Role of oxidative stress and autoimmunity in onset and progression of vitiligo

Vitiligo is an acquired depigmentation disorder characterized by the loss of functional melanocytes from the epidermis. Two major theories of vitiligo pathogenesis include autoimmunity and oxidative stress-mediated toxicity in melanocytes. The present study aimed to evaluate both the hypotheses in vitiligo patients and to investigate their role in the disease onset and progression. Antimelanocyte antibody levels and lipid peroxidation (LPO) levels were evaluated in 427 patients and 440 controls; antithyroid peroxidase (TPO) antibody levels were estimated in 102 patients and 72 controls. Patients showed a significant increase in LPO and antimelanocyte antibody levels compared to controls. Antimelanocyte antibody and LPO levels were higher in active vitiligo compared to stable. Only 9.8% of patients showed the presence of anti-TPO antibodies in their circulation. Oxidative stress may be the initial triggering event to precipitate vitiligo in Gujarat population, which is exacerbated by contributing autoimmune factors together with oxidative stress.

Efficacy of flexible ureteroscopy and laser lithotripsy for lower pole renal calculi

Objective:

Our aim was to determine whether flexible ureterorenoscopy and laser lithotripsy is efficacious and safe in treating lower pole renal calculi.

Materials and methods:

Patient, procedure and stone data of patients who underwent flexible ureterorenoscopy and laser lithotripsy at our referral centre were collected prospectively between November 2005 and November 2011 and entered into a designated database. In all, 242 procedures were performed in 198 patients.

Results:

The mean age was 51.2 years. The mean calculi size was 10.51 mm (range 4–27 mm). Thirty seven patients had more than one stone in the lower pole. An access sheath was used in 19 patients (9.6%), 171 (86.4%) had a ureteric stent inserted after the procedure, and 165 patients had a single procedure. Re-operation rate was 16.7%. Stone-free rates after one procedure were 89%, 80% and 41%, respectively, for calculi measuring 4–10 mm ( n=107), 11–20 mm ( n=76) and > 20 mm ( n=15). The overall stone-free rate was 83%, 91% and 95% after one, two and three procedures, respectively.

Conclusion:

Flexible ureterorenoscopy and laser lithotripsy is a safe and effective minimally invasive treatment option for patients with 4–20 mm lower pole calculi. Staged procedures, however, become necessary as the size of the stone increases greater than 20 mm, and this should be mentioned when counselling patients for their primary procedure.

Afatinib use in non-small cell lung cancer previously sensitive to epidermal growth factor receptor inhibitors: the United Kingdom Named Patient Programme

INTRODUCTION

Afatinib prolongs progression-free survival (PFS) in patients with non-small cell lung cancer (NSCLC) who were previously sensitive to erlotinib or gefitinib. This study investigated experience of afatinib under a Named Patient Use (NPU) programme.

PATIENTS AND METHODS

Retrospective data for 63 patients were collected, including demographics, dose, toxicity and clinical efficacy.

RESULTS

Response rate and median PFS were 14.3% and 2.6months, respectively. Diarrhoea and rash were the most common toxicities; 46% of patients required a dose reduction and 41% had a dose delay.

CONCLUSIONS

Efficacy and safety in the NPU programme are consistent with the LUX-Lung 1 trial.

Suicide and attempted suicide trends in Mianwali, Pakistan: social perspective

This study aimed to examine the epidemiology and potential causes of suicides and attempted suicide cases that were reported to Rescue 1122 Mianwali in Pakistan. The data were collected prospectively for 2011. One hundred and eight suicides were reported during the study period. Four (4%) victims were found dead at the scene and 104 (96%) were taken to hospital. There were 84(78%) men and 24(22%) women and 98 (90%) were aged 11-30 years. Toxic substances (36%), pesticides (31%) and drug overdose (11%) were the most common materials/methods used. Depression/mental illness (33%), socioeconomic conditions (24%) and unemployment (21%) were the major reasons for attempting suicide. Suicide is a sensitive and multifaceted problem that needs to be addressed in Pakistan.

Sleep apnoea and its relationship with cardiovascular, pulmonary, metabolic and other morbidities

Sleep apnoea (OSAS) is a multisystem disorder. There is a high prevalence of cardiovascular and metabolic morbidities in patients investigated for sleep apnoea. We aim to evaluate any association between cardiovascular, metabolic and pulmonary co morbidities in patients investigated for OSAS and whether clinical findings based on Epworth sleep score (ESS) and snoring helps in diagnosing sleep apnoea. 258 consecutive patients who were electively admitted for sleep assessment in Peamount Hospital, Dublin from Sept 2009 to Aug 2011 were retrospectively reviewed. 139/258 were diagnosed as OSAS. Cardiovascular, metabolic and pulmonary co morbidities were 46.12%, 37.2% and 29% respectively. There is no correlation found between ESS, Snoring with Apnoea Hypopnoea Index in OSAS group. Screening for OSAS should be considered in patients with certain cardiovascular and metabolic disorders. PSG is so far considered the gold standard investigation to diagnose OSAS and better clinical evaluating tools need to be formulated.

Factors associated with Helicobacter pylori infection, results from a developing country - Pakistan

BACKGROUND

It is known that blood group antigens are related to the development of peptic ulcer and gastric carcinoma. Infections due to H. pylori are most widespread among the developing regions due to poor standard of public health. This study sought to determine the association of H. pylori with ABO blood groups, age, gender, and smoking status among inpatients at a public sector hospital in Karachi.

MATERIALS AND METHODS

A cross-sectional study was conducted at endoscopy suite at a public sector hospital in Karachi in the year 2011. All the symptomatic patients coming for upper GIT endoscopy were included in this study.

RESULTS

Biopsy for histopathology was taken from 93 patients, with an age range from 15-65 years. Age group of 15 to 20 years was found to be associated with H. pylori infection but without significance (p-value 0.83). In all, 36 (38.7%) turned out to be H. pylori positive with a significant male preponderance (p=0.04). Distribution of ABO blood groups in H. pylori positive group were A=31.4%, B=15.4%, AB=25.0% and O=53.7%, with a statistically significant link for blood group O (p=0.05) . Rhesus factor was also compared but significant relationship was evident (p-value 0.73).

CONCLUSIONS

This study demonstrated that H. pylori infection can be related to ABO blood group, middle age persons and male gender. People of blood group O are more prone to develop infection related gastritis, ulcers, and even perforations, so they should be more cautious against transmission of the bacterium.

The intensity of QuantiFERON TB-gold response does not differentiate active from latent tuberculosis

We analyzed positive QuantiFERON (QFT) assays, performed between July 2009 and April 2011 in the Mercy University Hospital, Cork, Ireland, which included, 94 patients with latent tuberculosis (LTBI) and 35 patients with active tuberculosis. There was no difference in the intensity of response between patients with LTBI and active tuberculosis (p = 0.1589). In patients with LTBI, there were no correlations between age (p = 0.353), sex (p = 0.476), smoking (p = 0.323), contact (p = 0.612), Mantoux response (p = 0.055), Irish nationality (p=0.768), previous BCG vaccination (p = 0.504), WCC (p = 0.187), lymphocyte count (p = 0.786), neutrophil count (p = 0.157) and the intensity of QFT response. Similarly in patients with active TB, there were no correlations between these variables and QFT response. The intensity of QFT response does not help to differentiate active from LTBI. The intensity of QFT response is not influenced by age, sex, smoking, remoteness of contact history, Mantoux response, nationality, CXR abnormalities, BCG vaccination and peripheral lymphocyte count.

Evaluation of the pressure leak test in increasing the lifespan of flexible ureteroscopes

INTRODUCTION

Flexible ureteroscopes are expensive and delicate instruments that are integral in the offering of a minimally invasive technique of diagnosis and treatment of urolithiasis. Published literature has identified the importance of early damage recognition in preventing frequent use of the scope that would lead to further damage and high repair and replacement costs. Our study was designed to examine the outcome of the pressure leak test on the condition of flexible ureteroscopes after every use and analysing the damage and costs of maintenance.

PATIENTS AND METHODS

A prospective study was designed with two treatment groups. Group 1, 95 consecutive procedures (n = 95) of flexible ureterorenoscopy and laser fragmentation of renal calculi were performed with ACMI DUR 8, (a scope with no in-built leak test facility). This was compared against group 2, where 98 procedures of laser fragmentation of renal calculi (n = 98) were performed using Storz Flex X(2) Ureteroscopes (with a in-built leak test facility). All scopes in Group 2 were tested for pressure leak after every procedure and the outcome of the tests recorded.

RESULTS

Both groups were comparable for grade of surgeon; stone location, size & number; access sheath usage and duration of lasering. In Group 1, there were seven scope damages resulting in repairs/replacement amounting to costs $46264.40 (7.1% damage). In Group 2, three scopes revealed a positive pressure leak test, implying damage with repair costs of $9952.80 (3.1% damage) (p < 0.05). Significant cost savings and reduction in downtime were made in Group 2.

CONCLUSIONS

Pressure leak testing following flexible ureterorenoscopy helped to significantly control costs of maintenance and repair. Newer scopes should have a leak testing mechanism as it prevents further detrimental damage to the scope, build-up of repair costs are avoided and there is an increase in the longevity of these delicate instruments.

Role of endothelium-derived hyperpolarising factor in acetylcholine-mediated vasodilatation in skin

AIM

Acetylcholine (ACh) is an endothelium-dependent vasodilator used to investigate endothelial function in the microcirculation. The mediators of its vasodilatory effects are not clear, but endothelium-derived hyperpolarising factor (EDHF) is thought to contribute, and appears to have particular importance in smaller peripheral vessels. The aim of this study was to investigate the role of EDHF in ACh-mediated vasodilator responses in human forearm skin.

METHODS

Laser Doppler imaging was used to measure forearm skin blood flow responses to iontophoretic administration of ACh in 7 healthy men. ACh in a 10-mg/mL solution was administered in accumulating doses using increasing delivery currents of 10, 15, 20, 50 and 100 µA. The measurements were repeated on subsequent visits when the effects of EDHF were blocked using intra-arterial sulphaphenazole at 2 mg/min (a cytochrome P-450 inhibitor), nitric oxide (NO) was blocked using intra-arterial administration of the NO synthetase inhibitor l-NG-monomethyl arginine (l-NMMA) at 4 µmol/min, and prostanoids were blocked with oral aspirin 1 g.

RESULTS

The microvascular response to ACh was significantly attenuated by sulphaphenazole alone (P=0.018), l-NMMA alone (P<0.001) and the combination of sulphaphenazole plus l-NMMA (P<0.001), and aspirin had no additional effect.

CONCLUSION

EDHF is a significant contributor to the vasodilatory effects of ACh in the human dermal microcirculation. Information about abnormalities in specific pathways of endothelial function in patient groups may help in the targeting of appropriate drug therapies.

Intra-aortic balloon pump counterpulsation: are we optimizing the management of cardiogenic shock?

Intra-aortic balloon pump counterpulsation (IABPC) has been used in various forms for decades. The change in physiology brought about by their use is conceptually appealing in managing cardiogenic shock and mechanical complications of myocardial infarction. A common myth is that this method of managing acute cardiological emergencies is to be limited to the realms of this specialist field. However, as medical physicians an appreciation and understanding of this novel therapy is essential not only as a lifesaving measure but also as a bridging therapy to more definitive management in the acute medical setting. IABPC is a safe and under-utilized technique despite featuring in all major international guidelines (ESC and ACC) for the management of cardiogenic shock secondary to acute coronary syndromes. Without awareness of this intervention we may be suboptimally managing patients in the first instance. To improve awareness we examine the evidence supporting the use of the IABPC therapy and the contraindications to their use. Complications and advances in technology are also addressed.

Emerging anticoagulants

Warfarin, heparin and their derivatives have been the traditional anticoagulants used for prophylaxis and treatment of venous thromboembolism. While the modern clinician is familiar with the efficacy and pharmacokinetics of these agents, their adverse effects have provided the impetus for the development of newer anticoagulants with improved safety, ease of administration, more predictable pharmacodynamics and comparable efficacy. Research into haemostasis and the coagulation cascade has made the development of these newer anticoagulants possible. These drugs include the factor Xa inhibitors and IIa (thrombin) inhibitors. Direct and indirect factor Xa inhibitors are being developed with a relative rapid onset of action and stable pharmacokinetic profiles negating the need for close monitoring; this potentially makes them a more attractive option than heparin or warfarin. Examples of direct factor Xa inhibitors include apixaban, rivaroxaban, otamixaban, betrixaban and edoxaban. Examples of indirect factor Xa inhibitors include fondaparinux, idraparinux and idrabiotaparinux. Direct thrombin inhibitors (factor IIa inhibitors) were developed with the limitations of standard heparin and warfarin in mind. Examples include recombinant hirudin (lepirudin), bivalirudin, ximelagatran, argatroban, and dabigatran etexilate. This review will discuss emerging novel anticoagulants and their use for the prophylaxis and management of venous thromboembolism, for stroke prevention in nonvalvular atrial fibrillation and for coronary artery disease.

Specialised fetal and maternal service: outcome of pre-gestational diabetes

The objective of the study was to determine the outcome of pregnancies with pre-gestational diabetes mellitus (PGDM) in the presence of a specialised maternal and fetal service. Prospective data included mothers with documented pre-gestational diabetes (PGDM) delivered between 1 January 2007 and 31 December 2009. A total of 138 patients with PGDM were included in this study. The post-lunch glucose level at 34 weeks was significantly lower than at 30 weeks' gestation (p =0.007) and 37 weeks' gestation (p =0.02). No correlation was observed between maternal blood sugar and birth weight. The incidence of pre-term labour, stillbirth and admission to the NICU was similar to the control group. Caesarean section rate was 39.1%, and the main indication was previous caesarean section. The incidence of fetal anomalies was significantly higher than in the control group. It was concluded that the presence of specialised maternal and fetal clinics reduces complications related to prenatal glycaemic control. However, complications related to preconception care remains high.

Rehabilitation interventions in patients with acute demyelinating inflammatory polyneuropathy: a systematic review

Acute inflammatory demyelinating polyneuropathy (Guillain-Barré syndrome, GBS) can be a significant cause of new long-term disability, which is thought to be amenable to rehabilitation. Rehabilitation is an expensive resource and the evidence to support its justification is urgently needed. This systematic review presents an evidence-based overview of the effectiveness of various rehabilitation interventions in adults with GBS and the outcomes that are affected. Medline, EMBASE, CINAHL, AMED, PEDro, LILACS and the Cochrane Library were searched up to March 2012 for studies reporting outcomes of GBS patients following rehabilitation interventions that addressed functional restoration and participation. Two reviewers applied the inclusion criteria to select potential studies and independently extracted data and assessed the methodological quality. Included studies were critically appraised using GRADE methodological quality approach. Formal levels of evidence of each intervention were assigned using a standard format defined by National Health and Medical Research Council. Fourteen papers (one systematic review, one randomized controlled trial, one case-control study, five cohort studies and six case series/reports) that described a range of rehabilitation interventions for persons with GBS were evaluated for the "best" evidence to date. One high quality randomised controlled trial demonstrated effectiveness of higher intensity multidisciplinary ambulatory rehabilitation in reducing disability in persons with GBS in the later stages of recovery, compared with lesser intensity rehabilitation intervention for up to 12 months. Four observational studies, further demonstrated some support for improved disability and quality of life following inpatient multidisciplinary rehabilitation up to 12 months. Evidence for uni-disciplinary rehabilitation interventions is limited, with 'satisfactory' evidence for physical therapy in reducing fatigue, improving function and quality of life in persons with GBS. This review provides "good" evidence to support multidisciplinary rehabilitative intervention in adults with GBS; and "satisfactory" evidence for physical therapy in these patients. Evidence for other uni-disciplinary interventions is limited or inconclusive. The gaps in existing research should not be interpreted as ineffectiveness of rehabilitation intervention in GBS. Further research is needed with appropriate study designs, outcome measurement, type of modalities and cost-effectiveness of these interventions.

Assessment of fidelity and utility of the whole-genome amplification for the clinical tests offered in a histocompatibility and immunogenetics laboratory

Increasing emphasis on the use of molecular tests in a histocompatibility and immunogenetics laboratory (HIL) poses a potential problem of lack of sufficient DNA to perform multiple genetic analyses. In this study, we report the feasibility, fidelity and utility of multiple displacement amplification (MDA) method to perform whole-genome amplification (WGA) to generate DNA specimens that can be analyzed by multiple molecular techniques and can be used for different clinical tests offered by an HIL. The MDA-generated DNA when compared with the native DNA showed 100% congruency in genotyping of 37 genes/loci using multiple downstream molecular techniques: sequence-based typing and sequence-specific primer-based typing for 5 human leukocyte antigen (HLA) class I and II genes (HLA-A, B, C, DRB1 and DQB1), luminex-based sequence-specific oligonucleotide (SSO) genotyping for a panel of 16 killer immunoglobulin-like receptor (KIR) genes and automated fragment size analysis for a panel of 15 short tandem repeat (STR) loci and amelogenin gene. For post-allogeneic hematopoietic cell transplantation (HCT) chimerism analysis, MDA-generated DNA appeared useful for enriching pre-transplant DNA but not for enriching post-transplant chimeric DNA. Overall, our results show that MDA-based WGA could generate DNA of high yield and fidelity that can be used for various clinical tests and research purposes.

Dietary flaxseed oil supplementation ameliorates the effect of cisplatin on brush border membrane enzymes and antioxidant system in rat intestine

Cisplatin (CP; cis-diamminedichloroplatinum II) is a drug widely used against different types of solid tumors. Patients receiving CP, however, experience very profound and long lasting gastrointestinal symptoms. Recently, ω-3 polyunsaturated fatty acid-enriched flaxseed/flaxseed oil (FXO) has shown numerous health benefits. The present study was undertaken to investigate whether FXO can prevent CP-induced adverse biochemical changes in the small intestine of rats. A single intraperitoneal dose of CP (6 mg/kg body weight) was administered to male Wistar rats fed with control diet (CP group) and FXO diet (CPFXO group). Administration of CP led to a significant decline in the specific activities of brush border membrane enzymes both in the mucosal homogenates and in the isolated membrane vesicles. Lipid peroxidation and total sulfhydryl groups were altered upon CP treatment, indicating the generation of oxidative stress. The activities of SOD, catalase and glutathione peroxidase also decreased in CP-treated rats. In contrast, dietary supplementation of FXO prior to and following CP treatment significantly attenuated the CP-induced changes in all these parameters. FXO feeding markedly enhanced resistance to CP-elicited adverse gastrointestinal effects. The results suggest that FXO owing to its intrinsic biochemical/antioxidant properties is an effective agent in reducing the adverse effects of CP on intestine.

Schizophrenia, culture and neuropsychology: sensory deficits, language impairments and social functioning in Chinese-speaking schizophrenia patients

BACKGROUND

While 20% of schizophrenia patients worldwide speak tonal languages (e.g. Mandarin), studies are limited to Western-language patients. Western-language patients show tonal deficits that are related to impaired emotional processing of speech. However, language processing is minimally affected. In contrast, in Mandarin, syllables are voiced in one of four tones, with word meaning varying accordingly. We hypothesized that Mandarin-speaking schizophrenia patients would show impairments in underlying basic auditory processing that, unlike in Western groups, would relate to deficits in word recognition and social outcomes.

METHOD

Altogether, 22 Mandarin-speaking schizophrenia patients and 44 matched healthy participants were recruited from New York City. The auditory tasks were: (1) tone matching; (2) distorted tunes; (3) Chinese word discrimination; (4) Chinese word identification. Social outcomes were measured by marital status, employment and most recent employment status.

RESULTS

Patients showed deficits in tone-matching, distorted tunes, word discrimination and word identification versus controls (all p<0.0001). Impairments in tone-matching across groups correlated with both word identification (p<0.0001) and discrimination (p<0.0001). On social outcomes, tonally impaired patients had 'lower-status' jobs overall when compared with tonally intact patients (p<0.005) and controls (p<0.0001).

CONCLUSIONS

Our study is the first to investigate an interaction between neuropsychology and language among Mandarin-speaking schizophrenia patients. As predicted, patients were highly impaired in both tone and auditory word processing, with these two measures significantly correlated. Tonally impaired patients showed significantly worse employment-status function than tonally intact patients, suggesting a link between sensory impairment and employment status outcome. While neuropsychological deficits appear similar cross-culturally, their consequences may be language- and culture-dependent.

Rosuvastatin might have an effect on C-reactive protein but not on rheumatoid disease activity: Tayside randomized controlled study

The aim of this study was to study the effects of rosuvastatin in patients with rheumatoid arthritis (RA) looking at the C-reactive protein (CRP), interleukin-6 (IL-6) and joint disease activity. Fifty RA patients were randomized in a double-blind placebo-controlled trial to receive either 10 mg of rosuvastatin or placebo as an adjunct to existing disease-modifying antirheumatic therapy. Patients were followed up for a six-month period. Measurements were done at baseline and six months. CRP and IL-6 were measured in the blood. RA disease activity was measured using disease activity score based on 28 joint counts (DAS 28). When analysing from baseline to six months there was no difference between the rosuvastatin and placebo groups in rheumatoid disease activity (–0.01; standard deviation [SD], 1.08; and +0.18; SD, 0.95; respectively; P value 0.509). There was a trend towards improvement in CRP in the rosuvastatin group (–3.23; SD, 18.18) compared with the placebo group (+17.43; SD, 38.03); P value, 0.161. IL-6 showed a trend towards worsening in the rosuvastatin group (+0.15; SD, 1.09) compared with placebo (–0.73; SD, 1.4); P value, 0.054. These data show that rosuvastatin with might decrease the CRP independent to IL-6 in patients with RA but does not improve the overall rheumatoid disease activity.

Studies on the protective effect of flaxseed oil on cisplatin-induced hepatotoxicity

Cisplatin (CP) is known as one of the most potent chemotherapeutic antitumor drugs. The tissue-specific toxicity of CP in the kidneys is well documented. However, at higher doses less common toxic effects such as hepatotoxicity may arise. Since CP remains one of the most effective antineoplastic drug used in chemotherapy, strategies to protect tissues against CP toxicity are of clinical interest. Recently, ω-3 polyunsaturated fatty acids (PUFAs) from certain plants/seeds notably flaxseed have shown numerous health benefits. In view of this, the present study investigates the protective effect of flaxseed oil (FXO) on CP-induced damage in liver. Rats were pre-fed normal diet and the diet rich in FXO for 10 days and then a single dose of CP (6 mg/kg body weight) was administered intraperitoneally while still on diet. Serum/urine parameters, enzymes of carbohydrate metabolism and oxidative stress were analyzed. CP caused perturbation of the antioxidant defense as reflected by the decrease in the activities of catalase, superoxide dismutase and glutathione peroxidase. Further the activities of various enzymes involved in glycolysis, tricarboxylic acid cycle, gluconeogenesis and hexose monophosphate shunt pathways were determined and were found to be differentially altered by CP treatment. However, these alterations were ameliorated in CP-treated rats fed on FXO. Present results show that dietary supplementation of FXO in CP-treated rats ameliorated CP-induced hepatotoxic and other deleterious effects due to its intrinsic biochemical/antioxidant properties.

Tumour necrosis factor gene polymorphism and disease prevalence

Tumour necrosis factor (TNF), an important proinflammatory cytokine, plays a role in the regulation of cell differentiation, proliferation and death, as well as in inflammation, innate and adaptive immune responses, and also implicated in a wide variety of human diseases. The presence of DNA sequence variations in regulatory region might interfere with transcription of TNF gene, influencing the circulating level of TNF and thus increases the susceptibility to human diseases (infectious, cancer, autoimmune, neurodegenerative and other diseases). In this review, we have comprehensively analysed various published case-control studies of different types of human diseases, in which TNF gene polymorphism played a role, and computationally predicted several single nucleotide polymorphisms (SNPs) lie in transcription factor-binding sites (TFBS) of transcription factors (TFs). It has been observed that TNF enhancer polymorphism is implicated in several diseases, and TNF rs1800629 and rs361525 SNPs are the most important in human disease susceptibility as these might influence the transcription of TNF gene. Thirty-two SNPs lies in TFBS of 20 TFs have been detected in the TNF upstream region. It has been found that TNF enhancer polymorphism influences the serum level of TNF in different human diseases and thus affects the susceptibility to diseases. The presence of DNA sequence variation in TNF gene causes the modification of transcriptional regulation and thus responsible for association of susceptibility/resistance with human diseases.

Systematic review of multidisciplinary rehabilitation in patients with multiple trauma

Background

Multiple trauma is a cause of significant disability in adults of working age. Despite the implementation of trauma systems for improved coordination and organization of care, rehabilitation services are not yet routinely considered integral to trauma care processes.

Methods

MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine, Physiotherapy Evidence Database, Latin American and Caribbean Literature on Health Sciences and Cochrane Library databases were searched up to May 2011 for randomized clinical trials, as well as observational studies, reporting outcomes of injured patients following multidisciplinary rehabilitation that addressed functional restoration and societal reintegration based on the International Classification of Functioning, Disability and Health.

Results

No randomized and/or controlled clinical trials were identified. Fifteen observational studies involving 2386 participants with injuries were included. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach assessed methodological quality as ‘poor’ in all studies, with selection and observer bias. Although patients with low functional scores showed improvement after rehabilitation, they were unable to resume their pretrauma level of activity. Their functional ability was significantly associated with motor independence on admission and early acute rehabilitation, which contributed to a shorter hospital stay. Injury location, age, co-morbidity and education predicted long-term functional consequences. Trauma care systems were associated with reduced mortality. The gaps in evidence include: rehabilitation settings, components, intensity, duration and types of therapy, and long-term outcomes for survivors of multiple trauma.

Conclusion

Rehabilitation is an expensive resource and the evidence to support its justification is needed urgently. The issues in study design and research methodology in rehabilitation are challenging. Opportunities to prioritize trauma rehabilitation, disability management and social reintegration of multiple injury survivors are discussed.

Multidisciplinary care for Guillain-Barré syndrome

BACKGROUND

Guillain-Barré syndrome (GBS) can be a significant cause of new long-term disability, which is thought to be amenable to multidisciplinary care. However, the evidence base of its effectiveness is unclear.

AIM

The aim of this systematic review is to assess the effectiveness of multidisciplinary care in adults with GBS, the types of approaches that are effective (setting, type, intensity) and the outcomes that are affected.

METHODS

The search strategy comprised: The Cochrane Neuromuscular Disease Group Specialized Register and the Cochrane Central Register of Controlled Trials; MEDLINE, EMBASE, AMED, PEDro, LILACS and CINAHL (up to May 2010). Selected studies included randomized and controlled clinical trials that compared multidisciplinary care in GBS with a control (routine local service, lower level of intervention); or studies that compared multidisciplinary care in different settings or at different levels of intensity of therapy. Best evidence synthesis was based on methodological quality. Three observational studies were also reported but they make limited contribution to evidence base synthesis.

RESULTS

No randomized or controlled clinical trials were identified. Evidence from three low-quality observational studies provide some support for improved disability in the short term (6 months) with high intensity rehabilitation; and for improved participation and quality of life.

CONCLUSION

The gaps in existing research should not be interpreted as ineffectiveness of multidisciplinary care in GBS. Appropriate and methodologically robust study designs, responsive outcome measures; and more research in the setting, type and intensity of rehabilitation are needed.

Vasoactive properties of calcitonin gene-related peptide in human skin

AIM

Calcitonin gene-related peptide (CGRP) is a potential mediator of neurogenic inflammation in eczema, psoriasis and rosacea, and also contributes to vasodilatation and oedema in complex regional pain disorder. We investigated the feasibility of administering CGRP and its antagonist CGRP8-37 by iontophoresis in human skin to characterise their vasoactive profiles.

METHODS

Two doses of each peptide were administered by iontophoresis (5 and 10 min duration at 0.1 mA) to the forearm skin of 6 healthy young men. Skin blood flow responses over 25 min were assessed using laser Doppler imaging.

RESULTS

Iontophoresis of CGRP caused a gradual change in blood flow, with no significant difference in response between each dose. The peak change in flow had a coefficient of variation of 21% to 36%, while the variability of the total cumulative response was much greater. Iontophoresis of CGRP8-37 for 5 min caused only a small, transient increase in skin blood flow, while 10 min iontophoresis resulted in a significant increase in blood flow.

CONCLUSION

CGRP and CGRP8-37 can be administered by iontophoresis to human skin. Further experiments are needed to determine the optimum duration of iontophoresis and period of measurement.

Evaluation of the effects of long-term storage of bovine ear notch samples on the ability of 2 diagnostic assays to identify calves persistently infected with bovine viral diarrhoea virus

Research aimed at optimising diagnostic laboratory procedures is central to the development of effective bovine viral diarrhoea virus (BVDV) control programmes. BVDV is a single-stranded RNA virus that crosses the placenta to infect foetuses, resulting in reproductive losses due to foetal death or persistently infected calves that die early in life. Persistently infected animals are widely accepted to be the primary reservoir of BVDV and the largest source of infection. This poses important challenges to overall animal/herd health and can cause major losses to the cattle industry. Long-term storage of bovine ear notch samples from calves persistently infected with BVDV may adversely affect the ability of diagnostic assays to detect the virus efficiently. In order to test this hypothesis, ear notch samples from 7 animals were divided into 2 groups. One set was subjected to prompt formalin fixation and the other set stored either as fresh samples without preservatives at -2 degrees C, or soaked overnight in phosphate buffered saline followed by freezing of the supernatant fluid at -2 degrees C. Frozen ear notches and ear notch supernatant yielded positive results with an antigen-capture, enzyme linked immunosorbent assay (AC-ELISA) for the duration of the study (6 months) and optical density (OD) values remained significantly within range. There was no significant difference between storing fresh ear notch samples or PBS at -2 degrees C. However, positive immunohistochemistry (IHC) staining on formalin fixed ear notches started to fade between Day 17 and Day 29 when stored at room temperature. It was concluded that fresh ear notches could safely be stored at -2 degrees C for a period of 6 months prior to testing for BVD viral antigens.

Valeriana jatamansi partially reverses liver cirrhosis and tissue hyperproliferative response in rat

Valeriana jatamansi (family, Valerianaceae) is a traditional medicinal herb in the Indian subcontinent. This study provides experimental evidence indicating the therapeutic effect of the extract prepared from the dried rhizome of the herb in an animal model of liver cirrhosis and on cell proliferation. Liver cirrhosis was induced in rats by thioacetamide (0.03% in drinking water for 16 weeks). After inducing liver cirrhosis, rats were administered the extract orally for 9 weeks. Treatment was found to partially reverse the elevated levels of alkaline phosphatase, γ-glutamyl transferase and selected biochemical markers of hepatic injury including drug-metabolizing enzymes. Histopathology of the hepatic tissue confirmed the therapeutic effect of the extract which corroborated with the biochemical changes. The extract is also reported to ameliorate hepatic cell proliferation in rats injected with thioacetamide. The study has implications in finding a treatment for liver cirrhosis in humans.

Novel image analysis tools for evaluating the androgen receptor in the prostate needle biopsy: Impact on future systems-based outcome models

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Background: A systems-based model was previously developed and validated to predict disease progression (DP) using pretreatment clinical data and standardized, robust prostate needle biopsy (PNB) tissue metrics. We sought to apply novel, advanced immunofluorescent (IF) image analysis methods to re-assess PNB androgen receptor (AR) and Ki67 expression profiles and identify cut-points useful for understanding and guiding therapeutic decision making.

Methods: Pretreatment clinical features and PNB H&E / IF images on 306 patients (91% cT1-T2b, 66% PSA</=10ng/mL; 49% Gleason biopsy score </=6) from the original study cohort were obtained. IF images were re-processed using a novel CK18 and DAPI algorithm to optimize segmentation of the tumor (epithelial) nuclear (TEN) and stromal compartments. The original threshold for determining TEN Ki67was retained. An enhanced image analysis approach was applied to calculate the normalized ratio of maximum AR levels in TEN to stromal nuclei. Feature performance was evaluated with the concordance index (CI); AR and Ki67 cut-point (CP) analysis and new multivariate models were completed.

Results: Increasing amounts of Ki67 and two new AR features reflecting different percentages of the maximum AR level in TEN were associated with a shorter time to DP (Ki67 CI0.37, AR-ratio 21, CI0.30 and AR-ratio 22, CI0.33). Several cut-points were identified including: Ki67 CP 0.04, hazard ratio (HR) of 3.1, p-value 0.0005 (sensitivity 64%, specificity 68%); ARratio-21 CP 0.90, HR 3.8, p-value 0.0001 (sensitivity 78%, specificity 73%) and ARratio-22 CP 0.87, HR 2.2, p-value 0.013 (sensitivity 68%, specificity 68%). A multivariate model for predicting DP consisted of 4 weighted features including the biopsy Gleason score, the ARratio-22, and two morphometric (H&E&IF) variables.

Conclusions: Novel image analysis methods to analyze biomarker attributes in PNB specimens confirm and enhance our understanding of AR and Ki67 in disease progression. Such approaches will become useful tools for finalizing biomarker cut-points, performing pharmacodynamic assessment and establishing parameters for guiding therapy.

[Table: see text]

P01-308-Pervasive developmental disorders and inpatient admission in adolescents: Psychiatric co-morbidity and challenges in clinical and community interventions

Introduction

Co-morbidity is to be expected in autistic spectrum disorders directly or indirectly (1). 65% of children and adolescents with Asperger's suffer from an additional psychiatric disorder (2). Misdiagnosis or delayed diagnosis is a serious problem, and the average age at diagnosis of Aspergers is several years later than for autism (3).

A small yet significant number of offenders with autism who engage in illegal behaviour find themselves socially excluded or detained in secure provisions for prolonged periods(4).

Aims

Wider understanding of factors leading to inpatient admission in young people with Pervasive developmental disorder.

Early detection and management of mental disorder and risks, in order to meet complex needs in community.

Objectives

Innovative and comprehensive assessment of mental health, psychological and social needs.

Risk assessment and management shared by multidisciplinary team and Community teams.

Method

Retrospective case notes study of 11 patients admitted over 2 years.

Results

81.8% presented with risk to others.54.5% had diagnosis of ASD on admission. 36.3% had forensic history. Average age of diagnosis was 14 years. 18.1%were misdiagnosed.

Conclusion

The review confirms that misdiagnosis and delayed diagnosis remains a problem. Also co-morbid substance misuse and risk taking behaviour get admitted to secure inpatient units. Inpatient assessment can in significant number of cases divert trajectory away from criminal justice system.