Five-year longitudinal assessment of the downstream impact on schistosomiasis transmission following closure of the Three Gorges Dam

BACKGROUND

Schistosoma japonicum is a major public health concern in the Peoples' Republic of China (PRC), with about 800,000 people infected and another 50 million living in areas at risk of infection. Based on ecological, environmental, population genetic and molecular factors, schistosomiasis transmission in PRC can be categorised into four discrete ecosystems or transmission modes. It is predicted that, long-term, the Three Gorges Dam (TGD) will impact upon the transmission of schistosomiasis in the PRC, with varying degree across the four transmission modes.

METHODOLOGY/PRINCIPAL FINDINGS

We undertook longitudinal surveillance from 2002 to 2006 in sentinel villages of the three transmission modes below the TGD across four provinces (Hunan, Jiangxi, Hubei and Anhui) to determine whether there was any immediate impact of the TGD on schistosomiasis transmission. Eight sentinel villages were selected to represent both province and transmission mode. The primary end point measured was human incidence. Here we present the results of this five-year longitudinal cohort study. Results showed that the incidence of human S. japonicum infection declined considerably within individual villages and overall mode over the course of the study. This is also reflected in the yearly odds ratios (adjusted) for infection risk that showed significant (P<0.01) downward trends in all modes over the follow-up period.

CONCLUSIONS/SIGNIFICANCE

The decrease in human S. japonicum incidence observed across all transmission modes in this study can probably be attributed to the annual human and bovine PZQ chemotherapy. If an increase in schistosome transmission had occurred as a result of the TGD, it would be of negligible size compared to the treatment induced decline seen here. It appears therefore that there has been virtually no immediate impact of the TGD on schistosomiasis transmission downstream of the dam.

Case studies emphasising the difficulties in the diagnosis and management of alveolar echinococcosis in rural China

Background

Human alveolar echinococcosis (AE) is caused by the accidental ingestion of the eggs of the fox tapeworm Echinococcus multilocularis. AE occurs frequently in rural western China due to the poor levels of hygiene, the close contact of people with dogs, and the lack of appropriate facilities for the correct and rapid diagnosis of the disease.

Findings

We describe a case of a patient with hepatic AE, and AE metastases of the brain. She was mistakenly diagnosed with suspected undifferentiated metastatic cancer of the liver and brain, and with a pulmonary bacterial infection, but was subsequently correctly diagnosed during a follow-up field survey for echinococcosis. The diagnosis of brain AE was confirmed by pathological examination of tissue biopsies removed during neurosurgery. We also briefly describe other symptomatic and asymptomatic AE cases, identified by chance, likely due to the inadequate facilities available in rural communities in China for AE diagnosis and management, since the rapid and accurate diagnosis of metastatic AE requires a high level of expertise in the appropriate diagnostic procedures.

Conclusions

This report highlights the necessity for an upgrade in the diagnosis, treatment, prevention and control of AE in rural China.

Neuroschistosomiasis

Schistosomiasis (bilharzia) is a neglected tropical disease caused by digenetic trematode platyhelminths of the genus Schistosoma. Neuroschistosomiasis is one of the most severe clinical outcomes associated with schistosome infection. Neurological complications early during the course of infection are thought to occur through in situ egg deposition following aberrant migration of adult worms to the brain or spinal cord. The presence of eggs in the CNS induces a cell-mediated Th2-driven periovular granulomatous reaction. The mass effect of thousands of eggs and the large granulomas concentrated within the brain or spinal cord explain the signs and symptoms of increased intracranial pressure, myelopathy, radiculopathy and subsequent clinical sequelae. Myelopathy (acute transverse myelitis and subacute myeloradiculopathy) of the lumbosacral region is the most common neurological manifestation of S. mansoni or S. haematobium infection, whereas acute encephalitis of the cortex, subcortical white matter, basal ganglia or internal capsule is typical of S. japonicum infection. Cerebral complications include encephalopathy with headache, visual impairment, delirium, seizures, motor deficits and ataxia, whereas spinal symptoms include lumbar pain, lower limb radicular pain, muscle weakness, sensory loss and bladder dysfunction. The finding of eggs in the stool or a positive serology, provides supportive but not direct evidence of neuroschistosomiasis. A definitive diagnosis can only be made with histopathological study showing Schistosoma eggs and granulomas. Schistosomicidal drugs (notably praziquantel), steroids and surgery are currently used for the treatment of neuroschistosomiasis. During the 'acute phase' of the disease, neuroschistosomiasis is treated with corticosteroids which are augmented with a course of praziquantel once female worm ovipositioning commences. Surgery should be reserved for special cases such as in those with evidence of medullary compression and in those who deteriorate despite clinical management.

A 5-year longitudinal study of schistosomiasis transmission in Shian village, the Anning River Valley, Sichuan Province, the Peoples' Republic of China

Background

Schistosoma japonicum is a major public health concern in the Peoples' Republic of China (PRC), with over one million people infected and another 50 million living in areas at risk of infection. Based on ecological, environmental, population genetic and molecular factors, schistosomiasis transmission in PRC can be categorised into four discrete ecosystems or transmission modes. It is predicted that the Three Gorges Dam (TGD) will impact upon the transmission of schistosomiasis in the PRC, with varying degree across the four transmission modes. We undertook longitudinal surveillance from 2002 to 2006 in sentinel villages both above and below the TGD across five provinces (Hunan, Jiangxi, Hubei, Anhui and Sichuan) to determine whether there was any impact of the TGD on schistosomiasis transmission during its construction. Here we present the results from a schistosomiasis-endemic village located above the dam in Sichuan Province.

Results

Baseline results showed a human S. japonicum prevalence of 42.0% (95% CI: 36.6-47.5). At follow-up, results showed that the incidence of S. japonicum infection in the selected human cohort in Shian decreased by three quarters from 46% in 2003 to 11.3% in 2006. A significant (P < 0.01) downward trend was also evident in the yearly adjusted (for water contact) odds ratios. Over the four years of follow-up, the incidence of S. japonicum infection in bovines declined from 11.8% in the first year to zero in the final year of follow-up.

Conclusions

The substantial decrease in human (75%) and bovine (100%) incidence observed in Shian village can probably be attributed to the annual human and bovine PZQ treatment of positives; as seen in drug (PZQ) intervention studies in other parts of PRC. If an increase in schistosome transmission had occurred as a result of the TGD, it would be of negligible size compared to the treatment induced decline seen here. It appears therefore that the construction of the TGD had virtually no impact on schistosomiasis transmission in Shian village over the period of study. Furthermore, contrary to previous reports from Sichuan downplaying the role of animals in human schistosome transmission, bovines may indeed play a role.

Schistosomiasis elimination: lessons from the past guide the future

Schistosomiasis is a major neglected tropical disease, with more than 200 million people infected and close to 800 million at risk. The disease burden is estimated to exceed 70 million disability-adjusted life-years. The anthelmintic drug praziquantel is highly effective in killing adult schistosome worms, but it is unable to kill developing schistosomes and so does not prevent reinfection. As a result, current praziquantel-based control programmes in Asia and sub-Saharan Africa are not effective or sustainable in the long term. The control of neglected tropical diseases, including schistosomiasis, is a funding priority for several donor agencies, with over US$350 million committed until 2013. Here we put forward an argument that donor funds would be more effectively spent on the development of a multi-faceted, integrated control programme, which would have a greater and longer lasting effect on disease transmission than the current chemotherapy-based programmes. The development of a transmission-blocking vaccine is also of great importance. A multi-faceted integrated control programme that incorporates a vaccine, even if only partly effective, has the potential to eliminate schistosomiasis. This integrated-approach model has the potential to improve the health of a billion of the world's poorest people and its effect cannot be underestimated.

Human cases of simultaneous echinococcosis and tuberculosis - significance and extent in China

During analysis of retrospective community survey data, we identified two patients from Xiji County, south Ningxia Hui Autonomous Region with simultaneous echinococcosis and tuberculosis (TB), representing the first such reports for China. As the echinococcosis chronicity increased, the immune profile in both subjects changed from a Th1 to Th2 response, as shown by a TB skin test, originally positive, becoming negative. Such an elevated Th2 immune profile, with subsequent suppression of the Th1 immune response, is a common feature of chronic helminth infections. Given the difficulties in definitive diagnosis, and the potential increased susceptibility for TB infection in patients with advanced echinococcosis, we suggest that combined TB/echinococcosis surveys be undertaken in this area in the future. This would allow early diagnosis of both TB and echinococcosis cases with better prognosis for effective and sustainable treatment outcomes, ultimately reducing associated morbidity and mortality, and also the overall financial costs to the individual and the public health care system in this under developed part of China.

Conquering 'snail fever': schistosomiasis and its control in China

Schistosomiasis japonica is a serious parasitic disease and a major health risk for more than 60 million people living in the tropical and subtropical zones of south China. The disease is a zoonosis and its cause, the parasitic trematode Schistosoma japonicum, has a range of mammalian reservoirs, making control efforts difficult. Current control programs are heavily based on community chemotherapy with a single dose of the highly effective drug praziquantel. However, vaccines (for use in bovines and in humans) in combination with other control strategies are needed to eliminate the disease. In this review, we provide an overview of the transmission, clinical features, pathogenesis, diagnosis, treatment, genetics and susceptibility, epidemiology, and prospects for control of schistosomiasis japonica in China. The threat posed by the Three Gorges Dam may undermine control efforts because it will change the local ecology and associated schistosomiasis transmission risks over the next decade and beyond.

A cluster-randomised intervention trial against Schistosoma japonicum in the Peoples' Republic of China: bovine and human transmission

BACKGROUND

Zoonotic schistosomiasis japonica is a major public health problem in China. Bovines, particularly water buffaloes, are thought to play a major role in the transmission of schistosomiasis to humans in China. Preliminary results (1998-2003) of a praziquantel (PZQ)-based pilot intervention study we undertook provided proof of principle that water buffaloes are major reservoir hosts for S. japonicum in the Poyang Lake region, Jiangxi Province.

METHODS AND FINDINGS

Here we present the results of a cluster-randomised intervention trial (2004-2007) undertaken in Hunan and Jiangxi Provinces, with increased power and more general applicability to the lake and marshlands regions of southern China. The trial involved four matched pairs of villages with one village within each pair randomly selected as a control (human PZQ treatment only), leaving the other as the intervention (human and bovine PZQ treatment). A sentinel cohort of people to be monitored for new infections for the duration of the study was selected from each village. Results showed that combined human and bovine chemotherapy with PZQ had a greater effect on human incidence than human PZQ treatment alone.

CONCLUSIONS

The results from this study, supported by previous experimental evidence, confirms that bovines are the major reservoir host of human schistosomiasis in the lake and marshland regions of southern China, and reinforce the rationale for the development and deployment of a transmission blocking anti-S. japonicum vaccine targeting bovines.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12609000263291.

A randomized, double-blind, placebo-controlled trial of safety and efficacy of combined praziquantel and artemether treatment for acute schistosomiasis japonica in China

OBJECTIVE

To evaluate the safety and efficacy of combining artemether (AM) and praziquantel (PZQ) in different regimens for treating acute schistosomiasis japonica.

METHODS

We undertook a randomized, double-blind, placebo-controlled trial within four specialized schistosomiasis hospitals in the Dongting Lake region, Hunan province, China, between May 2003 and December 2005. Study participants were randomized into one of four treatment regimes: group A received 60 mg/kg PZQ + 6 mg/kg AM; group B received 60 mg/kg PZQ + AM placebo; group C received 120 mg/kg PZQ + 6 mg/kg AM; and group D received 120 mg/kg PZQ + AM placebo. All participants were followed up over a 45-day period. The primary endpoint of the trial was human infection status (determined by positive stool examination). Secondary endpoints involved clinical observations and blood biochemistry, including monitoring haemoglobin and alanine aminotransferase levels over time.

FINDINGS

Treatment efficacies of the four different treatment regimens were 98.0%, 96.4%, 97.7% and 95.7% for group A, B, C, and D respectively (P > 0.05). The group B had a greater treatment efficacy (96.4%) than the group D (95.7%) (P > 0.05). Group A treatment was better for clearance of fever (P < 0.05) and resulted in a shorter hospitalization time (P < 0.05).

CONCLUSION

This is the first report of a randomized, double-blind, placebo-controlled trial for evaluating combined chemotherapy with AM and two different dosages (60 mg/kg and 120 mg/kg) of PZQ in the treatment of acute schistosomiasis japonica in China. The combination of AM and PZQ chemotherapy did not improve treatment efficacy compared with PZQ alone. PZQ given as a dosage of 60 mg/kg (1 day, 3 x 20 mg/kg doses at 4-5 hour intervals) may be as effective as a dosage of 120 mg/kg (6 days, 20 mg/kg for each day split into 3 doses at 4-5 hour intervals).

Transmission dynamics of Schistosoma japonicum in the lakes and marshlands of China

BACKGROUND

Schistosoma japonicum is a major public health concern in China, with over one million people infected and another 40 million living in areas at risk of infection. Unlike the disease caused by S. mansoni and S. haematobium, schistosomiasis japonica is a zoonosis, involving a number of different mammalian species as reservoir hosts. As a result of a number of published reports from China, it has long been considered that bovines, particularly water buffaloes, play a major role in human S. japonicum transmission there, and a drug-based intervention study (1998-2003) around the Poyang Lake in Jiangxi Province provided proof of concept that water buffaloes are, indeed, major reservoirs of human infection in this setting.

METHODS AND FINDINGS

In this study we incorporated recently obtained epidemiological information to model the steady-state S. japonicum transmission as well as the impact of the removal of S. japonicum transmission attributable to water buffaloes on human infection rates across six different endemic scenarios within three villages in the Dongting (Hunan) and Poyang (Jiangxi) lakes of southern China. Similar results were obtained for all scenarios. Steady-state S. japonicum infection rates remained constant and human prevalence and incidence were predicted to fall considerably over time. The model showed that the contribution of S. japonicum water buffalo transmission to human infection ranged from 39.1% to 99.1% and predicted that the removal of water buffalo transmission would reduce parasite reproductive rates below 1. This indicates that without the contribution of water buffaloes, S. japonicum transmission is interrupted and unsustainable. These scenarios are generalizable to other endemic villages in the lake and marshland areas of China where a similar cycle of snail infection and infection/reinfection of humans and bovines occurs.

CONCLUSIONS

Along with previous epidemiological data, our findings strongly support water buffaloes as an important component of the transmission cycle that affects humans in the lake and marshlands region of China, a feature which appears to differ from the situation prevalent in the Philippines where their contribution is less pronounced. Our conclusions underscore the rationale for removal, replacement or treatment of water buffaloes, and for the development and deployment of a transmission blocking buffalo vaccine against S. japonicum for this setting to achieve the goal of transmission control. The Chinese Government has recently commenced a new integrated national strategy to improve on existing approaches to control schistosomiasis in the lake and marshlands region by reducing bovines and humans as a source of S. japonicum infection to Oncomelania snails.

DNA-based vaccines protect against zoonotic schistosomiasis in water buffalo

Schistosomiasis japonica is an endemic, zoonotic disease of major public health importance in China where water buffaloes account for approximately 75% of disease transmission. Interventions that reduce schistosome infection in water buffaloes will enhance their health simultaneously reducing disease transmission to humans. While chemotherapy has proved successful, it requires continued time consuming and expensive mass treatments. A more sustainable option would be development of vaccines that reduce transmission of S. japonicum from bovines to replace bovine chemotherapy. We performed two randomized double blind trials in water buffaloes to determine if DNA vaccines encoding triose-phosphate isomerase (SjCTPI), or the tetraspanin 23 kDa integral membrane protein (SjC23), alone or fused to bovine heat shock protein 70 (Hsp70) could induce a level of immunity conducive to long-term sustainable control. Groups of water buffaloes (15/group) received three intramuscular injections, 4 weeks apart. Booster immunizations were co-administered with a plasmid DNA encoding IL-12. Four weeks after the last injection, water buffaloes were challenged with 1000 cercariae, and vaccine efficacy analyzed 8 weeks later. Water buffaloes vaccinated with SjCTPI-Hsp70 or SjCTPI plasmids had worm burdens reduced by 51.2% and 41.5%, respectively. Importantly, fecal miracidial hatching was reduced by 52.1% and 33.2% respectively compared to control vaccinated water buffaloes. Vaccination with SjC23-Hsp70 and SjC23 plasmids reduced worm burdens by 50.9% and 45.5%, respectively, and fecal miracidial hatching by 52.0% and 47.4%. A mathematical model of schistosome transmission predicts that schistosome vaccines capable of reducing water buffaloes' fecal egg output by 45%, alone or in conjunction with praziquantel treatment, will lead to a significant reduction in transmission of schistosomiasis. Both DNA vaccines tested here exceed this hypothetical level. Indeed, mathematical modeling of SjCTPI-Hsp70 and SjC23-Hsp70 alone and in conjunction with human chemotherapy showed a significant reduction in transmission almost to the point of elimination.

DNA-based vaccines protect against zoonotic schistosomiasis in water buffalo

Schistosomiasis japonica is an endemic, zoonotic disease of major public health importance in China where water buffaloes account for approximately 75% of disease transmission. Interventions that reduce schistosome infection in water buffaloes will enhance their health simultaneously reducing disease transmission to humans. While chemotherapy has proved successful, it requires continued time consuming and expensive mass treatments. A more sustainable option would be development of vaccines that reduce transmission of S. japonicum from bovines to replace bovine chemotherapy. We performed two randomized double blind trials in water buffaloes to determine if DNA vaccines encoding triose-phosphate isomerase (SjCTPI), or the tetraspanin 23 kDa integral membrane protein (SjC23), alone or fused to bovine heat shock protein 70 (Hsp70) could induce a level of immunity conducive to long-term sustainable control. Groups of water buffaloes (15/group) received three intramuscular injections, 4 weeks apart. Booster immunizations were co-administered with a plasmid DNA encoding IL-12. Four weeks after the last injection, water buffaloes were challenged with 1000 cercariae, and vaccine efficacy analyzed 8 weeks later. Water buffaloes vaccinated with SjCTPI-Hsp70 or SjCTPI plasmids had worm burdens reduced by 51.2% and 41.5%, respectively. Importantly, fecal miracidial hatching was reduced by 52.1% and 33.2% respectively compared to control vaccinated water buffaloes. Vaccination with SjC23-Hsp70 and SjC23 plasmids reduced worm burdens by 50.9% and 45.5%, respectively, and fecal miracidial hatching by 52.0% and 47.4%. A mathematical model of schistosome transmission predicts that schistosome vaccines capable of reducing water buffaloes' fecal egg output by 45%, alone or in conjunction with praziquantel treatment, will lead to a significant reduction in transmission of schistosomiasis. Both DNA vaccines tested here exceed this hypothetical level. Indeed, mathematical modeling of SjCTPI-Hsp70 and SjC23-Hsp70 alone and in conjunction with human chemotherapy showed a significant reduction in transmission almost to the point of elimination.

Agrobacterium-mediated transformation of embryogenic cultures and plant regeneration in Vitis rotundifolia Michx. (muscadine grape)

A method to produce transgenic plants of Vitis rotundifolia was developed. Embryogenic cultures were initiated from leaves of in vitro grown shoot cultures and used as target tissues for Agrobacterium-mediated genetic transformation. A green fluorescent protein/neomycin phosphotransferase II (gfp/nptII) fusion gene that allowed for simultaneous selection of transgenic cells based on GFP fluorescence and kanamycin resistance was used to optimize parameters influencing genetic transformation. It was determined that both proembryonal masses (PEM) and mid-cotyledonary stage somatic embryos (SE) were suitable target tissues for co-cultivation with Agrobacterium as evidenced by transient GFP expression. Kanamycin at 100 mg l(-1) in the culture medium was effective in suppression of non-transformed tissue and permitting the growth and development of transgenic cells, compared to 50 or 75 mg l(-1), which permitted the proliferation of more non-transformed cells. Transgenic plants of "Alachua" and "Carlos" were recovered after secondary somatic embryogenesis from primary SE explants co-cultivated with Agrobacterium. The presence and stable integration of transgenes in transgenic plants was confirmed by PCR and Southern blot hybridization. Transgenic plants exhibited uniform GFP expression in cells of all plant tissues and organs including leaves, stems, roots, inflorescences and the embryo and endosperm of developing berries.

Transgenic plants from shoot apical meristems of Vitis vinifera L. "Thompson Seedless" via Agrobacterium-mediated transformation

Shoot apical meristem explants of Vitis vinifera "Thompson Seedless" were used for Agrobacterium-mediated genetic transformation. It was determined that the meristems had to be subjected to a dark growth phase then wounded to obtain transgenic plants. Morphological and histological studies illustrated the role of wounding to expose apical meristem cells for transformation. A bifunctional egfp/nptII fusion gene was used to select kanamycin resistant plants that expressed green fluorescent protein (GFP). Kanamycin at a concentration of 16 mg L(-1) in selection medium resulted in recovery of non-chimeric transgenic plants that uniformly expressed GFP, whereas 8 mg L(-1) kanamycin allowed non-transgenic and/or chimeric plants to develop. Polymerase chain reaction (PCR) and Southern blot analyses confirmed the presence of transgenes and their stable integration into the genome of regenerated plants. Up to 1% of shoot tips produced stable transgenic cultures within 6 weeks of treatment, resulting in a total of 18 independent lines.

A cluster-randomized bovine intervention trial against Schistosoma japonicum in the People's Republic of China: design and baseline results

We describe the design and report baseline results of a cluster-randomized intervention to determine the importance of bovines for Schistosoma japonicum transmission in southern China. The study involves four matched village pairs in Hunan and Jiangxi Provinces, with a village within each pair randomly selected as intervention (human and bovine praziquantel treatment) or control (human praziquantel treatment only). Total study population prevalences at baseline were 12.4% (n = 5,390) and 15.2% (n = 1,573) for humans and bovines, respectively; village prevalences were similar within pairs. Bovine contamination index calculations showed that bovines less than 24 months of age were responsible for 74% of daily bovine environmental contamination with S. japonicum eggs. The village characteristics and baseline results underpin a rigorous study, which has major implications for deployment of a transmission-blocking bovine vaccine against S. japonicum. The combination of such a vaccine with other control strategies could potentially eliminate S. japonicum from southern China.

Isolation by improved thermal asymmetric interlaced PCR and characterization of a seed-specific 2S albumin gene and its promoter from grape (Vitis vinifera L.)

A seed-specific 2S albumin gene and its promoter region of grape (Vitis vinifera L.) were isolated using an improved thermal asymmetric interlaced PCR that allowed efficient amplification of target sequence of up to 3 kbp in length directly from genomic DNA. The 2S albumin VvAlb1 (for V. vinifera 2S albumin 1) gene from different grape cultivars encompasses a coding region of 504-540 nucleotides corresponding to a deduced amino acid sequence of 167-179 residues. This deduced protein contains up to 30% glutamine residues and eight cysteine residues arranged in a pattern highly conserved among 2S albumins for disulfide bond formation. DNA sequence alignment revealed that the same VvAlb1 gene among different grape cultivars varied greatly, including an insertion of up to 36 bp near the 3' end of the gene sequence isolated from 'Thompson Seedless'. DNA sequence analysis indicated that several conserved seed-specific regulatory motifs were clustered within a 0.6-kbp region 5' upstream of the transcription start site. To further test promoter activity, the sequence of this region was used to drive a bifunctional EGFP/NPTII fusion gene in Agrobacterium-mediated transformation of grape somatic embryos and leaf discs of grape and tobacco (Nicotiana tabacum L.). A high level of GFP expression, comparable with that derived from an enhanced double CsVMV promoter, was observed in the cotyledonary but not hypocotyl and vegetative tissues of grape and tobacco. These results suggest that the VvAlb1 gene promoter isolated is capable of conferring seed-specific gene expression.

Bi-directional duplex promoters with duplicated enhancers significantly increase transgene expression in grape and tobacco

Novel bi-directional duplex promoters (BDDP) were constructed by placing two identical core promoters divergently on both upstream and downstream sides of their duplicated enhancer elements. Estimates of promoter function were obtained by creating versions of CaMV 35S and CsVMV BDDPs that contained reporter marker genes encoding beta-glucuronidase (GUS) and enhanced green fluorescent protein (EGFP) interchangeably linked either to the upstream or downstream core promoters. GUS was used for quantitative analysis of promoter function, whereas, EGFP allowed visual qualitative evaluation. In addition, the GUS and EGFP genes placed in downstream positions were modified by translational fusion with neomycin phosphotransferase (NPTII) to allow simultaneous monitoring of promoter activity and selection of stable transformants. These versions of BDDP were compared with each other and with equivalent unidirectional constructs by evaluating their expression in grape and tobacco. For 35S promoter constructs tested in grape somatic embryos (SE), BDDP exhibited transient GUS expression 206- and 300-fold greater in downstream and upstream configurations, respectively, compared to a unidirectional 35S core promoter. Compared with a unidirectional double enhanced 35S promoter, BDDPs exhibited 0.5- and 3-fold increased GUS expression from downstream and upstream core promoters, respectively. The same differences in expression levels determined quantitatively with GUS were distinguished qualitatively with EGFP. Constructs using CsVMV core promoters yielded results relative to those obtained with 35S promoter. For example, the upstream BDDP CsVMV core promoter provided a 200-fold increase in GUS expression compared to a unidirectional core promoter. However, CsVMV promoter was found to have higher promoter activity than 35S promoter in both BDDP and unidirectional constructs. Incorporation of an additional duplicated enhancer element to BDDPs resulted in increased expression. For example, a 35S BDDP with two divergently arranged duplicated enhancer elements resulted in over a 6-fold increase in GUS expression in stably transformed tobacco plants compared to a BDDP with one duplicated enhancer element. Data demonstrate that BDDP composed of divergently-arranged core promoters separated by duplicated enhancers, all derived from a single promoter sequence, can be used to significantly enhance transgene expression and to direct synchronized expression of multiple transgenes.

Comparative anatomy and morphology of Vitis vinifera (Vitaceae) somatic embryos from solid- and liquid-culture-derived proembryogenic masses

Ontogeny of somatic embryos of grapevine (Vitis vinifera) produced from solid- and liquid-culture-derived proembryogenic masses (PEM) was compared using light and scanning electron microscopy. Somatic embryos produced from solid-medium-derived PEM (SPEM) had large cotyledons, little or no visible suspensor structure, and a relatively undeveloped concave shoot apical meristem, whereas those from liquid-medium-derived PEM (LPEM) had smaller cotyledons, a distinct suspensor, and a flat-to-convex shoot apical meristem. The convex shoot apical meristem in LPEM-derived somatic embryos formed as early as the heart stage of development; it was 4-6 cell layers deep and rich in protein. Suspensors persisted in fully developed and mature LPEM-derived somatic embryos. The SPEM-derived somatic embryos exhibited dormancy, as do mature zygotic embryos, which also have a rudimentary suspensor, whereas LPEM-derived embryos were not dormant. We hypothesize that the presence of a persistent suspensor in LPEM-derived somatic embryos modulates development, ultimately resulting in rapid germination and a high plant-regeneration rate.

In-vitro selection of Vitis vinifera 'Chardonnay' with Elsinoe ampelina culture filtrate is accompanied by fungal resistance and enhanced secretion of chitinase

Proembryogenic masses of grapevine (Vitis vinifera L.) 'Chardonnay' (clone 02Ch) were exposed to the culture filtrate of Elsinoe ampelina (deBary) Shear, the causal agent of anthracnose disease. After four or five cycles of recurrent in-vitro selection with medium containing 40% fungal culture filtrate, putative resistant lines RC1 and RC2 respectively, were established. The selected lines inhibited the growth of E. ampelina and Fusarium oxysporium (Schlecht.) (isolated from watermelon) in a dual-culture assay and reduced the growth of mycelium on a conditioned-medium test, thus suggesting the involvement of extracellular compounds in resistance. Sodium dodecyl sulfate-polyacrylamide (SDS-PAGE) gel electrophoresis of extracellular proteins from spent suspension-culture medium showed enhanced secretion of new proteins by selected lines. A 36-kDa protein was immunodetected by a chitinase antiserum. This chitinase continued to express constitutively in differentiated somatic embryos and also in the intercellular fluids of plants regenerated from the selected lines. Somatic embryos from selected lines grew uninhibitedly in a medium containing 40% fungal culture filtrate, whereas non-selected (control) somatic embryos became necrotic and died within a few days. Plants regenerated from selected lines exhibited resistance to infection by E. ampelina in both greenhouse tests and detached leaf bioassays. Results suggest that embryogenic cells can be selected for resistance following in-vitro selection, resulting in resistant plants. Whether or not resistant cells pre-existed in the original embryogenic culture or were induced by the selection pressure could not be determined.

Endovascular treatment of a pseudoaneurysm of a recipient external carotid artery following radiation and free tissue transfer

Radical resection and reconstruction after preoperative radiation has become routine treatment for patients with certain types and stages of head and neck cancers. When microvascular flap reconstruction is required, the recipient vessels have been subjected to radiation, making them more thrombogenic and friable, thus increasing the risks of postoperative complications. The authors report a patient who received preoperative radiation therapy for rhabdomyosarcoma of the infratemporal fossa and who underwent a radical resection and free rectus musculocutaneous flap reconstruction. The free flap covered the base of the brain from the nasopharynx and closed an intraoral defect. The donor artery was anastomosed end to side to the external carotid artery stump. The patient developed a pseudoaneurysm of the external carotid artery stump 1 month postoperatively, which was treated with endovascular coil embolization without loss of the flap. Percutaneous transcatheter endovascular treatment of pseudoaneurysms that develop after free tissue transfer in head and neck reconstruction has not been reported previously. One month after surgery, endovascular occlusion of the main arterial supply to the flap did not compromise its viability because of collateral revascularization from the peripheral tissue bed, despite the patient's history of radiation.

The physician healer: ancient magic or modern science?

The therapeutic role of general practitioners (GPs) is one that, over the years, has slowly diminished with the growing fashion for evidence-based medicine. However, it is clear that the art of healing and the strength of the doctor-patient relationship play a vital role in improving the well-being of patients. This is exemplified by the placebo effect, where the attitude of the doctor can make an appreciable difference to the psychological response of the patient who feels the need to be understood and listened to empathically. By maximizing the role of the physician healer, there is considerable scope for bridging the gap left by the impersonality of medical science, while at the same time increasing the GP's effectiveness.

Teenagers and risk-taking: pregnancy and smoking

Teenage pregnancy and teenage smoking are both areas of concern in the United Kingdom. This study found that girls who had had a teenage pregnancy were more likely to smoke than those who had not conceived as teenagers.