Electron beam damage studies of synthetic 6-line ferrihydrite and ferritin molecule cores within a human liver biopsy

In order to achieve an accurate understanding of the crystal structure of 6-line ferrihydrite (6LFh) and ferritin molecule cores within a human liver biopsy using transmission electron microscopy (TEM), electron beam damage should be considered. For the case of 6LFh, the electron energy loss near-edge structure (ELNES) of core ionisation edges in the electron energy loss spectrum (EELS) combined with multiple linear least-square (MLLS) fitting of reference spectra together with analysis of selected area electron diffraction (SAED) patterns suggests that the iron in 6LFh is solely octahedrally coordinated Fe3+. With increasing electron dose, an increasing percentage of this octahedrally coordinated Fe3+ migrates to tetrahedral sites. When the dose exceeds 3 x 10(8) electrons/nm2, Fe2+ is found to be present in the material. This method also indicates that the iron in ferritin molecule cores within a human liver biopsy is the same as in 6LFh, entirely Fe3+ in octahedral coordination with oxygen. Again the percentage of octahedrally coordinated Fe3+ decreases as the accumulated electron dose increases and Fe2+ is produced in the liver biopsies when the electron dose exceeds 10(6)electrons/nm2.

Production of [15O]water at low-energy proton cyclotrons

We report a simple system for producing [15O]H2O from 15N in a nitrogen/hydrogen gas target with recycling of the target nitrogen, allowing production on low-energy proton-only accelerators with minimal consumption of isotopically enriched 15N. The radiolabeled water is separated from the target gas and radiolytically produced ammonia by temporary freezing in a small trap at -40 degrees C.

Novel use of accelerator mass spectrometry for the quantification of low levels of systemic therapeutic recombinant protein

Although 14C-labelling has been routinely used for small molecules, this technique is not routinely applied to therapeutic proteins due to difficulties of incorporating the label into the protein to a sufficiently high specific activity. An analytical method known as accelerator mass spectrometry (AMS) offers an extremely sensitive method of 14C quantification, thereby enabling (14)C-labeling methods to be applied to therapeutic protein detection. The therapeutic protein CAT-192 (metelimumab), a human anti-TGFss1 monocloncal antibody was manufactured in the presence of 14C-precursors resulting in a low specific activity product (1.4% 14C incorporation). [14C]-CAT-192 was administered to rats (1mg/kg and 222, 22 and 2.2 dpm/kg) and serum samples were collected. 14C in serum samples from the 2.2 dpm dosing was not detectable but samples from the 22 and 2220 dpm doses were measured by AMS and by ELISA for comparison. By both ELISA and AMS bioassay, the half-lives approximated 140 h (S.E.M. 15 h). The estimates of clearance were also comparable, 7.3 and 4.6 x 10(-4)ml/h/g (S.E.M. 6.6 and 5.1 x 10(-5)) for ELISA and AMS, respectively. The estimated limit of quantification (LOQ) was approximately 1 ng/ml, about 15 times lower than the ELISA LOQ of 15.6 ng/ml.

A series of systematic reviews to inform a decision analysis for sampling and treating infected diabetic foot ulcers

OBJECTIVES

To review systematically the evidence on the performance of diagnostic tests used to identify infection in diabetic foot ulcers (DFUs) and of interventions to treat infected DFUs. To use estimates derived from the systematic reviews to create a decision analytic model in order to identify the most effective method of diagnosing and treating infection and to identify areas of research that would lead to large reductions in clinical uncertainty.

DATA SOURCES

Electronic databases covering period from inception of the database to November 2002.

REVIEW METHODS

Selected studies were assessed against validated criteria and described in a narrative review. The structure of a decision analytic model was derived for two groups of patients in whom diagnostic tests were likely to be used.

RESULTS

Three studies that investigated the performance of diagnostic tests for infection on populations including people with DFUs found that there was no evidence that single items on a clinical examination checklist were reliable in identifying infection in DFUs, that wound swabs perform poorly against wound biopsies, and that semi-quantitative analysis of wound swabs may be a useful alternative to quantitative analysis. However, few people with DFUs were included, so it was not possible to tell whether diagnostic performance differs for DFUs relative to wounds of other aetiologies. Twenty-three studies investigated the effectiveness (n = 23) or cost-effectiveness (n = 2) of antimicrobial agents for DFUs. Eight studied intravenous antibiotics, five oral antibiotics, four different topical agents such as dressings, four subcutaneous granulocyte colony stimulating factor (G-CSF), one evaluated oral and topical Ayurvedic preparations and one compared topical sugar versus antibiotics versus standard care. The majority of trials were underpowered and were too dissimilar to be pooled. There was no strong evidence for recommending any particular antimicrobial agent for the prevention of amputation, resolution of infection or ulcer healing. Topical pexiganan cream may be as effective as oral antibiotic treatment with ofloxacin for the resolution of local infection. Ampicillin and sulbactam were less costly than imipenem and cilastatin, a growth factor (G-CSF) was less costly than standard care and cadexomer iodine dressings may be less costly than daily dressings. A decision analytic model was derived for two groups of people, those for whom diagnostic testing would inform treatment--people with ulcers which do not appear infected but whose ulcer is not progressing despite optimal concurrent treatment--and those in whom a first course of antibiotics (prescribed empirically) have failed. There was insufficient information from the systematic reviews or interviews with experts to populate the model with transition probabilities for the sensitivity and specificity of diagnosis of infection in DFUs. Similarly, there was insufficient information on the probabilities of healing, amputation or death in the intervention studies for the two populations of interest. Therefore, we were unable to run the model to inform the most effective diagnostic and treatment strategy.

CONCLUSIONS

The available evidence is too weak to be able to draw reliable implications for practice. This means that, in terms of diagnosis, infection in DFUs cannot be reliably identified using clinical assessment. This has implications for determining which patients need formal diagnostic testing for infection, on whether empirical treatment with antibiotics (before the results of diagnostic tests are available) leads to better outcomes, and on identifying the optimal methods of diagnostic testing. With respect to treatment, it is not known whether treatment with systemic or local antibiotics leads to better outcomes or whether any particular agent is more effective. Limited evidence suggests that both G-CSF and cadexomer iodine dressings may be less expensive than 'standard' care, that ampicillin/sulbactam may be less costly than imipenem/cilastatin, and that an unlicensed cream (pexiganan) may be as effective as oral ofloxacin. Further research is needed to ascertain the characteristics of infection in people with DFUs that influence healing and amputation outcomes, to determine whether detecting infection prior to treatment offers any benefit over empirical therapy, and to establish the most effective and cost-effective methods for detecting infection, as well as the relative effectiveness and cost-effectiveness of antimicrobial interventions for DFU infection.

Delayed detection of cleft palate: an audit of newborn examination

AIMS

To identify prevalence of delayed detection of cleft palate, and associated factors that could lead to improved identification at neonatal clinical examination.

METHODS

Audit of hospital notes, parental questionnaire incorporating open ended questions, and telephone questionnaire of junior doctors in the referring hospitals incorporating fixed choice questions.

RESULTS

Of 344 cleft palate patients without cleft lip or submucous cleft palate, the day the cleft was detected was recorded in 92%. Delayed detection, after the first day, was 28% overall, distributed as 37% with isolated cleft palate and 23% with syndromic cleft palate. Narrow V shaped clefts were more likely to be delayed in detection compared with broad U shaped clefts, as were soft palate clefts compared with hard palate clefts. Five with isolated cleft palates were not detected until after the first year. Babies born at home were unlikely to be detected on day 1. Symptoms were significantly increased in the delayed detection group for feeding problems and nasal regurgitation. A telephone questionnaire of trainee paediatricians in referring units revealed that digital examination was more commonly practised than visual inspection, and few recalled receiving specific instruction on examination of the palate.

CONCLUSION

Delayed detection of cleft palate was not uncommon, and the features of those more likely to be missed suggested digital examination was related. Trainee doctors and midwives should be instructed to inspect visually using a light and tongue depressor, then digitally if submucous cleft palate is suspected.

A field trial evaluation of the effectiveness and benefit of cydectin long-acting injectable and ivomec injectable as used one time in grazing stocker cattle

Use of moxidectin long-acting injectable and ivermectin injectable in female Bos taurus beef-type calves was evaluated in terms of efficacy (fecal egg counts) and performance parameters (weight gain). In this 150-day study, moxidectin-treated calves gained 20% more weight than did ivermectin-treated and control calves. Mean fecal egg count reductions ranged from 76.7 to 99.0 for moxidectin and -0.8 to 83.4 for ivermectin. Moxidectin long-acting injection provided efficacious (immediate as well as long-term) egg count suppressions as well as enhanced animal productivity (weight gains). The study also showed that Cooperia spp appear poised to present the most immediate challenges once long-acting macrocyclic lactone treatments become available.

Differential protease, innate immunity, and NF-kappaB induction profiles during lung inflammation induced by subchronic cigarette smoke exposure in mice

Cigarette smoke exposure is a major determinant of adverse lung health, but the molecular processes underlying its effects on inflammation and immunity remain poorly understood. Therefore, we sought to understand whether inflammatory and host defense determinants are affected during subchronic cigarette smoke exposure. Dose-response and time course studies of lungs from Balb/c mice exposed to smoke generated from 3, 6, and 9 cigarettes/day for 4 days showed macrophage- and S100A8-positive neutrophil-rich inflammation in lung tissue and bronchoalveolar lavage (BAL) fluid, matrix metalloproteinase (MMP) and serine protease induction, sustained NF-kappaB translocation and binding, and mucus cell induction but very small numbers of CD3+CD4+ and CD3+CD8+ lymphocytes. Cigarette smoke had no effect on phospho-Akt but caused a small upregulation of phospho-Erk1/2. Activator protein-1 and phospho-p38 MAPK could not be detected. Quantitative real-time PCR showed upregulation of chemokines (macrophage inflammatory protein-2, monocyte chemoattractant protein-1), inflammatory mediators (TNF-alpha, IL-1beta), leukocyte growth and survival factors [granulocyte-macrophage colony-stimulating factor, colony-stimulating factor (CSF)-1, CSF-1 receptor], transforming growth factor-beta, matrix-degrading MMP-9 and MMP-12, and Toll-like receptor (TLR)2, broadly mirroring NF-kappaB activation. No upregulation was observed for MMP-2, urokinase-type plasminogen activator, tissue-type plasminogen activator, and TLRs 3, 4, and 9. In mouse strain comparisons the rank order of susceptibility was Balb/c > C3H/HeJ > 129SvJ > C57BL6. Partition of responses into BAL macrophages vs. lavaged lung strongly implicated macrophages in the inflammatory responses. Strikingly, except for IL-10 and MMP-12, macrophage and lung gene profiles in Balb/c and C57BL/6 mice were very similar. The response pattern we observed suggests that subchronic cigarette smoke exposure may be useful to understand pathogenic mechanisms triggered by cigarette smoke in the lungs including inflammation and alteration of host defense.

Influence of host diversity on development of epidemics: an evaluation and elaboration of mixture theory

ABSTRACT A spatiotemporal/integro-difference equation model was developed and utilized to study the progress of epidemics in spatially heterogeneous mixtures of susceptible and resistant host plants. The effects of different scales and patterns of host genotypes on the development of focal and general epidemics were investigated using potato late blight as a case study. Two different radial Laplace kernels and a two-dimensional Gaussian kernel were used for modeling the dispersal of spores. An analytical expression for the apparent infection rate, r, in general epidemics was tested by comparison with dynamic simulations. A genotype connectivity parameter, q, was introduced into the formula for r. This parameter quantifies the probability of pathogen inoculum produced on a certain host genotype unit reaching the same or another unit of the same genotype. The analytical expression for the apparent infection rate provided accurate predictions of realized r in the simulations of general epidemics. The relationship between r and the radial velocity of focus expansion, c, in focal epidemics, was linear in accordance with theory for homogeneous genotype mixtures. The findings suggest that genotype mixtures that are effective in reducing general epidemics of Phytophthora infestans will likewise curtail focal epidemics and vice versa.

A regional audit of iatrogenic perforation of tumours of the oesophagus and cardia

INTRODUCTION

With the rising incidence of oesophageal cancer, palliative treatment has an increasingly important role. With median survival unlikely to exceed 6 months, in advanced disease the palliative therapy chosen must not hasten patient's demise.

AIM

To establish the outcome of both modern and historical palliative treatment in oesophageal tumours, with emphasis on the aetiology and outcome of iatrogenic perforation.

METHODS

Patients with oesophageal or cardia carcinoma treated within the West Midlands between 1992 and 1996 were identified retrospectively. Information was gathered from hospital case notes and the regional cancer intelligence unit with hospitals visited to capture data. All episodes were entered into a dedicated database.

RESULTS

Of the 3660 patients who were treated, 2529 received palliation as primary treatment, with 5259 palliative procedures performed; 164 iatrogenic perforations were recorded; 83 were due to diagnostic endoscopy (endoscopic perforation) with the reminder due to interventional palliative procedures. Median survival from all forms of palliation was 138 days. Following perforation survival was 95 days after interventional palliative procedure and 58 days after endoscopic perforation (P > 0.05). Thirty-day mortality after emergency surgery was 11.8% with mean survival of 7.5 months.

CONCLUSION

Perforation at diagnostic endoscopy is associated with substantial mortality despite rapid intervention. Patients with suspected cancer must be investigated with extreme care to reduce iatrogenic complications.

Chlamydia trachomatis prevalence in men in the mid-west of Ireland

OBJECTIVES

To estimate the prevalence of chlamydia infection in young men in the Mid-Western Health Board Region of Ireland, and to determine risk factors for its acquisition.

METHODS

Consecutive men attending orthopaedic clinics (OPD), and a university sports arena (UL) were recruited to a chlamydia prevalence study. All men aged 17-35 who had been sexually active and had not passed urine in the last hour were eligible. Information about chlamydia was given, informed consent obtained, and a self administered questionnaire was completed. A first void urine (FVU) was collected and tested by ligase chain reaction (LCR).

RESULTS

82% (207/252) of men from OPD, and 60% (186/310) from UL participated. 6.3% (13/207) from the OPD and 5.4% (10/186) from UL tested LCR positive, giving an overall prevalence of 5.9% (23/393). Proved risk factors for chlamydial positivity were: (1) more than one sexual partner in previous 6 months, (2) more than eight lifetime sexual partners, (3) current symptoms (dysuria or discharge). No statistical significance was found for age, condom use, smoking, days since last sexual intercourse and previous GUM clinic attendance. No statistically significant difference to cost effective prevalence of 6% was shown.

CONCLUSIONS

A 5.9% prevalence of Chlamydia trachomatis was found which is cost effective to screen and treat. Non-invasive screening of men in the community was possible. Numbers of sexual partners and current symptoms were significant risk factors. Since only 25% of men in this laboratory were diagnosed with chlamydia outside the GUM clinic, compared with 59% of women, it is important that community screening of men is promoted.

Psychosocial outcomes at 18 months after good neurological recovery from aneurysmal subarachnoid haemorrhage

OBJECTIVES

To evaluate functioning, 18 months after surgery, of 49 patients with good neurological recovery following aneurysmal subarachnoid haemorrhage (SAH), and to determine the extent of any improvements in disturbances of mood, cognitive functioning, and levels of activity and participation previously observed at 9 month follow up.

METHODS

SAH patients, matched for age, gender, and occupation with healthy control participants, completely quantitative measures of mood (HADS, FIES, BDI) and activity/participation (BICRO-39 scales), and a brief cognitive assessment battery (verbal fluency, digit span, prose recall). Controls completed the HADS and the BICRO-39.

RESULTS

Patients showed some recovery of cognitive functioning, though impairments of prose recall persisted. Anxiety and depression symptoms were higher in patients than in controls, but fewer than 20% scored in the clinical range on any questionnaires except for RIES-Intrusive thoughts (22%); only three showed signs of full blown post-traumatic stress disorder. Almost half showed elevated dependence on others for domestic activities and organisation and abnormally low levels of employment. Very little variance in outcome was predicted by demographic variables, neurological or cognitive impairment, prior life stress, or mood. However, levels of social activity and self-organisation were related to persisting fatigue.

CONCLUSIONS

The observed decline in intrusive thoughts and avoidance over time is consistent with that seen after life threatening illness or trauma. The persistent reductions in independence and levels of employment may in some cases reflect considered lifestyle adjustments rather than adverse and unwanted changes but in others indicate a need for focused rehabilitation.

Rotational malalignment of the tibia following reamed intramedullary nail fixation

OBJECTIVE

To determine the incidence and severity of tibial malrotation following reamed intramedullary nail fixation as measured by computerized tomography and to determine the repeatability of computed tomography measurement in the assessment of rotational malreduction.

DESIGN

Prospective cohort.

SETTINGS

Level 1 trauma center.

PARTICIPANTS

Twenty-five consecutive patients with 25 tibial shaft fractures.

INTERVENTION

All patients were treated with reamed intramedullary nailing. Appropriate radiographs and a postoperative lower extremity computed tomography scan were obtained for each patient who consented to the study.

MAIN OUTCOME MEASURE

Rotational alignment of affected tibia as compared to a version of the normal contralateral limb. Malrotation was defined as an internal/external rotation deformity greater than 10degrees.

RESULTS

Malrotation, comparing the fractured limb to normal limb, was determined using a similar measurement method previously described in the literature. Two patients declined inclusion, and in one case, the computed tomography was not acceptable for analysis. Malrotation, comparing the fractured limb to the normal limb, was determined using the measurements from axial computed tomography images. Results revealed a mean absolute rotational difference of 6.7degrees (SD +/-6.3degrees). Rotational malreduction ranged from 15degrees of internal rotation to 22degrees of external rotation. Five of the 22 tibia (22%) were malrotated greater than 10degrees. A larger degree of deformity was seen with certain injury patterns. The intraobserver and interobserver repeatability testing revealed a mean absolute difference between paired malrotation calculations of 3.4degrees and 3.9degrees, respectively, and a repeatability coefficient of 8degrees for both.

CONCLUSION

Computed tomography measurement is a repeatable method of assessing tibial torsion and in this study revealed a significantly higher incidence of rotational malreduction than that previously reported in the literature.

Using the Health Assessment Questionnaire and welfare benefits advice to help people disabled through arthritis to access financial support

OBJECTIVES

To test, in a variety of health settings, the ability of the Health Assessment Questionnaire (HAQ) disability index to predict the eligibility of patients with moderate or severe arthritis for disability living allowance or attendance allowance.

METHODS

The study included patients from 20 general practices and four hospital out-patient departments across four areas in the southwest of England. Adults with an established diagnosis of rheumatoid arthritis, or osteoarthritis of the hip or knee, and who were not in receipt of Disability Living Allowance (DLA) or Attendance Allowance (AA) were sent an HAQ. Those who scored 1.5 or more were offered an appointment with a welfare advice worker at which they completed an application for DLA or AA. After 3 months they were contacted by the advice worker and asked about the outcome of their applications.

RESULTS

Over half of those who completed an HAQ scored 1.5 or over (moderate to severe disability as measured by the HAQ) and were offered advice from experienced welfare benefits advisors. Of these, 87% applied for DLA or AA. Sixty-nine per cent of the applicants were successful. Those scoring 1.75 and over were more likely to be awarded benefit (73% success CLs 67, 79) than people scoring between 1.5 and 1.625 where 55% (CLs 41,69) of applicants were successful.

CONCLUSION

The HAQ was shown to be a good predictor of eligibility for AA or DLA. It can be used, in a variety of health settings, to indicate patients who, with help from an experienced advisor, are likely to gain increased financial help.

Blood Pressure and Outcome after Severe Pediatric Traumatic Brain Injury

BACKGROUND

The relationship between systolic blood pressure and outcome in children after severe traumatic brain injury (TBI) is unclear. We examined the relationship between age-appropriate systolic blood pressure (AASBP) percentile and outcome after severe pediatric TBI.

METHODS

We examined the association between AASBP percentiles and outcome in 172 children younger than 14 years of age with a Glasgow Coma Scale score < 9. Outcome was evaluated using discharge Glasgow Outcome Scale score. Poor outcome was defined as a Glasgow Outcome Scale score < 4.

RESULTS

Poor outcome was associated with AASBP < 75th percentile (odds ratio, 4.2; 95% confidence interval, 2.1-8.3). Patients with systolic blood pressure (SBP) > or = 90 mm Hg and AASBP < 75th percentile had a higher odds for poor outcome compared with patients with SBP > or = 90 mm Hg and AASBP > or = 75th percentile (odds ratio, 3.5; 95% confidence interval, 1.7-7.3). CONCLUSION AASBP < 75th percentile was associated with poor outcome after severe pediatric TBI, even when SBP was > or = 90 mm Hg.

The effect of a nutritional source of tryptophan on dieting-induced changes in brain 5-HT function

BACKGROUND

Dieting in healthy women results in a decrease in the availability of tryptophan (TRP), the amino-acid precursor of serotonin (5-HT), for brain 5-HT synthesis. This is associated with increases in the prolactin response to 5-HT drug challenge suggesting a 'supersensitivity' of 5-HT neuroendocrine responses. The aim of the study was to assess whether increased TRP intake during dieting would prevent the changes in TRP availability and 5-HT neuroendocrine function.

METHOD

Fifty female subjects underwent a 1000 kcal daily diet for 3 weeks. In the final week of the diet subjects were randomly allocated to receive either nutritionally-sourced TRP (1.8 g daily) or placebo in a double-blind, parallel group, design.

RESULTS

TRP supplementation failed to modify the dieting-induced reduction in fasting TRP availability to the brain. However, in contrast to placebo-treated subjects, subjects receiving additional TRP did not show enhanced prolactin responses to intravenous TRP challenge.

CONCLUSIONS

The decrease in TRP availability produced by dieting may be due to increased TRP metabolism rather than decreased TRP intake. While TRP treatment did not increase fasting TRP availability it may have modified the effect of dieting on brain 5-HT function. Further studies will be needed to see if this effect of TRP has consequences for the effectiveness of dieting as means of weight control.

Acute administration of nutritionally sourced tryptophan increases fear recognition

RATIONALE

The serotonin precursor tryptophan (TRP) has been widely used as a nutritional supplement and antidepressant. Recently, however, the use of TRP has been severely restricted due to its association with the eosinophilic myalgic syndrome, an autoimmune disorder probably caused by ingestion of a contaminant produced in certain TRP manufacturing processes.

OBJECTIVES

To determine the bioavailability of a nutritional source of TRP obtained from milk protein and to assess whether administration of this material produced neuroendocrine and neuropsychological effects consistent with increased brain serotonin activity.

METHODS

We studied 24 healthy subjects who ingested approximately 1.8 g of nutritionally-sourced TRP or placebo in a double-blind, parallel group, design. We carried out venous sampling for amino acid and hormone estimation and performed a test of emotional processing using a facial expression recognition task.

RESULTS

The nutritionally-sourced TRP caused a substantial increase in the availability of TRP in plasma. Relative to placebo the TRP material produced some evidence of an increase in plasma cortisol, and enhanced the perception of fearful and happy facial expressions.

CONCLUSIONS

A nutritional source of TRP increased the availability of TRP for brain serotonin synthesis and produced endocrine and neuropsychological changes consistent with increased brain serotonin function. The effect of TRP on emotional processing may be relevant to its reported activity in primate studies of social behaviour.

Effect of sub-lethal concentrations of aluminium on the filtration activity of the freshwater mussel Anodonta cygnea L. at neutral pH

Significant amounts of aluminium (Al) are commonly present in rivers and lakes, largely in particulate form in neutral waters. Freshwater bivalves, as filter feeders are therefore exposed to both particulate and dissolved metal and are potentially vulnerable to Al. The effect of Al on filtering behaviour of the freshwater mussel Anodonta cygnea L. was investigated during short (1 hour) and long-term (15 days) exposure to environmentally relevant concentrations (250 and 500 microg l(-1)) at neutral pH. Water flow through the outflow siphon was monitored as an indicator of pumping capacity. Short-term (1 hour) exposure to 500 microg l(-1) added Al produced an irreversible decrease in the duration of filtering periods, presumably as an avoidance response to the toxicant. One-hour exposure 250 microg l(-1) Al had no detectable effect. When mussels were exposed to 250 or 500 microg l(-1) added Al for 15 days, siphon activity measured in days 11-15 of exposure was inhibited by 50% and 65%, respectively, compared to pre-exposure levels. Recovery occurred following transfer of mussels to uncontaminated water. Interaction between Al and freshwater bivalves at neutral pH may affect both the performance of the mussels and the chemical speciation of the metal in the natural environment.

Treatment of oro-facial hypersensitivity following brain injury

A 56 year old man who was 10 months post-severe traumatic brain injury was unable to tolerate oral hygiene. He had oro-facial hypersensitivity, oral dyspraxia and limited oral function. Poor oral hygiene with coating of oral structures and infection was present. An intensive systematic desensitization programme over 2 weeks, even at this late stage post-injury, increased oral tolerance and allowed full oral hygiene. Participation in oral hygiene and functional patterns of movement also improved, enabling some oral nutritional intake. This case study provides controlled evidence, very little of which exists in the literature, to demonstrate the effectiveness of these treatment techniques

Contractures in the post-stroke wrist: a pilot study of its time course of development and its association with upper limb recovery

BACKGROUND

Contractures are common in a stroke population, yet there is little information on the time course of development.

OBJECTIVES

Investigate quantitatively changes associated with contracture formation in an acute stroke population.

STUDY DESIGN

Longitudinal study on 22 subjects who were 2-4 weeks post stroke.

OUTCOME MEASURES

Contractures were assessed by quantifying the resting posture, resistance to passive movement and passive range of movement. Upper limb function was measured using the Action Research Arm Test and the Nine-Hole Peg Test. Active range of extension, wrist extension strength (isometric), grip strength and neglect were also measured. REPEATED MEASURES: Following an initial assessment, repeated measurements were taken at 4, 8, 20 and 32 weeks after recruitment.

RESULTS

Two distinct subgroups, one capable of some functional movement (F group; 8 subjects) and another which was not (NF group; 14 subjects), were identified at the start of the study. The NF group showed changes associated with contracture formation at the wrist, i.e., reduction in the passive range of movement, an increase in resistance to passive movement and a worsening of the flexion posture. Changes were observed from the time of recruitment even though neglect improved. The F group showed improvements in upper limb function and there was no evidence to support contracture formation.

CONCLUSIONS

Subjects most prone to contracture formation were those who showed no signs of early functional recovery (2-4 weeks after the stroke). Changes consistent with adaptive shortening were seen from week 4 of the study period.

The NCI/CIT microArray database (mAdb) system - bioinformatics for the management and analysis of Affymetrix and spotted gene expression microarrays

A scalable, modular, enterprise-level system for both microarray databasing and analysis over the Internet has been developed over the past four years by the National Cancer Institute's Center for Cancer Research in collaboration with NIH's Center for Information Technology. This completely Web-based system, called mAdb (for microArray database), is currently supporting over 810 registered users and collaborators at NIH and contains over 22,000 microarray experiments, making it one of the largest collections of microarray data in existence. In addition, the mAdb system has been ported for the Netherlands Cancer Institute, the Genome Institute of Singapore, and the CDC. This system has been used for a wide variety of scientific experiments spanning the range from cancer to studies of early development, and for human, mouse, rat, yeast, and numerous microbial organisms.

Linear IgA disease: successful treatment with erythromycin

Conventional first-line treatments for linear IgA disease (and the related chronic immunobullous disease of childhood) include topical steroids and dapsone, both of which may be associated with potentially serious side-effects. Alternative anti-inflammatory therapies such as tetracycline and macrolide antibiotics, have been used to treat other immunobullous disorders and we now report an adult case of linear IgA disease and a paediatric case of mixed immunobullous disease of childhood that both responded to the macrolide antibiotic erythromycin. The mode of action is speculative and anti-inflammatory mechanisms are unclear. Nevertheless, from a clinical perspective, erythromycin may have a role in the treatment of linear IgA disease and could be considered ahead of many other, perhaps potentially more toxic, therapies.

Genetic variability in the insulin signalling pathway may contribute to the risk of late onset Alzheimer's disease

OBJECTIVE

To test the hypothesis that polymorphic variation in insulin signalling genes may underlie the shared risk of dysfunctional insulin signalling and late onset Alzheimer's disease (AD). The p85alpha subunit of phosphatidyl inositol 3 kinase (PIK3R1) and the regulatory subunit 3 of protein phosphatase 1 (PPP1R3) were selected as candidate genes because both encode key proteins involved in insulin signalling and because polymorphisms in these genes have been previously implicated in insulin resistance or type II diabetes.

METHODS

Analysis of the Met326Ile PIK3R1 and the Asp905Tyr PPP1R3 polymorphisms in 202 patients with late onset AD and 160 or 170 age matched normal subjects.

RESULTS

Logistic regression analysis using the recessive genetic model showed significant differences in genotype and allelic frequencies between the AD group and normal controls (genotypes: odds ratio (OR) 2.09, 95% confidence interval (CI) 1.17 to 3.74, p = 0.01; alleles: OR 1.99, 95% CI 1.17 to 3.40, p = 0.01) for the Met326Ile PIK3R1 polymorphism that were female specific. Additionally, in the dominant genetic model a marginally significant association in genotype frequencies between the Asp905Tyr PPP1R3 polymorphism and AD was observed (genotypes: OR 1.85, 95% CI 1.03 to 3.30, p = 0.04; alleles: OR 1.68, 95% CI 0.98 to 2.88, p = 0.06). Both polymorphisms were tested for their interactions with sex and the presence of the apolipoprotein E epsilon 4 allele.

CONCLUSIONS

The results support the hypothesis for a common genetic aetiology predisposing to insulin resistance and AD.

Comprehensive resource: Skeletal gene database

The Skeletal Gene Database (SGD) is an integrated resource that provides comprehensive information about bone-related genes, mRNA, and proteins expressed in human and mouse, with rich links to numerous other electronic tools. SGD contains expressed sequence tag (EST) data from all the skeletal-related cDNA libraries that are available to the public. It supplies the query/data access analytic tools for users to search and compare each gene expressed in skeletal tissue(s). The results derived from EST tissue expression profiling will allow users to get the data on the mRNA copy numbers of each gene expressed in each tissue and its normalized value. From the SGD, researchers can obtain information regarding the name, symbol, size, exon/intron number, chromosomal location, LocusLink, and related disease (if any is known) of each gene. This electronic compendium also furnishes information on the protein of the corresponding gene including the protein size (amino acid number and molecular weight). It provides swift and ready access to other useful databases including OMIM, UniGene and PUBMED. The data will be updated regularly in step with current and future research, thereby providing what we hope will serve as a highly useful source of information and a powerful analytic tool to the scientific community.

Psychosocial outcomes at three and nine months after good neurological recovery from aneurysmal subarachnoid haemorrhage: predictors and prognosis

OBJECTIVES

To investigate (1) the prevalence of various aspects of cognitive and psychosocial dysfunction, including post-traumatic stress symptoms, over nine months after subarachnoid haemorrhage (SAH); (2) whether SAH is preceded by increased life stress; (3) to what extent adverse outcomes may be predicted from preillness life stress, early neurological impairment, age, and sex; and (4) relations between emotional and functional outcomes.

METHODS

52 patients with good neurological recovery after surgery for SAH were each matched for age, sex, and occupation with a healthy control participant. SAH patients were assessed three and nine months postdischarge on measures of cognitive functioning, mood, and social functioning. Objective stressors and subjective life change during the preceding year were rated retrospectively. Controls completed measures of mood and social functioning once only.

RESULTS

Compared with controls, SAH patients showed increased mood disturbance, subtle cognitive impairment, and abnormally low independence and participation on measures of social functioning. 60% showed clinically significant post-traumatic stress symptomatology (intrusive thoughts or avoidance of reminders) at three months and 30% at nine months. Independence in activities of daily living was greatly reduced in half to a third of the sample at both three and nine months. Productive employment was below the 10th percentile of the control group for 75% of patients at three months and for 56% at nine months; this outcome could not be predicted from selected demographic, premorbid, or clinical variables but dependence on others for organisational activities was predicted by impaired prose recall. Mood at nine months was strongly predicted by prior mental health problems, poor physical health, dysphasia, and impaired prose recall at three months. There was no evidence of an abnormally high level of stressful life events in the year before SAH, although patients rated their subjective level of stress in this period slightly more highly than did the control participants.

CONCLUSIONS

These findings highlight the need for structured support and treatment after surgery for SAH to reduce persisting mood disturbance and increase independence and participation.

The influence of 4G/5G polymorphism in the plasminogen activator inhibitor-1 gene promoter on the incidence, growth and operative risk of abdominal aortic aneurysm

BACKGROUND

a single base pair deletion/insertion (4G/5G) polymorphism in the plasminogen activator inhibitor (PAI-1) promoter appears to influence PAI-1 synthesis (increased PAI-1 and inhibition of fibrinolysis with the 4G allele) and survival after severe trauma.

OBJECTIVE

to identify whether the 4G/5G polymorphism influences the natural history of abdominal aortic aneurysm (AAA).

METHODS

Four hundred and sixty patients with small AAA were genotyped for the 4G/5G polymorphism. AAA growth was assessed from serial ultrasonographic measurements, subject to linear regression analysis. Mortality following eventual elective surgery was recorded.

RESULTS

the frequency of the 3 genotypes (4G4G, 4G5G and 5G5G) was in Hardy-Weinberg equilibrium and similar to that in a healthy population. The mean aneurysm growth rate was 0.37, 0.35 and 0.44 cm/year respectively for patients of 4G4G, 4G5G and 5G5G genotype respectively, p = 0.07. The 30d mortality following open elective aneurysm repair was 8% (7/87), 8% (11/145) and 0% (0/56) for patients of 4G4G, 4G5G and 5G5G genotype respectively, giving a higher mortality for those carrying a 4G allele p = 0.03.

CONCLUSIONS

polymorphism of the PAI-1 gene promoter does not influence the development of AAA, although AAA growth is faster for patients of 5G5G genotype. However, this genotype (5G5G), which is associated with enhanced fibrinolysis, appears protective following open aneurysm repair. This effect of PAI-1 genotype on survival following surgery is likely to have widespread significance in vascular and general surgery.

Lichen sclerosus. A review

Lichen sclerosus is a chronic inflammatory skin condition that can cause substantial physical and psychological morbidity. It most commonly affects women in the anogenital region, but may affect any area of skin in either sex at any age. Not only does it cause itching and soreness, but also urinary and sexual problems. There is an increased risk of developing squamous cell carcinoma in the genital area in both female and male sufferers, thus long term follow-up may be justified. The aetiology of Lichen sclerosus is unknown but genetic factors play a role, and chronic infection had been postulated but not proven. The association with autoimmune disease is also well recognized. The mainstay of treatment for genital lichen sclerosus is potent topical steroid. Surgery may be required only to relieve the effect of scarring. Current research to understand the pathogenesis of disease may allow us to target specific intervention in the future.

Surgical workload and outcome after resection for carcinoma of the oesophagus and cardia

BACKGROUND

Performing cancer surgery in high-volume centres may lead to improved outcomes. This study explored the relationship between annual workload and outcome following resection for carcinoma of the oesophagus and cardia.

METHODS

The study was a retrospective case-note review of 1125 patients who had surgery for cardio-oesophageal cancer in the West Midlands region of England. Outcome measures were 30-day mortality and long-term survival.

RESULTS

The overall 30-day mortality rate was 10.0 per cent with a median survival of 14 months and a 5-year survival rate of 17.2 per cent. Increasing age, advanced stage of disease and emergency resection independently affected outcome adversely. Forty-one infrequent operators (fewer than four resections per year) performed 146 resections (13.0 per cent), 18 intermediate operators (between four and 11 resections per year) performed 488 resections (43.4 per cent) and five frequent operators (12 or more resections per year) performed 491 resections (43.6 per cent). The 30-day mortality rate was greatest in the infrequent group (15.1 per cent) compared with both the intermediate group (6.6 per cent; adjusted odds 0.40, P = 0.004) and the frequent group (11.8 per cent; odds 0.73, P = 0.28). There were no differences in survival rates between the groups, and no difference in outcome between high- and low-volume hospitals.

CONCLUSION

In this unselected population-based series there was little evidence of a trend of improving 30-day mortality rate with increasing workload, or between workload and long-term survival.

Community based rehabilitation after severe traumatic brain injury: a randomised controlled trial

OBJECTIVE

Evaluation of multidisciplinary community based outreach rehabilitation after severe traumatic brain injury (TBI).

METHODS

A randomised controlled trial compared outreach treatment (mean of two sessions a week for 27.3 (SD 19.1) weeks) in community settings such as participants' homes, day centres, or workplaces, with provision of written information detailing alternative resources. Follow up for an average of 24.8 months after initial allocation was by a blinded independent assessor. Participants were aged 16-65, had sustained severe TBI between 3 months and 20 years previously, and had no other neurological conditions. Of 110 initially allocated, 48 outreach and 46 information participants were successfully followed up. Primary outcome measures (Barthel index (BI) and the brain injury community rehabilitation outcome-39 (BICRO-39)) focused on levels of activity and participation. Secondary measures were the functional independence measure and the functional assessment measure (FIM+FAM) and, in a subgroup of 46 participants, the hospital anxiety and depression scale. Analyses were non-parametric.

RESULTS

outreach participants were significantly more likely to show gains on the BI and the BICRO-39 total score and self organisation and psychological wellbeing subscales. There were likewise strong trends (p<0.10) for BICRO personal care and mobility, and on the FIM+FAM for personal care and cognitive functions. Differential improvements were not seen for indices of socializing, productive employment, anxiety, or depression. Median changes on individual subscales were small, reflecting the diversity of the clinical population; however, 40% of outreach but only 20% of information participants made a clinically significant improvement of 2+ points on at least one BICRO-39 scale. Time since injury was unrelated to the magnitude of gains.

CONCLUSIONS

This is the first RCT of multidisciplinary community rehabilitation after severe TBI, and suggests that even years after injury it can yield benefits which outlive the active treatment period.

A boy with cutaneous necrosis occurring during treatment with levamisole

We present a child on long-term treatment with levamisole, and heterozygous for factor V Leiden, who developed cutaneous necrosis associated with formation of p-ANCA and lupus anticoagulant. Symptoms resolved when the levamisole treatment was stopped.

Relation of gene expression phenotype to immunoglobulin mutation genotype in B cell chronic lymphocytic leukemia

The most common human leukemia is B cell chronic lymphocytic leukemia (CLL), a malignancy of mature B cells with a characteristic clinical presentation but a variable clinical course. The rearranged immunoglobulin (Ig) genes of CLL cells may be either germ-line in sequence or somatically mutated. Lack of Ig mutations defined a distinctly worse prognostic group of CLL patients raising the possibility that CLL comprises two distinct diseases. Using genomic-scale gene expression profiling, we show that CLL is characterized by a common gene expression "signature," irrespective of Ig mutational status, suggesting that CLL cases share a common mechanism of transformation and/or cell of origin. Nonetheless, the expression of hundreds of other genes correlated with the Ig mutational status, including many genes that are modulated in expression during mitogenic B cell receptor signaling. These genes were used to build a CLL subtype predictor that may help in the clinical classification of patients with this disease.

Importance of complete DNA digestion in minimizing variability of 8-oxo-dG analyses

Estimates of 8-oxo-2'-deoxyguanosine (8-oxo-dG) in DNA vary at least one order of magnitude using different quantitative methods or even the same method. Our hypothesis is that an incomplete DNA hydrolysis to nucleosides by the conventional nuclease P1 (NP1) and alkaline phosphatase (AP) digestion system plays an important role in contributing to the variability of measurements using HPLC coupled with UV and electrochemical (EC) detection. We show here that factors, such as the amount of DNA, choice of enzymes, their activities, and incubation time, can affect DNA digestion and, thus, cause variability in 8-oxo-dG levels. The addition of DNase I and phosphodiesterases I and II to the NP1 + AP system improves the DNA digestion by completely releasing normal nucleosides and 8-oxo-dG, thereby reducing the interday variations of 8-oxo-dG levels. Diethylenetriamine pentaacetic acid (DTPA), an iron chelator, prevented background increases of 8-oxo-dG during DNA digestion, as well as during the waiting period in the autosampler when a batch of DNA samples is analyzed by HPLC. After optimization of the DNA digestion conditions, the interday variability of 8-oxo-dG measurements using commercially available salmon testes DNA (ST DNA) were 26% over a period of 2 years. Under these optimal conditions, our laboratory variability may contribute as little as 13% to the overall variability as shown by assessment of oxidative DNA damage in a population of smokers. Based on our results, we believe that the modified DNA digestion conditions will provide much more accurate 8-oxo-dG determinations and, thus, more reliable estimates of cancer risk.

Psychosis and aggression in Alzheimer's disease: the effect of dopamine receptor gene variation

This study investigated possible associations between selected polymorphisms in the dopamine receptor genes DRD1 and DRD3 with the presence of psychotic phenomena or aggressive behaviour in a community based cohort of 134 patients with late onset Alzheimer's disease. An association was found between the presence of psychotic symptoms and aggressive behaviour and the DRD1 polymorphism and between the presence of psychosis, but not aggression, and the DRD3 polymorphism. Specifically, carriers of the DRD1 B2 allele were more likely to be aggressive or experience hallucinations whereas homozygous carriers of the DRD3 1 allele were more likely to experience delusions.

Increased common carotid intima-media thickness in UK African Caribbeans and its relation to chronic inflammation and vascular candidate gene polymorphisms

BACKGROUND AND PURPOSE

Individuals of African Caribbean descent who live in the United Kingdom have an increased risk of stroke. The reasons for this are not fully understood, but differences in genetic predispositions or other novel stroke risk factors could play a role. US blacks have been reported to have increased common carotid artery wall thickness, or intima-media thickness (IMT), measured by ultrasound. We measured carotid IMT in UK African Caribbeans compared with UK whites and determined whether different distributions of polymorphisms in potential candidate vascular genes or differences in measures of chronic inflammation or infection could account for any difference.

METHODS

In a population study, common carotid artery IMT was measured in 202 white men and 89 African Caribbean men. The distribution of polymorphisms in ACE, paraoxonase 1, paraoxonase 2, and methylenetetrahydrofolate reductase genes was determined. Serum C-reactive protein and Helicobacter pylori seropositivity were determined.

RESULTS

Carotid IMT was increased in African Caribbeans even after controlling for cardiovascular risk factors, including homocysteine and social class: beta=0.113, 95% CI 0.036 to 0.189, P=0.004. There was a significant interaction with smoking and mean IMT (P=0.022), and the difference in both measures of IMT between ethnic groups was largely limited to individuals who had never smoked. There were significant ethnic differences in the distributions of 3 of the 4 candidate genes studied (ACE, paraoxonase 1, and methylenetetrahydrofolate reductase). H pylori seropositivity was increased in African Caribbeans (78.7% versus 53% in UK whites). However, neither the genetic polymorphisms nor H pylori seropositivity was related to IMT, and ethnic differences in their distribution did not account for the increased IMT seen in African Caribbeans.

CONCLUSIONS

Carotid IMT is increased in UK African Caribbeans even after controlling for conventional risk factors. There are highly significant ethnic differences in the distribution of many potential cerebrovascular candidate genes. Although those we examined did not explain the ethnic differences in IMT, other genetic predispositions or environmental exposures could account for these differences.

Extracts of Flourensia cernua (L): volatile constituents and antifungal, antialgal, and antitermite bioactivities

The chemical components of tarbush (Flourensia cernua) leaves were fractionated by extracting successively with hexanes, diethyl ether, and ethanol. Volatile profiles of each fraction were identified by using GC-MS. The hexanes fraction contained mostly monoterpenoids, while the ethanol fraction volatiles were primarily sesquiterpenoids. Crude fractions were tested for activity against fungi, algae, and termites. Application of as little as 1 microg of the essential oil from the hexanes fraction was sufficient to provide visible antifungal activity in bioautography assays. The diethyl ether fraction showed selective activity against the cyanobacterium responsible for the 2-methylisoborneol-induced off-flavor sometimes associated with catfish farming operations. All three fractions exhibited a high degree of antitermite activity.