A(2,2) cells was variable. Genotype did not affect levels of IL-1alpha mRNA, so differential cleavage of the precursor is a feasible mechanism. However, genotype also had no effect on inhibition of IL-1alpha release by pretreatment with calpain inhibitors, and calpain inhibitors reduced IL-1alpha and tumor necrosis factor alpha mRNA levels. Hence, calpain inhibitors probably affect inhibition of signal transduction pathway rather than cleavage of IL-1alpha protein. As ratios of mu-calpain/calpastatin were lowest in heterozygous donors, genetically determined IL-1alpha levels may modulate transcription of calpain and calpastatin. This could reduce the impact of IL1A genotype on IL-1alpha secretion and amplify individual variation in levels generated in culture.

Intra-operative parathyroid hormone monitoring in secondary hyperparathyroidism: is it useful?

OBJECTIVES

To assess the use of intra-operative parathyroid hormone (PTH) level monitoring as a predictor of persistent hypoparathyroidism after total parathyroidectomy in renal hyperparathyroidism.

SETTING

University Teaching Hospital Otorhinolaryngology and Head and Neck Surgery Unit.

PARTICIPANTS

All patients with renal hyperparathyroidism undergoing parathyroidectomy between January 2004 and July 2005. Twenty-nine patients were identified.

MAIN OUTCOME MEASURES

Comparison is made between pre- and intra-operative PTH levels (ioPTH) in patients who at 3 months postoperatively maintained hypoparathyroidism and patients who did not. Results were analysed to see whether ioPTH predicts maintenance of the hypoparathyroid state.

RESULTS

The mean preoperative PTH level was 932 pg/L (range: 58-1808). The mean postoperative PTH level was 147 pg/L (range: 16-498). The mean 3-month PTH level was 47 pg/L (range: <1-515). The mean postoperative PTH level for patients with a persistently high PTH level at 3 months was 286 pg/L (range: 272-299), compared with 63 pg/mL (16-160) in patients remaining normparathyroid, and 159 pg/L (range: 39-498) for patients with persistent hypoparathyroidism. If the normoparathyroid state is strictly considered to be failure following total parathyroidectomy, ioPTH is not predictive of hypoparathyroidism. However, ioPTH is indicative of biochemical resolution of the hyperparathyroid state (normo- or hypoparathyroidism).

CONCLUSION

We conclude that the use of ioPTH monitoring in the surgical management of secondary hyperparathyroidism fails to predict persistent hypoparathyroidism following total parathyroidectomy, but does predict biochemical resolution of hyperparathyroidism.

Case of adolescent with Paget-Schroetter syndrome and underlying thrombophilia due to an elevated lipoprotein (A)

Upper extremity deep vein thrombosis (UEDVT) is a rare disorder in children and is most often associated with a central venous catheter (CVC), cancer, or an underlying thrombophilia. In adults, repetitive or strenuous upper extremity activity has been linked to mechanical compression of the thoracic outlet resulting in subclavian vein thrombosis, also known as Paget-Schroetter Syndrome (PSS). We present the case of a 14 year old female who was found to have an UEDVT consistent with PSS. On subsequent thrombophila screening, she was noted to have a significantly elevated lipoprotein (a) level of 83 (normal: <30 mg/dL). She underwent 3 months of anticoagulation therapy prior to her first rib resection and in follow-up was noted to have complete patency of her subclavian vein. This case illustrates the necessity for thrombophilia screening in the pediatric patient with UEDVT despite evidence of anatomic abnormality or mechanical venous compression.

Combined autologous chondrocyte implantation and allogenic meniscus transplantation: a biological knee replacement

Meniscus deficient knees develop early osteoarthritis in the knee. Autologous Chondrocyte Implantation has provided a new dimension to the treatment of chondral defects in the knee, with 85% good to excellent results and a long-term durable outcome of up-to 11 years. However, it is contraindicated in meniscus deficient knees. Allogenic Meniscus Transplantation gives good symptomatic relief in meniscus deficient knees, with a success rate of 89%. However, it is contraindicated in advanced cartilage degeneration. We hypothesized that combination of these two might be a solution for bone-on-bone arthritis in young individuals. We studied a consecutive series of eight patients, with mean age of 43 years, presenting with large kissing chondral defects, secondary to the previous meniscectomy. All the patients were treated with a combination of Autologous Chondrocyte Implantation and Allogenic Meniscus Transplantation. Mean pre-operative Lysholm score was 49, which rose to mean of 66 at 1 year, an average increase by 16.4 points. Six patients showed significant improvement at one year. MRI scans showed good integration of the menisci with the capsule, without any rejection. Histology confirmed the integration. All the patients could lead an active life-style. Five patients maintained the improvement at a mean follow-up of 3.2 years. We could not find any deleterious effects of the combination of these two techniques. So we conclude that the combination of these two techniques together may act a one step towards a true biological knee replacement.

Mercury in traditional Tibetan medicine - panacea or problem?

Symptoms of mercury toxicity, biochemical changes, and blood/urine mercury levels were evaluated in a small group of patients. Six patients attending Delek Hospital, Dharamsala, India, taking mercury-containing traditional Tibetan medicine (TTM) (Group I), were compared with three patients taking non-mercury containing TTM (Group II) and healthy volunteers(Group II). Quantitative estimation of mercury ingestion based on chemical analysis was compared with US regulatory standards.

RESULTS

Group I were significantly older (mean 55 years+/-SE 6.4) range 26-69 years, than Group II (26.7 years+/-SE 5) range 17-34 years and Group III (32.5 years +/-SE 0.5) range 33-34 years (P =0.05). Group I took TTM on average for 51 months and had a mean of 2.5 non-specific, mercury-related symptoms. Group I had higher mean diastolic pressures (85 mmHg) than Group II (73 mmHg) (P=0.06) and more loose teeth. Mean daily mercury intake for Group I was 674 microg, estimated as 10 microg/kg per day. (Established reference dose for chronic oral exposure: 0.3 microg/kg per day.) Blood mercury levels were non-detectable, but mean urinary mercury levels for Group I were 67 microg/L (EPA levels <20 microg/L). Renal and liver function tests were not significantly different between groups and within normal clinical range.

CONCLUSIONS

Prolonged ingestion of mercury containing TTM is associated with absent blood levels, but relatively high urinary levels. Further studies are needed to evaluate toxicity and therapeutic potential.

‘Rumours of my death may have been greatly exaggerated’: a brief review of cell death in human intervertebral disc disease and implications for cell transplantation therapy

The avascular nature of the human intervertebral disc is thought to reduce the ability of resident disc cells to maintain their extracellular matrix, rendering the tissue susceptible to degeneration. It has also been suggested that the lack of a blood supply may result in disc cell death via nutrient deprivation. Therefore transplanting new cells into the disc to promote tissue regeneration would be akin to ‘putting cells in a coffin’ and doomed to failure. This review considers the available evidence for cell death in the human intervertebral disc, describing briefly the methods used to assay such death, and concludes that further analysis is required to ascertain whether extensive cell death truly is a marked feature of human intervertebral discs and whether it bears any relationship to disc degeneration and hence regenerative strategies.

Changes in localization of human discs large (hDlg) during keratinocyte differentiation is associated with expression of alternatively spliced hDlg variants

Alternative spliced variants of the human discs large (hDlg) tumour suppressor are characterized by combinations of insertions. Here, using insertions I2- and I3-specific antibodies, we show that I2 and I3 variants have distinct distributions in epidermal and cervical epithelia. In skin and cervix, I3 variants are found in the cytoplasm. Cytoplasmic localization of I3 variants decreases as cervical keratinocytes differentiate, concomitant with relocalization to the cell periphery. I2 variants are found at the cell periphery of differentiated epidermal and cervical keratinocytes. Nuclear localization of I2 variants was evident in both tissues, with concentration of nuclear I2 variants in basal and parabasal cervical keratinocytes. A prominent nuclear localization of hDlg in cells of hyperproliferative layers of psoriatic lesions, but not in mature differentiated keratinocytes, together with I2 redistribution in differentiating keratinocytes, suggests that nuclear hDlg functions may be pertinent to growth of undifferentiated cells. Supporting our findings in squamous tissues, a decrease of nuclear hDlg and an increase of membrane-bound and cytoplasmic hDlg upon calcium-induced keratinocyte differentiation were not concomitant processes. Furthermore, we confirm that the exit of I2 variants from the nucleus is linked to stimulation of epithelial differentiation. The dynamic redistribution of hDlg also correlated with a marked increase in the expression of I3 variants while the level of I2 variants showed only a moderate decrease. Because changes in the intracellular distribution of hDlg splice variants, and in their expression levels, correlate with changes in differentiation state we hypothesize that the different hDlg isoforms play distinct roles at various stages of epithelial differentiation.

Adverse reactions to polylactic acid injections in the periorbital area

BACKGROUND

Correction of aging changes and contour deformities has been addressed largely by tissue augmentation agents whose volume is injected into tissues to achieve the required result. Polylactic acid (PLA) is an agent that is injected with the aim of enhancing the host's own collagen deposition.

OBJECTIVE

We describe the development of multiple nodules and one case of a foreign-body granuloma formation following the administration of PLA to the face for correction of rhytides and contour deformities. Methods Four case presentations, including clinical history, injection protocol, histopathology, individual treatment, and their outcomes, are discussed with pertinent literature review.

RESULTS

Four patients who received injections of PLA developed nodules that were clinically similar in size, shape, and consistency. Histopathologic examination revealed the presence of a foreign-body granulomatous inflammatory reaction in one of the patients.

CONCLUSION

Cosmetic treatment with PLA may be complicated by disfiguring nodules that may mask a granulomatous reaction. PLA-induced nodules and foreign-body granulomas have proven difficult to treat. Therefore, PLA should only be injected in the infraorbital area by experienced injectors who have had appropriate training. In addition to this, PLA should be injected in a "depot" method below the muscle at a significantly diluted volume. Due to the complications encountered after the use of PLA, we feel that a cautionary warning regarding the use of PLA in this area may be prudent regardless of the abovementioned precautions.

Prevention of mother to child transmission of HIV infection in Pacific countries

INTRODUCTION

A generalized epidemic of HIV infection has been evolving in Papua New Guinea over the last decade, whereas in other Pacific Island countries and territories (PICT) HIV transmission has generally been less widespread. Programmes to detect HIV infection in pregnant women and to prevent mother to child transmission (MTCT) during either delivery or breast-feeding can decrease the incidence of infection in infants. The limited health infrastructure present in some PICT may delay the implementation of effective programmes to decrease MTCT of HIV.

METHODS

We used a standardized questionnaire to survey health-care providers in 22 PICT for information on the epidemiology of HIV infection and strategies used during 2004 to prevent MTCT of HIV infection in their country. We supplemented these survey responses with data obtained from regional organizations supporting national responses to HIV.

RESULTS

We obtained responses from 21 PICT. The reported prevalence of known HIV infection was >150 per 100 000 persons in Papua New Guinea, approximately 100 per 100 000 persons in French Polynesia, Guam, New Caledonia and Tuvalu and <50 per 100 000 persons in the remaining 14 PICT. Other than in Papua New Guinea, where an estimated 500 pregnant women had HIV infection diagnosed in 2004, reported HIV infection among pregnant women was rare. Ten PICT reported that an HIV antibody test was offered as a routine component of antenatal care and 11 reported that antiretroviral medications were available for the prevention of MTCT of HIV infection.

CONCLUSION

The prevalence of HIV infection differs greatly between PICT with a varying risk of MTCT of HIV infection. Successful prevention of MTCT of HIV infection throughout the PICT will require improved uptake of antenatal HIV antibody testing and better access to antiretroviral medications.

Effect of antiretroviral treatment and counselling on disclosure of HIV-serostatus in Johannesburg, South Africa

This prospective non-randomized study of clinic attendees, compares self-reported HIV disclosure patterns in relation to access to antiretroviral access and counselling. It was carried out in public sector hospital HIV clinics in Johannesburg, South Africa, and 144 HIV-positive men and women attending the HIV clinics participated in the study.The results showed that there was no correlation between being on antiretroviral therapy and disclosure of HIV status. There was also no correlation between disclosure of HIV status and with different levels of counselling and access to support groups. Disclosure levels were high (92% told at least one person), however, there was a high level of delayed (15% greater than a year) or non-disclosure (21%) to partners. Family members and partners provided most moral support after disclosure. Having access to antiretroviral therapy and support groups and available counselling did not seem to affect disclosure patterns. It is possible that a patients beliefs about their treatment plays a more important role for disclosure than the actual treatment itself. Other factors are also likely important for disclosure, such as the patient's social network especially with their families, and knowledge of the disease.

A prospective comparison of multidisciplinary treatment of oesophageal cancer with curative intent in a UK cancer network

AIMS

Combined modality therapy (with chemotherapy+/-radiotherapy) has become a standard treatment for locally advanced oesophageal cancer. However, there appears to be no compelling evidence for one treatment type or combination to suit all and at this time the clinical multi-disciplinary team (MDT) forms an important role in selecting optimal therapies for the individual. This prospective comparison in one cancer network, looks at the outcomes of this decision making process.

METHODS

Over a five year period 1998-2003, data were prospectively collected on all 330 consecutive patients, referred to a tertiary specialised MDT for whom curative treatment was the planned intent. Patients were managed according to an agreed local protocol and allocated to receive one of 5 treatments: surgery alone (S), pre-operative chemotherapy (C+S), pre-operative chemo-radiotherapy (CRT+S), definitive chemo-radiotherapy (CRT) and radiotherapy alone (RT).

RESULTS

The 2 and 5 year survival for all patients receiving potentially curative treatment were 49% and 26% respectively. With 2 and 5 year survival for S, CRT+S, C+S, CRT and RT being 53,21; 57,40; 37,27; 50,27; 23,0 months respectively. Of the surgical therapies, mortality was highest in the CRT+S group, versus C+S and S; 12.5%, 1.6%, 4.5% respectively (p=0.025). Non-surgical based therapies had more than double the incidence of local relapses compared to surgical based therapies; however the CRT group had an overall survival comparable with S alone. The commonest sites of distant relapse were liver (56%), lung (38%), bone (32%) and non-regional lymph nodes (24%).

CONCLUSION

The results suggest that in patients who are deemed unfit for surgical intervention, definitive chemoradiotherapy remains a viable alternative; they also lend further support to selected case triple modality therapy. These areas should be further examined in the context of randomised controlled phase III trials.

Lactate threshold does not influence metabolic responses during exercise in cyclists

The purpose of this study was to compare plasma markers of metabolic stress and other physiological parameters during prolonged endurance exercise of different intensity in trained subjects possessing a "high" or "low" lactate threshold (LT) expressed as a percentage (%) of peak power output (PPO). Fifteen trained male cyclists completed an incremental exercise test for determination of PPO and the LT (% PPO). Each subject then completed a 90-min and 20-min exercise trial at an intensity representing 75 and 85 % of PPO, respectively. Blood lactate (La), as well as plasma hypoxanthine (Hx) and uric acid (UA) were measured during each exercise trial. The responses in two groups, one (n = 8) with a LT approximately 65 % PPO (LT (low)), the other group (n = 7) with a LT approximately 75 % (LT (high)) (p < 0.01), were then compared. With the exception of UA, La and Hx increased significantly (p < 0.01) throughout each exercise trial compared to rest. However, there were no significant differences in each trial between the two groups of cyclists. There were also no significant differences in the other physiological parameters in each exercise trial between the subjects in LT (low) and LT (high). This study demonstrates that in trained cyclists homogeneous in terms of PPO, plasma markers of metabolic demand during prolonged exercise are not influenced by the LT when measured in an incremental exercise test.

Bristol COPD Knowledge Questionnaire (BCKQ): testing what we teach patients about COPD

Health professionals recommend education of patients about COPD. There is no satisfactory instrument to measure their knowledge and therefore to assess the results of education. A multiple-choice questionnaire (BCKQ) has been designed and tested. Each of 13 topics contains five statements for which there is a right or wrong answer. Its validity and consistency has been assessed, and the test re-test reliability and responsiveness measured after an interval of eight weeks. A copy of the multiple-choice questionnaire is given in the Appendix. The questionnaire was judged by patients and health professionals to have good content and face validity. It has good internal consistency for the 65 items. (Cronbach's alpha 0.73). It can be completed and scored within twenty minutes. The average score in subjects who had not received prior education was 54.7%. In a group not receiving education there was good test-retest reliability (r = 0.71). Following an eight-week education programme there was a significant improvement of 18.3 percentage points, and most of the increase was maintained for six months without any further formal education. BCKQ is suitable for both clinical and research purposes. It will test knowledge that is appropriate for COPD patients and can be used as an assessment tool for individual patients, or as a broad cross-sectional survey instrument. It will enable the effectiveness of education to be assessed and will be of value in developing and comparing different educational interventions.

Somatostatin receptor expression, tumour response, and quality of life in patients with advanced hepatocellular carcinoma treated with long-acting octreotide

Octreotide may extend survival in hepatocellular carcinoma (HCC). Forty-one per cent of HCCs have high-affinity somatostatin receptors. We aimed to determine the feasibility, safety, and activity of long-acting octreotide in advanced HCC; to identify the best method for assessing somatostatin receptor expression; to relate receptor expression to clinical outcomes; and to evaluate toxicity. Sixty-three patients with advanced HCC received intramuscular long-acting octreotide 20 mg monthly until progression or toxicity. Median age was 67 years (range 28–81 years), male 81%, Child–Pugh A 83%, and B 17%. The aetiologies of chronic liver disease were alcohol (22%), viral hepatitis (44%), and haemochromatosis (6%). Prior treatments for HCC included surgery (8%), chemotherapy (2%), local ablation (11%), and chemoembolisation (6%). One patient had an objective partial tumour response (2%, 95% CI 0–9%). Serum alpha-fetoprotein levels decreased more than 50% in four (6%). Median survival was 8 months. Thirty four of 61 patients (56%) had receptor expression detected by scintigraphy; no clear relationship with clinical outcomes was identified. There were few grade 3 or 4 toxicities: hyperglycaemia (8%), hypoglycaemia (2%), diarrhoea (5%), and anorexia (2%). Patients reported improvements in some symptoms, but no major changes in quality of life were detected. Long-acting octreotide is safe in advanced HCC. We found little evidence of anticancer activity. A definitive randomised trial would identify whether patients benefit from this treatment in other ways.

Gender differences among medical students in attitudes to learning about complementary and alternative medicine

OBJECTIVES

To explore gender differences in attitudes to CAM among Year 1, 2 and 3 medical students.

DESIGN

Survey; seven-item self-administered questionnaire.

SETTING

Plenary lectures at the start of semester 2 of the academic year at the University of Birmingham Medical School.

RESULTS

35.6% of 662 students were male and 64.4% female. Females were more likely than males to feel CAM has an important role in healthcare (p < 0.001). This difference increased through the medical course (p < 0.05). Females gave a more positive rating than males to the use of five therapies in healthcare (p < 001). Females were more positive than males about learning the theory (p < 0.001) and practice (p < 0.001) of CAM and a greater amount of CAM curriculum time (p < 0.001).

CONCLUSIONS

If CAM teaching is optional females may be more likely to choose it. An unexpected consequence of more women than men entering medical school may be a positive impact on the development of integrated medicine.

v-Myb represses the transcription of Ets-2

The v-Myb oncogene causes monoblastic leukemia and transforms only myelomonocytic cells in culture. The v-Myb protein is nuclear and binds to specific DNA sequences. To identify genes regulated by v-Myb, we utilized primary cells transformed by a retrovirus encoding a v-Myb-estrogen receptor (ER) fusion protein. The Ets-2 gene was not expressed in v-Myb-ER transformed cells in the presence of estradiol, but was expressed within 4 h after estradiol withdrawal. The expression of Ets-2 also increased dramatically following phorbol ester-induced differentiation of the v-Myb-transformed BM2 cell line. Conversely, CRYP-alpha, encoding a transmembrane tyrosine phosphatase, was expressed in the presence but not the absence of estradiol in v-Myb-ER transformed cells. CRYP-alpha was downregulated during the phorbol ester-induced differentiation of BM2 cells. Although LIM-3 expression was estradiol-inducible in v-Myb-ER transformed monoblasts, LIM-3 was expressed neither in primary yolk sac cells transformed by unfused v-Myb nor in BM2 cells. We conclude that although v-Myb has been intensively studied as a transcriptional activator, v-Myb can repress biologically relevant genes such as Ets-2, which promotes macrophage differentiation. In addition, we have shown that some genes that are regulated by a v-Myb-ER fusion protein may not be relevant to the biological function of the unfused v-Myb protein.

Senescence in human intervertebral discs

Intervertebral discs demonstrate degenerative changes relatively early in life. Disc degeneration, in turn, is associated with back pain and disc herniation, both of which cause considerable clinical problems in the western world. Cell senescence has been linked to degenerative diseases of other connective tissues such as osteoarthritis. Thus we investigated the degree of cell senescence in different regions of discs from patients with different disc disorders. Discs were obtained from 25 patients with disc herniations; from 27 patients undergoing anterior surgery for either back pain due to degenerative disc disease (n = 25) or spondylolisthesis (n = 2) and from six patients with scoliosis. In addition, four discs were obtained post-mortem. Samples were classified as annulus fibrosus or nucleus pulposus and tissue sections were assessed for the degree of cell senescence (using the marker senescence-associated-beta-galactosidase (SA-beta-Gal)) and the number of cells present in clusters. There were significantly more SA-beta-Gal positive cells in herniated discs (8.5% of cells) than those with degenerative disc disease, spondylolisthesis, scoliosis, or cadaveric discs (0.5% of cells; P < 0.001). There was more senescence of cells of the nucleus pulposus compared to those of the annulus fibrosus and in herniated discs a higher proportion of cells in cell clusters (defined as groups of three or more cells) were SA-beta-Gal positive (25.5%) compared to cells not in clusters (4.2%, P < 0.0001). This study demonstrates an increased degree of cell senescence in herniated discs, particularly in the nucleus where cell clusters occur. These clusters have been shown previously to form via cell proliferation, which is likely to explain the increased senescence. These findings could have two important clinical implications: firstly, that since senescent cells are known to behave abnormally in other locations, they may lead to deleterious effects on the disc matrix and so contribute to the pathogenesis and secondly, cells from such tissue may not be ideal for cell therapy and repair via tissue engineering.

Outbreak of E. coli O157 infection in the south west of the UK: risks from streams crossing seaside beaches

In August 2004 seven cases of Escherichia coli O157 infection were identified in children on holiday in Cornwall, southwest England, all of whom had stayed at different sites in the area. Isolates from all seven cases were confirmed as E. coli serogroup O157 phage type 21/28. We carried out a case-control study among holidaymakers who visited the beach. A standardised questionnaire was administered by telephone to parents. They were asked where on the beach the children had played, whether they had had contact with the stream that flowed across the beach, and about their use of food outlets and sources of food eaten. Cases were more likely to have played in the stream than controls (OR [1.72- undefined]). The time spent in the stream by cases was twice spent there by controls. Cases and controls were equally exposed to other suspected risk factors. PFGE profiles for all the cases were indistinguishable. Increased numbers of coliforms were found in the stream prior to the outbreak. Cattle were found grazing upstream. We suggest that the vehicle of infection for an outbreak of acute gastrointestinal illness caused by E. coli O157 was a contaminated freshwater stream flowing across a seaside beach. The onset dates were consistent with a point source. Heavy rainfall in the days preceding the outbreak might have lead to faeces from the cattle potentially contaminated by E. coli O157 contaminating the stream, thereby leading to the outbreak. Control measures included fencing off the part of the stream in which children played, and putting up warning signs around the beach.

Quality of hospital care in African American and white patients with ischemic stroke and TIA

OBJECTIVE

To examine whether differences exist in the in-hospital diagnostic evaluation and treatment of African American and white patients with ischemic stroke (IS) and TIA.

METHODS

The authors used a state-wide hospital-based stroke registry prototype designed to measure and track the quality of acute stroke care. Weighted descriptive statistics for each racial group are reported for the following variables, which were deemed to be potential confounders of the association between race and the quality of stroke care: age, gender, insurance status, emergency medical services arrival, functional status on presentation, modified Rankin score at discharge, stroke subtype, neurologist involved in care, and stroke pathway utilization. The magnitude and significance of the associations between race and each quality indicator of in-hospital acute stroke care were determined by separate multiple logistic regression models, adjusting for all potential confounding variables.

RESULTS

Among patients admitted with IS and TIA who were alive at discharge (n = 1,837), 340 (18.5%) were African American and 1497 (81.5%) were white. After multivariate analysis, African Americans were less likely to have a door-to-CT time of less than 25 minutes (odds ratio [OR] 0.13 [CI 0.049 to 0.32]), obtain cardiac monitoring (OR 0.54 [CI 0.29 to 1.03]), undergo dysphagia screening (OR 0.69 [CI 0.50 to 0.95]), and receive smoking cessation counseling (OR 0.27 [CI 0.17 to 0.42]).

CONCLUSIONS

Quality of hospital care for African American and white patients with acute ischemic stroke and TIA was similar in many respects. However, African Americans were less likely to receive a CT within 25 minutes of arrival, cardiac monitoring, dysphagia screening, and smoking cessation counseling.

Applying a moving total mortality count to the cities in the NMMAPS database to estimate the mortality effects of particulate matter air pollution

OBJECTIVES

To apply a new method for estimating the association between daily ambient particulate matter air pollution (PM) and daily mortality to data from over 100 United States cities contained in the National Morbidity, Mortality, and Air Pollution Study (NMMAPS) database and to see whether the results from the 90 cities NMMAPS analysis are robust to this different modelling approach. This new method has recently been shown to provide improved estimates for the association between PM and daily mortality when every-day PM data are unavailable. It avoids the need for selecting a lag of PM at which the mortality effects of PM are to be investigated.

METHODS

With the aid of analytical methods and databases developed for NMMAPS, Poisson log linear models controlling for long term trends and weather effects were used to estimate the association between PM and mortality for cities in the NMMAPS database using the new method. A two stage Bayesian hierarchical model was then used to combine city specific estimates to form a national average PM mortality effect estimate.

RESULTS

A 10 microg/m3 increase in PM was associated with a 0.12% increment in total mortality and a 0.17% increment in cardiovascular and respiratory mortality. These results are consistent with those found in the NMMAPS analysis.

CONCLUSIONS

There is a statistically significant association between short term changes in PM and mortality on average for the cities contained in the NMMAPS database. These findings are further evidence that this widespread pollutant adversely affects public health.

Outbreak of E. coli O157 infection in the south west of the UK: risks from streams crossing seaside beaches

In August 2004 seven cases of Escherichia coli O157 infection were identified in children on holiday in Cornwall, southwest England, all of whom had stayed at different sites in the area. Isolates from all seven cases were confirmed as E. coli serogroup O157 phage type 21/28. We carried out a case-control study among holidaymakers who visited the beach. A standardised questionnaire was administered by telephone to parents. They were asked where on the beach the children had played, whether they had had contact with the stream that flowed across the beach, and about their use of food outlets and sources of food eaten. Cases were more likely to have played in the stream than controls (OR [1.72- undefined]). The time spent in the stream by cases was twice spent there by controls. Cases and controls were equally exposed to other suspected risk factors. PFGE profiles for all the cases were indistinguishable. Increased numbers of coliforms were found in the stream prior to the outbreak. Cattle were found grazing upstream. We suggest that the vehicle of infection for an outbreak of acute gastrointestinal illness caused by E. coli O157 was a contaminated freshwater stream flowing across a seaside beach. The onset dates were consistent with a point source. Heavy rainfall in the days preceding the outbreak might have lead to faeces from the cattle potentially contaminated by E. coli O157 contaminating the stream, thereby leading to the outbreak. Control measures included fencing off the part of the stream in which children played, and putting up warning signs around the beach.