Ensembl 2008

The Ensembl project (http://www.ensembl.org) is a comprehensive genome information system featuring an integrated set of genome annotation, databases and other information for chordate and selected model organism and disease vector genomes. As of release 47 (October 2007), Ensembl fully supports 35 species, with preliminary support for six additional species. New species in the past year include platypus and horse. Major additions and improvements to Ensembl since our previous report include extensive support for functional genomics data in the form of a specialized functional genomics database, genome-wide maps of protein–DNA interactions and the Ensembl regulatory build; support for customization of the Ensembl web interface through the addition of user accounts and user groups; and increased support for genome resequencing. We have also introduced new comparative genomics-based data mining options and report on the continued development of our software infrastructure.

Cleavage stage versus blastocyst stage embryo transfer in assisted conception

BACKGROUND

Recent advances in cell culture media have led to a shift in IVF practice from early cleavage embryo transfer to blastocyst stage transfer. The rationale for blastocyst culture is to improve both uterine and embryonic synchronicity and self selection of viable embryos thus resulting in higher implantation rates.

OBJECTIVES

To determine if blastocyst stage embryo transfers (ETs) affect live birth rate and associated outcomes compared with cleavage stage ETs and to investigate what factors may influence this.

SEARCH STRATEGY

Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials, Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and Bio extracts. The last search date was January 2007.

SELECTION CRITERIA

Trials were included if they were randomised and compared the effectiveness of early cleavage versus blastocyst stage transfers.

DATA COLLECTION AND ANALYSIS

Of the 50 trials that were identified, 18 randomised controlled trials (RCTs) met the inclusion criteria and were reviewed. The primary outcome was rate of live birth. Secondary outcomes were rates per couple of clinical pregnancy, multiple pregnancy, high order pregnancy, miscarriage, failure to transfer embryos and cryopreservation. Quality assessment, data extraction and meta-analysis were performed following Cochrane guidelines.

MAIN RESULTS

Evidence of a significant difference in live-birth rate per couple between the two treatment groups was detected in favour of blastocyst culture (9 RCTs; OR 1.35, 95% CI 1.05 to 1.74 (Day 2/3: 29.4% versus Day 5/6: 36.0%)). This was particularly for trials with good prognosis patients, equal number of embryos transferred (including single embryo transfer) and those in which the randomisation took place on Day 3. Rates of embryo freezing per couple was significantly higher in Day 2 to 3 transfers (9 RCTs; OR 0.45, 95% CI 0.36 to 0.56). Failure to transfer any embryos per couple was significantly higher in the Day 5 to 6 group (16 RCTs; OR 2.85, 95% CI 1.97 to 4.11 (Day 2/3: 2.8% versus Day 5/6: 8.9%)) but was not significantly different for good prognosis patients (9 RCTs; OR 1.50, 95% CI 0.79 to 2.84).

AUTHORS' CONCLUSIONS

This review provides evidence that there is a significant difference in pregnancy and live birth rates in favour of blastocyst transfer with good prognosis patients with high numbers of eight-cell embryos on Day three being the most favoured in subgroup for whom there is no difference in cycle cancellation. There is emerging evidence to suggest that in selected patients, blastocyst culture maybe applicable for single embryo transfer.

[Treating heart failure with carvedilol in private practice (initiating treatment and follow-up at one year. The KEOPS study]

AIMS

This study aimed at describing usual conditions of carvedilol use in heart failure (HF) patients.

METHODS

KEOPS was a one-year, multi-centre, prospective pharmaco-epidemiological study in carvedilol treated HF patients recruited by private cardiologists.

RESULTS

Two thousand nine patients (mean age: 68) with heart failure were included by 401 cardiologists. 64% of patients were in class II of NYHA and 27% in class III, 87% of patients presented stable heart failure for at least four weeks. Contraindication to beta blocking was observed in 24% of patients, mean left ventricular fraction of ejection was 39% and only 39% of patients had mean left ventricular fraction of ejection<35%. Co-medications included a diuretic agent, ACE inhibitor or ARB in 68% of cases. Eighty three percent of patients had a titration of carvedilol (median duration=1 20 days). Thirty percent reached the recommended maximal dose. The dose of carvedilol at the titration's visit for all the patients (patient in stop included) was on average 30.5 +/- 22.1 mg/day with a median on 25 [confidence interval: 23-27] During the year of follow-up, 10% of patients have stopped the treatment (3% of patients having reached the maximum recommended dose of carvedilol versus 13% for the others), for cardiovascular reasons in 50% of patients (aggravation of heart failure: 28%, symptomatic arterial hypotension: 9%, symptomatic bradycardia: 5%). Finally, symptomatology of patients has improved during the study (59% of patients in class mild to severe at inclusion, versus 36% at the end of the observation), especially for the 30% of patients followed at one year and having reached the maximum recommended dose of carvedilol. Only in univariate analysis, patients with an inclusion high weight (>85 kg) were likely less to reach recommended maximal dose (37.2 versus 8.7%, p-value<0.0001), the patients with systolic heart failure had more chance than the patients with diastolic heart failure to reach the recommended maximal dose (31 versus 17.4%, p-value=0.006), in the same way, the lack of auricular supported more the reach of recommended maximal dose (31.2 versus 24.1%, p-value=0.018)

CONCLUSION

KEOPS study suggests an improvement of usual conditions of carvedilol compared to the last investigation but the persistence of prescription outside medical authorization and less dosage of this product compared with clinical studies.

Survival and recurrent disease after postoperative radiotherapy for early endometrial cancer: systematic review and meta-analysis

OBJECTIVE

To clarify the effect of postoperative (adjuvant) external-beam pelvic radiotherapy (EBRT) for different grades of early endometrial cancer.

SEARCH STRATEGY

Meta-analysis of data from randomised trials stratified by histological risk factors supported by cohort studies.

SELECTION CRITERIA

Cochrane methodology.

DATA

Seven randomised trials were identified. Five were eligible for meta-analysis. Homogeneity was confirmed (I2 < 25%).

MAIN OUTCOME MEASURES

Survival, site of recurrence and added complications.

MAIN RESULTS

EBRT after hysterectomy for low-risk disease increases the odds of death (OR for overall survival 0.71; 95% CI 0.52-0.96). EBRT does not appear to alter survival for intermediate-risk cancers (stage ICG1/2 and IBG3) (OR 0.97; 95% CI 0.69-1.35). In contrast, EBRT offers a significant disease-free survival advantage for high-risk cancer (OR 1.76; 95% CI 1.07-2.89). The survival advantage benefits one in ten women. The definition of high risk is variable across studies but focuses on ICG3 (deeply invasive, poorly differentiated) tumours. Pelvic EBRT reduces the risk of pelvic recurrent disease in all types of invasive endometrial cancer (OR 0.27; 95% CI 0.16-0.44), but local recurrence may respond to salvage treatment. The risk of distant metastasis appears to be increased significantly by prophylactic EBRT (OR 1.58; 95% CI 1.07-2.35), but this might be because pelvic relapse in untreated women alters reporting of metastatic disease.

AUTHORS' CONCLUSIONS

Adjuvant EBRT should not be used for low- (IA, IBG1) or intermediate-risk (IBG2) cancer, but it is associated with a 10% survival advantage for high-risk (stage ICG3) endometrial cancer. This challenges the role of a staging lymphadenectomy.

Phylogenetic Comparison of Rabies Viruses from Disease Outbreaks on the Svalbard Islands

Periodic wildlife rabies epizootics occur in Arctic regions. The original sources of these outbreaks are rarely identified. In 1980, a wildlife epizootic of rabies occurred on the previously rabies-free Svalbard Islands, Norway. After this outbreak of rabies in the arctic fox population (Alopex lagopus), only single cases have been reported from the Islands over the following two decades. Phylogenetic characterization of four viruses isolated from infected arctic foxes from Svalbard from three different time periods suggest that the source of these epizootics could have been migration of this species from the Russian mainland. Arctic fox migration has likely contributed to the establishment of another zoonotic disease, Echinococcus multilocularis, on Svalbard in recent years.

Tubal flushing for subfertility

BACKGROUND

A possible therapeutic effect of diagnostic tubal patency testing has been debated in the literature for half a century. Further debate surrounds whether oil-soluble or water-soluble contrast media might have the bigger fertility-enhancing effect.

OBJECTIVES

To evaluate the effect of flushing a woman's fallopian tubes with oil- or water-soluble contrast media on subsequent fertility outcomes in couples with infertility.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of trials (searched 31 January 2007), MEDLINE, EMBASE, Biological Abstract and reference lists of articles.

SELECTION CRITERIA

All randomised trials comparing tubal flushing with oil-soluble contrast media or tubal flushing with water-soluble media or with no treatment in women with subfertility.

DATA COLLECTION AND ANALYSIS

Four authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

Twelve trials involving 2079 participants were included. Tubal flushing with oil-soluble media versus no intervention was associated with a significant increase in the odds of live birth (Peto OR 2.98, 95% CI 1.40 to 6.37) and of pregnancy (Peto OR 3.30, 95% CI 2.00 to 5.43). For the comparison of tubal flushing with oil-soluble media versus tubal flushing with water-soluble media, the increase in the odds of live birth for tubal flushing with oil-soluble versus water-soluble media (Peto OR 1.49, 95% CI 1.05 to 2.11) was based on two trials where statistical heterogeneity was present and the higher quality trial showed no significant difference; there was no evidence of a significant difference in the odds of pregnancy (Peto OR 1.21, 95% CI 0.95 to 1.54). The addition of oil-soluble media to flushing with water-soluble media showed no evidence of a significant difference in the odds of pregnancy (Peto OR 1.28, 95% CI 0.92 to 1.79) or live birth (Peto OR 1.06, 95% CI 0.64 to 1.77). There were no serious adverse event reported.

AUTHORS' CONCLUSIONS

There is evidence of effectiveness of tubal flushing with oil-soluble contrast media in increasing the odds of pregnancy and live birth versus no intervention. Future robust randomised trials, comparing oil-soluble versus water-soluble media, water-soluble media versus no intervention and tubal flushing versus established treatments for infertility would be a useful further guide to clinical practice.

Effect of massage of the hamstring muscles on selected electromyographic characteristics of biceps femoris during sub-maximal isometric contraction

The aim of this study was to investigate whether a single massage of the hamstring muscles would alter selected electromyographic characteristics of biceps femoris during a sub-maximal isometric contraction. Eleven healthy young males participated in this crossover study. They were randomly assigned to two groups, receiving either a 15-minute hamstring muscle massage or a 15-minute prone rest. One week later they returned to receive the alternate intervention. Immediately pre- and post-intervention, participants were instructed to contract their muscles just sufficiently to maintain right knee flexion (5 degrees from full extension) for 30 seconds. Simultaneous to this contraction, surface electromyography (EMG) was used to record the electrical activity of right biceps femoris. Electromyograms were analyzed by calculating the averaged/integrated EMG (aEMG) and median frequency (MF) for each of 14 one-second windows, sampled every two seconds throughout the 30-second contractions per participant. Mean values of aEMG and MF were calculated per participant (aEMGmean and MFmean), pre- and post-massage or rest intervention. Group means (n = 11) of aEMGmean and MFmean were then calculated and compared using a repeated measures analysis of variance (ANOVA) procedure (p < 0.05). Rates of change of aEMG and MF throughout each 30-second contraction were represented by their respective gradients as functions of time. These gradients were similarly compared pre- to post-intervention using repeated measures ANOVA (p < 0.05). For the young healthy males considered in this study, a single massage of the hamstring muscles had no statistically significant effects on selected electromyographic characteristics of biceps femoris during sub-maximal isometric contractions (p > 0.05).

Clinicopathologic correlation in PGRN mutations

BACKGROUND

Frontotemporal dementia (FTD) has been linked to the microtubule associated protein tau (MAPT) gene region of chromosome 17. However, many chromosome-17 linked FTLDs do not have MAPT mutations or tau protein deposits, but have ubiquitin positive, tau and alpha-synuclein negative inclusions. Mutations in the progranulin (PGRN) gene, located 1.7 Mb from MAPT at 17q21.31, were recently discovered in some of these individuals. The pathologic phenotype in all cases has thus far included ubiquitinated neuronal intranuclear inclusions (NIIs) and neuronal cytoplasmic inclusions (NCIs).

METHODS

PGRN mutation analysis was performed in 12 individuals. Informed consent was obtained from next of kin under an IRB-approved protocol. We compared clinical and pathologic findings in those cases with and without PGRN mutations.

RESULTS

PGRN mutations were found in four patients, two with clinical FTD and a positive family history, and two with clinical primary progressive aphasia (PPA), one with and one without a family history. All four cases with, and five of eight cases without, PGRN mutations had ubiquitinated NCIs and NIIs. Brains of individuals with PGRN mutations are associated with more frequent frontal NCIs and dystrophic neurites, less frequent dentate gyrus NCIs, and more frequent striatal NIIs than FTLD-U cases without PGRN mutations.

CONCLUSION

PGRN mutations at 17q21 may occur in apparently sporadic frontotemporal lobar dementia with ubiquitinated inclusions cases and in cases presenting with either primary progressive aphasia or the behavioral variant of frontotemporal dementia. Some cases without PGRN mutations also have ubiquitinated neuronal intranuclear inclusions. Clinicopathologic differences are observed among individuals with and without PGRN mutations.

Comparative analysis of the full genome sequence of European bat lyssavirus type 1 and type 2 with other lyssaviruses and evidence for a conserved transcription termination and polyadenylation motif in the G-L 3' non-translated region

We report the first full-length genomic sequences for European bat lyssavirus type-1 (EBLV-1) and type-2 (EBLV-2). The EBLV-1 genomic sequence was derived from a virus isolated from a serotine bat in Hamburg, Germany, in 1968 and the EBLV-2 sequence was derived from a virus isolate from a human case of rabies that occurred in Scotland in 2002. A long-distance PCR strategy was used to amplify the open reading frames (ORFs), followed by standard and modified RACE (rapid amplification of cDNA ends) techniques to amplify the 3' and 5' ends. The lengths of each complete viral genome for EBLV-1 and EBLV-2 were 11 966 and 11 930 base pairs, respectively, and follow the standard rhabdovirus genome organization of five viral proteins. Comparison with other lyssavirus sequences demonstrates variation in degrees of homology, with the genomic termini showing a high degree of complementarity. The nucleoprotein was the most conserved, both intra- and intergenotypically, followed by the polymerase (L), matrix and glyco- proteins, with the phosphoprotein being the most variable. In addition, we have shown that the two EBLVs utilize a conserved transcription termination and polyadenylation (TTP) motif, approximately 50 nt upstream of the L gene start codon. All available lyssavirus sequences to date, with the exception of Pasteur virus (PV) and PV-derived isolates, use the second TTP site. This observation may explain differences in pathogenicity between lyssavirus strains, dependent on the length of the untranslated region, which might affect transcriptional activity and RNA stability.

Adjuvant radiotherapy for stage I endometrial cancer

BACKGROUND

The role of adjuvant radiotherapy (both pelvic external beam radiotherapy and vaginal intracavity brachytherapy) in stage I endometrial cancer following total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO) remains unclear.

OBJECTIVES

To assess the efficacy of adjuvant radiotherapy following surgery for stage I endometrial cancer.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CancerLit, Physician Data Query (PDQ) of National Cancer Institute. Handsearching was also carried out where appropriate.

SELECTION CRITERIA

Randomised controlled trials (RCTs) which compared adjuvant radiotherapy versus no radiotherapy following surgery for patients with stage I endometrial cancer were included.

DATA COLLECTION AND ANALYSIS

Quality of the studies was assessed and data collected using a predefined data collection form. The primary endpoint was overall survival. Secondary endpoints were locoregional recurrence, distant recurrence and endometrial cancer death. Data on quality of life (QOL) and morbidity were also collected. A meta-analysis on included trials was performed using the Cochrane Collaboration Review Manager Software 4.2.

MAIN RESULTS

The meta-analysis was performed on four trials (1770 patients). The addition of pelvic external beam radiotherapy to surgery reduced locoregional recurrence, a relative risk (RR) of 0.28 (95% confidence interval (CI) 0.17 to 0.44, p < 0.00001), which is a 72% reduction in the risk of pelvic relapse (95% CI 56% to 83%) and an absolute risk reduction of 6% (95% CI of 4 to 8%). The number needed to treat (NNT) to prevent one locoregional recurrence is 16.7 patients (95% CI 12.5 to 25). The reduction in the risk of locoregional recurrence did not translate into either a reduction in the risk of distant recurrence or death from all causes or endometrial cancer death. A subgroup analysis of women with multiple high risk factors (including stage 1c and grade 3) showed a trend toward the reduction in the risk of death from all causes and endometrial cancer death in patients who underwent adjuvant external beam radiotherapy.

AUTHORS' CONCLUSIONS

Patients with stage I endometrial carcinoma have different risks of local and distant recurrence depending on the presence of risk factors including stage 1c, grade 3, lymphovascular space invasion and age. Though external beam pelvic radiotherapy reduced locoregional recurrence by 72%, there is no evidence to suggest that it reduced the risk of death. In patients with multiple high risk factors, including stage 1c and grade 3, there was a trend towards a survival benefit and adjuvant external beam radiotherapy may be justified. For patients with only one risk factor, grade 3 or stage 1c, no definite conclusion can be made and data from ongoing studies ( ASTEC; Lukka) are awaited. External beam radiotherapy carries a risk of toxicity and should be avoided in stage 1 endometrial cancer patients with no high risk factors.

Surgical interruption of pelvic nerve pathways in dysmenorrhea: a systematic review of effectiveness

OBJECTIVES

To assess the effectiveness of surgical interruption of pelvic nerve pathways in primary and secondary dysmenorrhea. Data sources. The Cochrane Menstrual Disorders and Subfertility Group Trials Register (9 June 2004), CENTRAL (The Cochrane Library, Issue 2, 2004), MEDLINE (1966 to Nov. 2003), EMBASE (1980 to Nov. 2003), CINAHL (1982 to Oct. 2003), MetaRegister of Controlled Trials, the citation lists of review articles and included trials, and contact with the corresponding author of each included trial.

REVIEW METHODS

The inclusion criteria were randomized controlled trials of uterosacral nerve ablation or presacral neurectomy (both open and laparoscopic procedures) for the treatment of dysmenorrhea. The main outcome measures were pain relief and adverse effects. Two reviewers extracted data on characteristics of the study quality and the population, intervention, and outcome independently.

RESULTS

Nine randomized controlled trials were included in the systematic review. There were two trials with open presacral neurectomy; all other trials used laparoscopic techniques. For the treatment of primary dysmenorrhea, laparoscopic uterosacral nerve ablation at 12 months was better when compared to a control or no treatment (OR 6.12; 95% CI 1.78-21.03). The comparison of laparoscopic uterosacral nerve ablation with presacral neurectomy for primary dysmenorrhea showed that at 12 months follow-up, presacral neurectomy was more effective (OR 0.10; 95% CI 0.03-0.32). In secondary dysmenorrhea, along with laparoscopic surgical treatment of endometriosis, the addition of laparoscopic uterosacral nerve ablation did not improve the pain relief (OR 0.77; 95% CI 0.43-1.39), while presacral neurectomy did (OR 3.14; 95% CI 1.59-6.21). Adverse events were more common for presacral neurectomy than procedures without presacral neurectomy (OR 14.6; 95% CI 5-42.5).

CONCLUSION

The evidence for nerve interruption in the management of dysmenorrhea is limited. Methodologically sound and sufficiently powered randomized controlled trials are needed.

Evidence for trans-border movement of rabies by wildlife reservoirs between countries in the Balkan Peninsular

Rabies remains endemic in a number of reservoir species throughout southeast Europe. To investigate the relationship between rabies viruses within this region we have compared rabies virus nucleoprotein sequence data from a diverse panel of rabies samples from Bulgaria with available data from countries in the Balkan Peninsula. This analysis provides a first description of rabies isolates in Bulgaria and suggests that there is evidence for wildlife-mediated movement of rabies with countries to the west of Bulgaria including Serbia and Bosnia-Herzegovina but no evidence for a link with rabies foci in Turkey. We speculate that natural barriers such as the Balkan mountains may play a significant role in constraining the southerly spread of rabies in southeast Europe.

Insulin-sensitising drugs versus the combined oral contraceptive pill for hirsutism, acne and risk of diabetes, cardiovascular disease, and endometrial cancer in polycystic ovary syndrome

BACKGROUND

Insulin-sensitizing drugs (ISDs) have recently been advocated as possibly a safer and more effective long-term treatment than the oral contraceptive pill (OCP) in women with polycystic ovary syndrome (PCOS). It is important to directly compare the efficacy and safety of ISDs versus OCPs in the long-term treatment of women with PCOS.

OBJECTIVES

To assess the effectiveness and safety of ISDs versus the OCP (alone or in combination) in improving clinical, hormonal, and metabolic features of PCOS.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (September 2005), Cochrane Central Register of Controlled Trials (CENTRAL (Ovid), third quarter 2005), MEDLINE (1966 to September 2005), CINAHL (1982 to September 2005), and EMBASE (1988 to September 2005). References of the identified articles were handsearched, and pharmaceutical companies and experts in the field were also contacted for additional relevant studies.

SELECTION CRITERIA

Randomised controlled trials which compared ISDs versus the OCP (alone or in combination).

DATA COLLECTION AND ANALYSIS

Performed independently by two review authors.

MAIN RESULTS

Six trials were included for analysis, four of which compared metformin versus OCP (104 participants) and two of which compared OCP combined with metformin versus OCP alone (70 participants). Limited data demonstrated no evidence of difference in effect between metformin and the OCP on hirsutism and acne. There was either insufficient or no data on the relative efficacy of metformin or the OCP (alone or in combination) for preventing the development of diabetes, cardiovascular disease, or endometrial cancer. Metformin was less effective than the OCP in improving menstrual pattern (Peto odds ratio (OR) 0.08, 95% CI 0.01 to 0.45). Metformin resulted in a higher incidence of gastrointestinal (Peto OR 7.75, 95% CI 1.32 to 45.71), and a lower incidence of non-gastrointestinal (Peto OR 0.11, 95% CI 0.03 to 0.39), severe adverse effects requiring stopping of medication. Metformin was less effective in reducing serum androgen levels (total testosterone: weighted mean difference (WMD) 0.54, 95% CI 0.22 to 0.86; free androgen index: WMD 3.69, 95% CI 2.56 to 4.83). Metformin was more effective than the OCP in reducing fasting insulin (WMD -3.46, 95% CI -5.39 to -1.52) and not increasing triglyceride (WMD -0.48, 95% -0.86 to -0.09) levels, but there was insufficient evidence regarding comparative effects on reducing fasting glucose or cholesterol levels.

AUTHORS' CONCLUSIONS

Up to 12-months treatment with the OCP is associated with an improvement in menstrual pattern and serum androgen levels compared with metformin; but metformin treatment results in a reduction in fasting insulin and lower triglyceride levels than with the OCP. Side-effect profiles differ between the two drugs. There is either extremely limited or no data on important clinical outcomes such as the development of diabetes, cardiovascular disease, or endometrial cancer. There are no data comparing ISDs other than metformin (that is rosiglitazone, pioglitazone, and D-chiro-inositol) versus OCPs (alone or in combination).

Ensembl 2007

The Ensembl (http://www.ensembl.org/) project provides a comprehensive and integrated source of annotation of chordate genome sequences. Over the past year the number of genomes available from Ensembl has increased from 15 to 33, with the addition of sites for the mammalian genomes of elephant, rabbit, armadillo, tenrec, platypus, pig, cat, bush baby, common shrew, microbat and european hedgehog; the fish genomes of stickleback and medaka and the second example of the genomes of the sea squirt (Ciona savignyi) and the mosquito (Aedes aegypti). Some of the major features added during the year include the first complete gene sets for genomes with low-sequence coverage, the introduction of new strain variation data and the introduction of new orthology/paralog annotations based on gene trees.

Epidemiology of bat rabies in Germany

Rabies in European bats was first reported in Germany in 1954. In concordance with Denmark and the Netherlands, Germany has reported one of the highest numbers (n = 187) of European bat lyssavirus (EBLV)-positive cases in bats in Europe so far (1954-2005). A combined descriptive epidemiological and phylogenetic analysis on bat rabies and prevailing EBLVs is presented, comprising the past 50 years. So far, only the two lineages of EBLV-1 (genotype 5), a and b, have been detected. Although only 50% of the rabies-positive bats have been identified by species, the Serotine bat (Eptesicus serotinus) is the bat species most frequently infected. Single rabies cases have also been detected in a further five indigenous bat species. There is proven evidence for a substantial bias in the frequency of bat rabies cases in the north of Germany, with an endemic cluster in the northwesternmost low-lying plain areas adjacent to the Netherlands and Denmark. Improvements to bat rabies surveillance and research are discussed.

Airborne transmission of lyssaviruses

In 2002, a Scottish bat conservationist developed a rabies-like disease and subsequently died. This was caused by infection with European bat lyssavirus 2 (EBLV-2), a virus closely related to Rabies virus (RABV). The source of this infection and the means of transmission have not yet been confirmed. In this study, the hypothesis that lyssaviruses, particularly RABV and the bat variant EBLV-2, might be transmitted via the airborne route was tested. Mice were challenged via direct introduction of lyssavirus into the nasal passages. Two hours after intranasal challenge with a mouse-adapted strain of RABV (Challenge Virus Standard), viral RNA was detectable in the tongue, lungs and stomach. All of the mice challenged by direct intranasal inoculation developed disease signs by 7 days post-infection. Two out of five mice challenged by direct intranasal inoculation of EBLV-2 developed disease between 16 and 19 days post-infection. In addition, a simple apparatus was evaluated in which mice could be exposed experimentally to infectious doses of lyssavirus from an aerosol. Using this approach, mice challenged with RABV, but not those challenged with EBLV-2, were highly susceptible to infection by inhalation. These data support the hypothesis that lyssaviruses, and RABV in particular, can be spread by airborne transmission in a dose-dependent manner. This could present a particular hazard to personnel exposed to aerosols of infectious RABV following accidental release in a laboratory environment.

Accuracy of the 7-8-9 Rule for endotracheal tube placement in the neonate

OBJECTIVE

To determine accuracy of the 7-8-9 Rule in a cohort of neonates.

STUDY DESIGN

This study was cross-sectional in design. Seventy-five consecutive neonates who required oral intubation from June 2004 to November 2004 for cardiopulmonary failure, respiratory distress, or surfactant administration were the subjects of this study. The initial endotracheal tube (ETT) depth of insertion was determined using either an estimated birth weight or actual weight in the 7-8-9 Rule calculation followed by auscultation and subsequent adjustment if necessary. Midtracheal position was identified as the point halfway between the inferior clavicle and carina on a chest radiograph. The initial depth was compared to the midtracheal depth to determine clinical accuracy of the 7-8-9 Rule. The depth predicted by the 7-8-9 Rule was also calculated using only actual weights. This predicted depth was compared to the midtracheal depth to determine true accuracy of the 7-8-9 Rule. Accuracy was determined using mean paired differences with 95% confidence intervals (CI) between initial or predicted depth and ideal, midtracheal ETT depth. Linear regression was used to adjust for confounding variables.

RESULTS

Mean (range) gestational age was 32 weeks (23 to 44 weeks) and weight was 2001 g (490 to 4400 g). Eighteen (24%) infants weighed 1000 g or less, 20 (27%) weighed between 1001 and 2000 g, 21 (28%) weighed between 2001 and 3000 g, 15 (20%) weighed between 3001 and 4000 g, and one (1%) weighed more than 4000 g. Thirteen of the 18 extremely low birth weight infants weighed <750 g. The initial depth of insertion was 0.004 cm above midtracheal position (95% CI -0.13 to 0.14, P = 0.96). After controlling for head position, the initial depth did not significantly differ from the midtracheal position among weight groups. Predicted depth using the 7-8-9 Rule placed the ETT 0.12 cm above midtracheal position (95% CI -0.30 to 0.06, P = 0.20). However, after controlling for head position, the 7-8-9 Rule positioned the ETT significantly below midtracheal position in infants weighing <750 g (mean 0.62 cm; 95% CI 0.30 to 0.93, P=0.002).

CONCLUSIONS

The 7-8-9 Rule appears to be an accurate clinical method for endotracheal tube placement in neonates weighing more than 750 g. When the 7-8-9 Rule is applied to infants weighing <750 g, caution is warranted. The current rule may lead to an overestimated depth of insertion and potentially result in clinically significant consequences.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

There are three approaches to hysterectomy for benign disease - abdominal hysterectomy (AH), vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions - laparoscopic assisted vaginal hysterectomy (LAVH) where a vaginal hysterectomy is assisted by laparoscopic procedures that do not include uterine artery ligation, laparoscopic hysterectomy (which we will abbreviate to LH(a)) where the laparoscopic procedures include uterine artery ligation, and total laparoscopic hysterectomy (TLH) where there is no vaginal component and the vaginal vault is sutured laparoscopically.

OBJECTIVES

To assess the most appropriate surgical approach to hysterectomy.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group's Specialised Register of controlled trials (searched 23 March 2004), CENTRAL (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to Mar 2004), EMBASE (1985 to Mar 2004), Biological Abstracts (1968 to Mar 2004), the National Research Register and relevant citation lists.

SELECTION CRITERIA

Only randomised trials comparing one surgical approach to hysterectomy with another were included.

DATA COLLECTION AND ANALYSIS

Twenty-seven trials that included 3643 participants were included. Independent selection of trials and data extraction were employed following Cochrane guidelines.

MAIN RESULTS

The benefits of VH versus AH were shorter duration of hospital stay (WMD 1.0 day, 95%CI 0.7 to 1.2 days), speedier return to normal activities (WMD 9.5 days, 95%CI 6.4 to 12.6 days), fewer unspecified infections or febrile episodes (OR 0.42, 95%CI 0.21 to 0.83). The benefits of LH versus AH were lower intraoperative bloodloss (WMD 45.3 mls, 95%CI 17.9 to 72.7 mls) and a smaller drop in haemoglobin level (WMD 0.55g/L, 95%CI 0.28 to 0.82g/L), shorter duration of hospital stay (WMD 2.0 days, 95%CI 1.9 to 2.2 days), speedier return to normal activities (WMD 13.6 days, 95%CI 11.8 to 15.4 days), fewer wound or abdominal wall infections (OR 0.32, 95%CI 0.12 to 0.85), fewer unspecified infections or febrile episodes (OR 0.65, 95%CI 0.49 to 0.87), at the cost of longer operating time (WMD 10.6 minutes, 95%CI 7.4 to 13.8 minutes) and more urinary tract (bladder or ureter) injuries (OR 2.61, 95%CI 1.22 to 5.60). There was no evidence of benefits of LH versus VH and the operating time was increased (WMD 41.5 minutes, 95%CI 33.7 to 49.4 minutes). There was no evidence of benefits of LH(a) versus LAVH and the operating time was increased for LH(a) (WMD 25.3 minutes, 95%CI 10.0 to 40.6 minutes). There was statistical heterogeneity in many of the outcome measures when randomised trials were pooled for meta-analysis. No other statistically significant differences were found. However, for some important outcomes, the analyses were underpowered to detect important differences, or they were simply not reported in trials. Data were notably absent for many important long-term outcome measures.

AUTHORS' CONCLUSIONS

Significantly improved outcomes suggest VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH, however the length of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when the uterine arteries are divided laparoscopically and laparoscopic approaches require greater surgical expertise. The surgical approach to hysterectomy should be decided by a woman in discussion with her surgeon in light of the relative benefits and hazards. Further research is required with full reporting of all relevant outcomes, particularly important long-term outcomes, in large RCTs, to minimise the possibility of reporting bias. Further research is also required to define the role of the newer approaches to hysterectomy such as TLH.

Autoantibody biomarker opens a new gateway for cancer diagnosis

The list of cancer markers of current interest has grown considerably, but none of the markers used in clinical work is a true tumor marker. These cancer biomarkers are based on the determination of tumor antigens. Here, we report a single method of autoantibody enzyme immunoassay (EIA) screens for a spectrum of serum tumor markers. A comparison of the autoantibody-based EIA to conventional antigen EIA kits, using receiver operating characteristic (ROC) plots, showed that the autoantibody EIA can significantly enhance the sensitivity and specificity of tumor markers. The detection of serum autoantibodies for a spectrum of serum tumor markers, as demonstrated here, suggests that most, if not all, serum cancer biomarkers produce autoantibodies. A unique autoantibody biomarker screening method, as presented here, might therefore facilitate achieving the accurate and early diagnosis of cancer.

Wildlife rabies in Western Turkey: the spread of rabies through the western provinces of Turkey

The incidence of rabies has decreased in Turkey during recent years. However, an increasing number of rabies cases have been reported in the Aegean (western) region of Turkey. The virus appears to have maintained a foothold in the urban areas of the province of Izmir with only three cases per year being reported during the mid-1990s. Since 2001, the virus has been recorded in the previously rabies-free provinces of Manisa and Aydin. During this epizootic, cases have been reported in both dogs and foxes, and there has been an unusually high incidence of rabies in domestic livestock, especially cattle. This report describes the development of this epizootic and a preliminary phylogenetic study which suggests that the source of this epizootic was likely to have been the residual cases within Izmir rather than a fresh introduction of rabies from foci to the north (Istanbul) and the Eastern provinces of Turkey.

Molecular epidemiological study of Arctic rabies virus isolates from Greenland and comparison with isolates from throughout the Arctic and Baltic regions

We report a molecular epidemiological study of rabies in Arctic countries by comparing a panel of novel Greenland isolates to a larger cohort of viral sequences from both Arctic and Baltic regions. Rabies virus isolates originating from wildlife (Arctic/red foxes, raccoon-dogs and reindeer), from domestic animals (dogs/cats) and from two human cases were investigated. The resulting 400 bp N-gene sequences were compared with isolates representing neighbouring Arctic or Baltic countries from North America, the former Soviet Union and Europe. Phylogenetic analysis demonstrated similarities between sequences from the Arctic and Arctic-like viruses, which were distinct from rabies isolates originating in the Baltic region of Europe, the Steppes in Russia and from North America. The Arctic-like group consist of isolates from India, Pakistan, southeast Siberia and Japan. The Arctic group was differentiated into two lineages, Arctic 1 and Arctic 2, with good bootstrap support. Arctic 1 is mainly comprised of Canadian isolates with a single fox isolate from Maine in the USA. Arctic 2 was further divided into sub-lineages: 2a/2b. Arctic 2a comprises isolates from the Arctic regions of Yakutia in northeast Siberia and Alaska. Arctic 2b isolates represent a biotype, which is dispersed throughout the Arctic region. The broad distribution of rabies in the Arctic regions including Greenland, Canada and Alaska provides evidence for the movement of rabies across borders.

A randomised trial comparing the levonorgestrel intrauterine system and thermal balloon ablation for heavy menstrual bleeding

OBJECTIVE

To compare the levonorgestrel intrauterine system (LNG-IUS) (Mirena); Schering Co., Turku, Finland) and thermal balloon ablation (Thermachoice; Gynecare Inc., Menlo Park, CA, USA) for the treatment of heavy menstrual bleeding.

DESIGN

An open, pragmatic, prospective randomised trial.

SETTING

A menstrual disorders clinic at National Women's Hospital, Auckland, New Zealand.

POPULATION

Seventy-nine women with heavy menstrual bleeding randomised to the LNG-IUS (40 women) or the thermal balloon ablation (39 women).

METHODS

Women were randomised to treatment with the LNG-IUS or thermal balloon ablation and followed up by a postal and telephone questionnaire.

MAIN OUTCOME MEASURES

Menstrual loss measured by a pictorial bleeding assessment chart (PBAC) at 3, 6, 12 and 24 months. Patient satisfaction, quality of life and menstrual symptoms were assessed by questionnaire administered at 3, 6, 12 and 24 months. Treatment side effects and treatment failures were also recorded.

RESULTS

Both the treatments resulted in a significant reduction in PBAC scores. At 12 and 24 months, median PBAC scores were significantly lower in women treated with the LNG-IUS compared with women treated by thermal balloon ablation (11.5 versus 60.0 at 12 months [P= 0.002]; 12.0 versus 56.5 [P= 0.002] at 24 months). At 24 months, nine (35%) women still using the LNG-IUS had amenorrhoea compared with one (5%) woman successfully treated by thermal balloon ablation (P = 0.025). There were no significant differences in patient satisfaction between two treatments during follow up. Treatment failed in 11 (28%) women using the LNG-IUS and in 10 (26%) women treated with thermal balloon ablation. Overall, women in both groups showed an increased quality of life as a result of the treatment, with Short Form-36 scores increasing from 63.7 at randomisation to 76.1 at 24 months.

CONCLUSIONS

At 12 and 24 months of follow up, women with heavy menstrual bleeding treated with the LNG-IUS have significantly lower PBAC scores than women treated with thermal balloon ablation. Both the treatments resulted in a significant increase in overall quality of life, but there were no significant differences between either treatment in quality of life, patient satisfaction or the number of women requesting an alternative treatment during 24 months of follow up.

Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer

BACKGROUND

Ovarian cancer tends to be chemosensitive and confine itself to the surface of the peritoneal cavity for much of its natural history. These features have made it an obvious target for intraperitoneal chemotherapy. Chemotherapy for ovarian cancer is usually given as an intravenous infusion repeatedly over 5 to 8 cycles. Intraperitoneal chemotherapy (IP) is given by infusion of the chemotherapeutic agent directly into the peritoneal cavity. This may increase the anticancer effect with fewer systemic adverse effects in comparison to intravenous therapy.

OBJECTIVES

To determine if adding a component of the chemotherapy regime into the peritoneal cavity affects overall survival, progression free survival, quality of life (QOL) and toxicity for women receiving primary treatment of epithelial ovarian cancer.

SEARCH STRATEGY

The reviewers searched the UK Cochrane trials register, Gynaecological Cancer Group Specialised Register, computer databases and handsearched and cascade searched the major gynaecological oncology journals.

SELECTION CRITERIA

The analysis was restricted to randomised controlled trials assessing women with a new diagnosis of primary epithelial ovarian cancer, of any FIGO stage, following primary cytoreductive surgery. Standard intravenous chemotherapy was compared with chemotherapy that included a component of intraperitoneal administration.

DATA COLLECTION AND ANALYSIS

Two reviewers conducted data extraction independently. The reviewers retrieved data on overall and disease free survival as well as adverse events and QOL and then performed a meta-analysis of outcomes, using hazard ratios for time-to-event variables and relative risks for dichotomous outcomes.

MAIN RESULTS

Eight randomised trials studied 1819 women receiving primary treatment for ovarian cancer. Women were less likely to die if they received an intraperitoneal (IP) component to the chemotherapy (hazard ratio (HR) =0.79; 95% confidence interval (CI): 0.70 to 0.90)and the disease free interval (HR =0.79; 95%CI: 0.69 to 0.90) was also significantly prolonged. There may be greater serious toxicity with regard to gastrointestinal effects, pain and fever but less ototoxicity with the intraperitoneal than the intravenous route.

AUTHORS' CONCLUSIONS

This analysis establishes the benefit of IP chemotherapy. It increases overall survival and progression free survival from advanced ovarian cancer. The results of this meta-analysis provide the most reliable estimates of the relative survival benefits of IP over IV therapy and should be used as part of this decision making process. However, the potential for catheter related complications and toxicity needs to be considered when deciding on the most appropriate treatment for each individual woman. The optimal dose, timing and mechanism of administration cannot be addressed from this meta-analysis. This needs to be addressed in the next phase of clinical trials.

Development of a real-time, differential RT-PCR TaqMan assay for lyssavirus genotypes 1, 5 and 6

A number of RT-PCR methods have been reported for the detection of rabies and rabies-related viruses. Here, a single, closed tube, non-nested RT-PCR TaqMan assay to distinguish between Classical rabies virus and European bat lyssaviruses 1 and 2 in real time is described. The TaqMan assay is rapid, sensitive, specific and allows for the genotyping of unknown isolates concomitant with the RT-PCR. It can be applied quantitatively and the use of an internal control enables the quality of the isolated template to be assessed. The efficiency and dynamic range of the PCR has been established using isolated viral RNA and cloned control template. Comparative performance of the TaqMan assay against other diagnostic methodologies for the detection of rabies virus has been determined and the assay validated against a panel of archival samples and virus of unknown genotype from both Germany and the Sudan. Despite sequence heterogeneity between the different genotypes in the N-gene, a universal forward and reverse primer set have been designed allowing simplification of previously described assays. Rapid genotyping of two recent EBLV2 cases in the U.K. in Daubenton's bats and a recently imported human case of rabies has been performed using this test.

Molecular epidemiology of rabies viruses in Europe

Several different strains of classical rabies virus co-circulate in Europe. In order to investigate the roles of the host species and topography on the molecular epidemiology of these viruses, a 400 bp region of the nucleoprotein gene was sequenced and compared with more than 500 European virus isolates. Viruses from 21 European countries were represented including some unique panels of archived isolates from the former Republic of Yugoslavia, Estonia, the Czech Republic, Poland and Austria. Phylogenetic analysis of 198 unique sequences demonstrated numerous groups of viruses clustered at both geographical and host-species levels.

The diversity of rabies virus in Russia demonstrated by anti-nucleocapsid monoclonal antibody application and limited gene sequencing

A comparative analysis of anti-nucleocapsid monoclonal antibody (N-mAb) reaction profiles and DNA sequences was performed on 97 selected rabies virus (RABV) isolates from Russia and neighbouring states. A panel of 73 N-mAb from the Wistar Institute (Philadelphia, PA, USA), Veterinary Laboratories Agency (Weybridge, UK) and P-41 (Tübingen, Germany) was used. The sequence of a 400 bp fragment of the N gene was generated for all available isolates and a phylogenetic analysis of the fragment was carried out. The results of genetic and antigenic typing were in concordance, except for a few deviations. Three RABV variants with distinct antigenic patterns corresponded to well characterised genetic groups. The phylogenetic analysis also allowed the discrimination of RABVs with similar antigenic profiles originating from distant geographical locations in Russia and other states of the former Soviet Union. In some instances, more than one specific antigenic variant was detected within a phylogenetic group. A number of antigenic and genetic variants were associated with a specific host species (such as red fox, raccoon dog, wolf or polar fox) in different parts of Russia. A single, antigenically divergent, P-41-positive, rodent isolate from Siberia was described.

A randomised controlled trial of a new handheld vacuum extraction device

OBJECTIVE

To evaluate the effectiveness of a new handheld vacuum delivery device.

DESIGN

Randomised controlled trial.

SETTING

Southmead Hospital, Bristol, UK.

POPULATION

One hundred and ninety-four women requiring delivery with vacuum extraction.

METHODS

Women were recruited into the study while still in early labour. If during delivery, vacuum extraction was indicated they were then randomly allocated to either a new handheld vacuum device, the Kiwi Omnicup, or to a 'standard' vacuum cup selected by the obstetrician. The 'standard group' consisted of the silastic (66/98, 67%) or the metal cups (32/98, 33%). Study data were recorded at completion of the delivery and at 24-48 hours. An additional brief symptom questionnaire was completed by the mother at 10 days postnatally. Statistical analyses were done on an 'intention-to-treat' basis.

MAIN OUTCOME MEASURES

The primary outcome was the successful completion of delivery with the allocated instrument. Secondary outcomes were substantial fetal scalp trauma and substantial maternal trauma.

RESULTS

The Omnicup was associated with a significantly higher failure rate than the standard cup [34%vs 21%, odds ratio (OR) = 1.9 (1.01-3.6)]. This difference persisted after adjusting for confounding factors [adjusted OR = 2.25 (1.01-5.0)] and resulted in significantly more forceps deliveries in the Kiwi Omnicup group [22%vs 10%, unadjusted OR = 2.5 (1.1-5.5)]. The caesarean section rates were similar in both groups [9.4%vs 8.2%, OR = 1.2 (0.4-3.2)]. Rates of substantial scalp trauma and maternal trauma were similar in both groups. However, there were more cases of jaundice in the standard cup group [2.3%vs 12.0%, unadjusted OR = 0.18 (0.04-0.82) and adjusted OR = 0.10 (0.01-0.88)].

CONCLUSIONS

The Omnicup is not as successful at achieving a vaginal delivery as the combination of the currently used vacuum cups.

Cleavage stage versus blastocyst stage embryo transfer in assisted conception

BACKGROUND

In the past decade, advances in the understanding of nutrient requirements of embryos, has led to the evolution of culture media designed to support extended culture of embryos in vitro from the standard procedure of 2 to 3 days (for early cleavage embryo transfer) to 5 to 6 days (blastocyst culture). The rationale for blastocyst culture is to improve the synchronicity of uterine and embryonic development and provide a mechanism for self-selection of viable embryos. Since the initial widespread introduction of blastocyst culture in 1998, there has been conflicting reports about the clinical benefits of this technique.

OBJECTIVES

To determine if blastocyst stage embryo transfers (ETs) affects success rates compared with cleavage stage ETs and investigate what factors may influence this.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of controlled trials. We also searched the Cochrane Controlled Trials Register (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and Bio extracts. Attempts were made to identify trials from the National Research Register, the Clinical Trials Register and the citation lists of review articles and included trials. The last search date was May 2005. The first or corresponding author of each included trial was contacted for additional information.

SELECTION CRITERIA

Trials were included if they were randomised and compared the effectiveness of early cleavage versus blastocyst stage transfers.

DATA COLLECTION AND ANALYSIS

Of the 45 trials that were identified, 16 trials met the inclusion criteria and were reviewed. Primary outcomes were rates of live birth, clinical pregnancy and multiple-pregnancy rates per couple. Secondary outcomes were rates of miscarriage, failure to transfer embryos, freezing, implantation and high order pregnancy and per cycle data. Quality assessment and data extraction were performed independently by two review authors. Meta-analysis was performed using odds ratios (OR) for dichotomous outcomes and weighted mean differences for binary outcomes with 95% confidence intervals (CI).

MAIN RESULTS

There was no evidence of a difference in live-birth rate per couple between the two treatment groups (7 RCTs; OR 1.16, 95% CI 0.74 to 1.44 [Day 2/3 34.3% vs. Day 5/6 35.4%]); in the clinical pregnancy rate per couple (15 RCTs; OR 1.05, 95% CI 0.88 to 1.26 [Day 2/3 38.8% vs. 40.3%]) even for good prognosis patients (6 RCTs: OR 96% 1.06 CI 0.83 to 1.34). There was also no difference in multiple-pregnancy rate per couple (12 RCTs; OR 0.85, 95% CI 0.63 to 1.13) particularly in trials where equal numbers of embryos were transferred in both groups (6 RCTs: OR 0.91, 95% CI 0.63 to 1.32). There was no evidence of a difference in high order multiple-pregnancy rates per couple (5 RCTs; OR 0.44, 95% CI 0.15 to 1.33) or miscarriage rate per couple between the two groups (9 RCTs; OR 1.33, 95% CI 0.89 to 2.01). Rates of embryo freezing per couple was significantly higher in Day 2 to 3 transfers (9 RCTs; OR 0.45, 95% CI 0.36 to 0.57). Failure to transfer any embryos per couple was significantly higher in the Day 5 to 6 group (10 RCTs: OR 3.21, 95% CI 2.15 to 4.81[Day 2/3 3.5% vs D 5/6 10.1%]), but was not significantly different for good prognosis patients (7RCTs, OR 1.58 95% CI 0.65 to 3.82).

AUTHORS' CONCLUSIONS

There is no evidence of a difference in live birth or pregnancy outcomes between Day 2 to 3 and Day 5 to 6 transfer of embryos. Blastocyst transfer was associated with an increase in failure to transfer any embryos in a cycle and a decrease in embryo freezing rates. In the absence of data on cumulative live birth rates resulting from fresh and thawed cycles, it is not possible to determine if this represents an advantage or disadvantage.

Problem-based, peer-facilitated education about antibiotic prescribing

AIMS

To assess the feasibility and acceptability of a problem-based, peer-facilitated educational workshop about antibiotic prescribingfor GPs.

METHOD

PARTICIPANTS

All 39 GPs working in an average sized Local Health Care Co-operative (LHCC) in Glasgow.

INTERVENTION

Prospective collection of information about 10 prescriptions for antibiotics to assess learning needs in relation to antibiotic prescribing. Two and a half hour workshop involving problem-based group work based on the needs assessment and discussions with a consultant microbiologist, prescribing adviser and academic GP.

EVALUATION

Written feedback about the process of the educational intervention immediately after the workshop and outcome feedback collected after four weeks. Telephone interviews with non-participants.

RESULTS

Twenty-four GPs agreed to participate in the study. 19 of these completed the Needs Assessment and 14 of these completed the workshop. The method of learning needs assessment and the educational workshop were highly acceptable. "No time, too busy" was the main reason given for not taking part in the study.

CONCLUSION

Some GPs are unable to participate as fully as they would like in continuing professional learning activities due to competing workload pressures. Further research is required to investigate the necessary type and balance of learning activities and the barriers to engagement to ensure the most effective use of clinician time available for continuing educational activities.

Development of a real-time, TaqMan reverse transcription-PCR assay for detection and differentiation of lyssavirus genotypes 1, 5, and 6

Several reverse transcription-PCR (RT-PCR) methods have been reported for the detection of rabies and rabies-related viruses. These methods invariably involve multiple transfers of nucleic acids between different tubes, with the risk of contamination leading to the production of false-positive results. Here we describe a single, closed-tube, nonnested RT-PCR with TaqMan technology that distinguishes between classical rabies virus (genotype 1) and European bat lyssaviruses 1 and 2 (genotypes 5 and 6) in real time. The TaqMan assay is rapid, sensitive, and specific and allows for the genotyping of unknown isolates concomitant with the RT-PCR. The assay can be applied quantitatively and the use of an internal control enables the quality of the isolated template to be assessed. Despite sequence heterogeneity in the N gene between the different genotypes, a universal forward and reverse primer set has been designed, allowing for the simplification of previously described assays. We propose that within a geographically constrained area, this assay will be a useful tool for the detection and differentiation of members of the Lyssavirus genus.

Rabies human diploid cell vaccine elicits cross-neutralising and cross-protecting immune responses against European and Australian bat lyssaviruses

The ability of antibodies elicited against the rabies human diploid cell vaccine (HDCV) to neutralise European bat Lyssaviruses (EBLV types-1 and -2), Australian bat Lyssavirus and classical rabies virus (RABV) has been evaluated using modified fluorescent antibody virus neutralisation (mFAVN) assays. Ninety-six percent (48 of 50) of the human post-vaccinated sera tested cross-neutralised these viruses (>or=0.5 IU/ml). Cross-protection experiments using inbred mice (RIII, k/k haplotype) were also assessed. Mice were given HDCV (twice by the intra-peritoneal route) and challenged (intra-cranially or peripherally) with a lethal dose (25 MLD(50)) of the individual viruses. The vaccine conferred statistically significant protection in 80--100% of animals challenged via the peripheral route. Levels of protection were lower following intra-cranial (i.c.) challenge. Our data provides strong evidence for broad spectrum cross-neutralisation and cross-protection of phylogroup I lyssaviruses using rabies HDCV.

Effect of massage of the hamstring muscle group on performance of the sit and reach test

OBJECTIVE

To investigate if a single massage of the hamstring muscle group would alter the performance of the sit and reach test.

METHODS

Before treatment, each of 11 male subjects performed the sit and reach test. The treatment consisted of either massage of the hamstring muscle group (both legs, total time about 15 minutes) or supine rest with no massage. Performance of the sit and reach test was repeated after treatment. Each subject returned the subsequent week to perform the tests again, receiving the alternative treatment relative to their initial visit. Mean percentage changes in sit and reach scores after treatment were calculated for the massage and no massage treatments, and analysed using Student's t tests.

RESULTS

Mean (SD) percentage changes in sit and reach scores after massage and no massage were small (6.0 (4.3)% and 4.6 (4.8)% respectively) and not significantly different for subjects with relatively high (15 cm and above) values before treatment. Mean percentage changes in sit and reach scores for subjects with relatively low values before treatment (below 15 cm) were large (18.2 (8.2)% and 15.5 (16.2)% respectively), but no significant differences were found between the massage and no massage groups.

CONCLUSIONS

A single massage of the hamstring muscle group was not associated with any significant increase in sit and reach performance immediately after treatment in physically active young men.

Tubal flushing for subfertility

BACKGROUND

A possible therapeutic effect of diagnostic tubal patency testing has been debated in the literature for half a century. Further debate surrounds whether oil-soluble or water-soluble contrast media might have the bigger fertility-enhancing effect. Historically a variety of agents have been used to 'flush' the fallopian tubes, although tubal flushing does not currently form part of routine practice in the treatment of fertility delay.

OBJECTIVES

To evaluate the effect of flushing a woman's fallopian tubes with oil- or water-soluble contrast media on subsequent fertility outcomes in couples with infertility.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of trials (searched 2 March 2004), MEDLINE (1966 to Mar 2004), EMBASE (1980 to Mar 2004), Biological Abstract (1980 to Mar 2004) and reference lists of articles.

SELECTION CRITERIA

All randomised trials where tubal flushing with oil-soluble contrast media or tubal flushing with water-soluble media was compared with one another or with no treatment were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eleven randomised controlled trials were identified and included in this review. All trials were assessed for quality criteria. The studied primary outcome was live birth (and ongoing pregnancy), with secondary outcomes pregnancy, miscarriage, ectopic pregnancy, treatment complications including pain, intravasation of contrast medium, infection and haemorrhage, and image quality.

MAIN RESULTS

Tubal flushing with oil-soluble media versus no intervention (three trials including 381 participants) was associated with a significant increase in the odds of live birth (Peto OR 2.98, 95%CI 1.40 to 6.37) and of pregnancy (Peto OR 3.30, 95%CI 2.00 to 5.43). There were no data from RCTs to assess tubal flushing with water-soluble media versus no intervention. For the comparison of tubal flushing with oil-soluble media versus tubal flushing with water-soluble media (six trials including 1,483 participants), the increase in the odds of live birth for tubal flushing with oil-soluble versus water-soluble media (Peto OR 1.49, 95%CI 1.05 to 2.11) was based on two trials where statistical heterogeneity was present and the higher quality trial showed no significant difference; there was no evidence of a significant difference in the odds of pregnancy (Peto OR 1.24, 95%CI 0.97 to 1.57). The addition of oil-soluble media to flushing with water-soluble media (water-soluble plus oil-soluble media versus water-soluble media alone; three trials including 555 participants) showed no evidence of a significant difference in the odds of pregnancy (Peto OR 1.18, 95%CI 0.82 to 1.70) or live birth (Peto OR 1.06, 95%CI 0.64 to 1.77). Adverse event data were only available for the comparison OSCM versus WSCM: OSCM carried a significantly higher chance of intravasation (Peto OR 5.41, 95%CI 2.57 to 11.37) but a significantly lower chance of immediate pain (Peto OR 0.53, 95%CI 0.34 to 0.84), prolonged pain (Peto OR 0.26, 95%CI 0.15 to 0.45) and post-procedure bleeding (Peto OR 0.22, 95%CI 0.15 to 0.31), and no serious adverse events were reported.

AUTHORS' CONCLUSIONS

There is evidence of effectiveness of tubal flushing with oil-soluble contrast media in increasing the odds of pregnancy and live birth versus no intervention. The limited evidence of an increase in the odds of live birth from tubal flushing with oil-soluble contrast media versus water-soluble contrast media must be interpreted cautiously. Further robust randomised trials, comparing oil-soluble versus water-soluble media and comparing water-soluble media versus no intervention, would be a useful further guide to clinical practice. Further research is merited to ascertain the mechanism of the fertility enhancing effect of oil-soluble media, as to whether this is a 'tubal flushing' phenomenon, an effect on the intraperitoneal environment, or an implantation enhancing effect on the endometrium.

Archival study of a Finnish isolate from the 1988/89 rabies outbreak

An archival brain sample from an infected dog taken during the 1988/89 rabies outbreak in Finland was investigated to confirm that it was infected with classical rabies virus (genotype 1). The first 400 base pairs of the virus nucleoprotein gene were then sequenced and used to undertake a phylogenetic comparison between this isolate and a panel of rabies virus sequences from the Baltic region. The Finnish dog isolate was identical to a virus isolated from a raccoon-dog also recorded during the 1988/89 outbreak and closely related to a third isolate from the Russian city of Pskov. The implications of these observations for the possible source of the Finnish outbreak are discussed.

Surgical approach to hysterectomy for benign gynaecological disease

BACKGROUND

There are three approaches to hysterectomy for benign disease - abdominal hysterectomy (AH), vaginal hysterectomy (VH) and laparoscopic hysterectomy (LH). Laparoscopic hysterectomy has three further subdivisions - laparoscopic assisted vaginal hysterectomy (LAVH) where a vaginal hysterectomy is assisted by laparoscopic procedures that do not include uterine artery ligation, laparoscopic hysterectomy (which we will abbreviate to LH(a)) where the laparoscopic procedures include uterine artery ligation, and total laparoscopic hysterectomy (TLH) where there is no vaginal component and the vaginal vault is sutured laparoscopically.

OBJECTIVES

To assess the most appropriate surgical approach to hysterectomy.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders & Subfertility Group's Specialised Register of controlled trials (searched 23 March 2004), CENTRAL (The Cochrane Library Issue 1, 2004), MEDLINE (1966 to Mar 2004), EMBASE (1985 to Mar 2004), Biological Abstracts (1968 to Mar 2004), the National Research Register and relevant citation lists.

SELECTION CRITERIA

Only randomised trials comparing one surgical approach to hysterectomy with another were included.

DATA COLLECTION AND ANALYSIS

Twenty-seven trials that included 3643 participants were included. Independent selection of trials and data extraction were employed following Cochrane guidelines.

MAIN RESULTS

The benefits of VH versus AH were shorter duration of hospital stay (WMD 1.0 day, 95%CI 0.7 to 1.2 days), speedier return to normal activities (WMD 9.5 days, 95%CI 6.4 to 12.6 days), fewer unspecified infections or febrile episodes (OR 0.42, 95%CI 0.21 to 0.83). The benefits of LH versus AH were lower intraoperative bloodloss (WMD 45.3 mls, 95%CI 17.9 to 72.7 mls) and a smaller drop in haemoglobin level (WMD 0.55g/L, 95%CI 0.28 to 0.82g/L), shorter duration of hospital stay (WMD 2.0 days, 95%CI 1.9 to 2.2 days), speedier return to normal activities (WMD 13.6 days, 95%CI 11.8 to 15.4 days), fewer wound or abdominal wall infections (OR 0.32, 95%CI 0.12 to 0.85), fewer unspecified infections or febrile episodes (OR 0.65, 95%CI 0.49 to 0.87), at the cost of longer operating time (WMD 10.6 minutes, 95%CI 7.4 to 13.8 minutes) and more urinary tract (bladder or ureter) injuries (OR 2.61, 95%CI 1.22 to 5.60). There was no evidence of benefits of LH versus VH and the operating time was increased (WMD 41.5 minutes, 95%CI 33.7 to 49.4 minutes). There was no evidence of benefits of LH(a) versus LAVH and the operating time was increased for LH(a) (WMD 25.3 minutes, 95%CI 10.0 to 40.6 minutes). There was statistical heterogeneity in many of the outcome measures when randomised trials were pooled for meta-analysis. No other statistically significant differences were found. However, for some important outcomes, the analyses were underpowered to detect important differences, or they were simply not reported in trials. Data were notably absent for many important long-term outcome measures.

AUTHORS' CONCLUSIONS

Significantly improved outcomes suggest VH should be performed in preference to AH where possible. Where VH is not possible, LH may avoid the need for AH, however the length of the surgery increases as the extent of the surgery performed laparoscopically increases, particularly when the uterine arteries are divided laparoscopically and laparoscopic approaches require greater surgical expertise. The surgical approach to hysterectomy should be decided by a woman in discussion with her surgeon in light of the relative benefits and hazards. Further research is required with full reporting of all relevant outcomes, particularly important long-term outcomes, in large RCTs, to minimise the possibility of reporting bias. Further research is also required to define the role of the newer approaches to hysterectomy such as TLH.

Identification of a conserved linear epitope at the N terminus of the rabies virus glycoprotein

A novel, linear B-cell epitope has been identified at the N terminus of the rabies virus (RABV) glycoprotein. Screening of a phage-display library demonstrated that two glycoprotein-specific mAbs recognized a conserved sequence, WxxxDI, which aligned between aa 14 and 19 of the mature glycoprotein. Screening of truncated glycoprotein fragments with both mAbs confirmed the location of the epitope in the N-terminal region. Alignment of amino acid sequences from a range of RABV isolates indicated that the site was conserved in most viruses. Alignment with representatives of other lyssaviruses suggested that it is conserved within phylogroup I, which includes the European bat lyssaviruses, but not phylogroup II. A 12 aa synthetic peptide of this epitope was recognized by both mAbs and sera from a subset of rabies-vaccinated dogs. In a multimeric form, the peptide could induce an epitope-specific response following immunization in rabbits and mice.