High-level expression of biologically active human prolactin from recombinant baculovirus in insect cells

We examined the feasibility of high-level production of recombinant human prolactin, a multifunctional protein hormone, in insect cells using a baculovirus expression system. The human prolactin cDNA with and without the secretory signal sequence was cloned into pFastBac1 baculovirus vector under the control of polyhedrin promoter. Prolactin was produced upon infection of either Sf9 or High-Five cells with the recombinant baculovirus containing the human prolactin cDNA. The production of recombinant prolactin varied from 20 to 40 mg/L of monolayer culture, depending on the cell types. The prolactin polypeptide with its own secretory signal was secreted into the medium. N-terminal amino acid sequence analysis of the recombinant polypeptide purified from the culture medium indicated that the protein was processed similar to human pituitary prolactin. Carbohydrate analysis of the purified protein indicated that a fraction of the recombinant prolactin made in insect cells appeared to be glycosylated. Also, both secreted and nonsecreted forms of the recombinant prolactin in insect cells were biologically equivalent to the native human prolactin (pituitary derived) in the Nb2 lymphoma cell proliferation assay.

Improved indices of insulin resistance and insulin secretion for use in genetic and population studies of type 2 diabetes mellitus

Homeostasis model assessment (HOMA) provides indices of insulin secretion (beta) and insulin resistance (R) derived from fasting plasma glucose (FPG) and fasting plasma insulin (FPI) levels. However, these indices could not account for a significant heritability of fasting plasma glucose (FPG) (h2 = 0.75, P<0.01) in a group of 214 female twins. This result is consistent with a misclassification between effects due to insulin secretion and resistance in the HOMA indices. We report here evidence of such misclassification in the HOMA indices and describe a minor modification to the model which corrects it. Direct measures of insulin resistance (euglycaemic clamp) and secretion (i.v. glucose bolus) were obtained in 43 non-diabetic subjects. Heritability was estimated by statistical modelling of genetic and environmental influences in data from 214 non-diabetic female subjects. Modified HOMA (HOMA') indices were obtained from beta' = (Ln(FPI) - c)/FPG and R' = (Ln(FPI) - c)*FPG where c is a constant derived from regression analysis of Ln(FPI) vs FPG. Indices from both models correlated with the direct measures similarly (r = 0.63 (R), 0.49 (R'), 0.45 (beta), 0.39 (beta'), all P< 0.01). Directly measured insulin resistance and secretion were not significantly correlated (r = 0.13, P = 0.21). However, unmodified HOMA-beta and R were strongly related (r = 0.78, P<0.0001 vs. 0.13) demonstrating substantial misclassification. The relationship between beta' and R' (r = 0.13) was not different from that between the two direct measures and significant heritability of beta' (h2 = 0.68, P<0.01) and R' (h2 = 0.59, P<0.05) was evident in the twin data. The proposed modification to HOMA significantly reduces misclassification and reveals separate components of insulin resistance and insulin secretion in the heritability of FPG.

The dangerousness of youth-at-risk: the possibilities of surveillance and intervention in uncertain times

This paper will explore the dangerous possibilities provoked by the popular and promiscuous construction of the category of "youth-at-risk". In an age of large-scale and profound social changes, narratives of uncertainty and risk dominate popular, political and theoretical discourses about youth. Under these social conditions, the discourse of youth-at-risk is mobilized from a variety of intellectual and political positions in various attempts to regulate the behaviors and dispositions of youth. The paper will argue that these discourses provoke dangerous possibilities for the increased surveillance of, and intervention into, young people's lives by regulatory authorities (schools, police, health services, and juvenile justice systems) and the forms of expertise recruited by these agencies.

Technical cost of radiologic examinations: analysis across imaging modalities

PURPOSE

To determine the individual technical costs of general diagnostic radiographic, ultrasonographic (US), computed tomographic (CT), magnetic resonance (MR) imaging, and scintigraphic examinations and interventional radiology.

MATERIALS AND METHODS

The Radiology Cost and Productivity Benchmarking Study method of the University HealthSystem Consortium, a cooperative group of academic medical centers, was modified and extended to the six imaging modalities in a tertiary care academic setting. Hospital billing and cost records were analyzed for fiscal year 1996. Costs were divided into labor and nonlabor categories and were allocated to individual imaging modalities on the basis of resources consumed. Physician cost and hospital overhead were not included. Unit costs were analyzed per technical relative value unit (RVU) and per examination.

RESULTS

The costs per technical RVU for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $65. 06, $28.74, $20.95, $17.69, $42.19, and $89.03, respectively. The technical costs per examination for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $41.92, $50.28, $112.32, $266.96, $196.88, and $692.60, respectively.

CONCLUSION

The method of unit cost analysis for individual imaging modalities was successfully tested in a tertiary care setting. The method should be adopted to allow cost comparison across many institutions, which will permit the promotion of best practices.

Bizarre parosteal osteochondromatous proliferation (Nora's lesion) of the sesamoid: a case report

We report the a case of Nora's lesion (Bizarre Parosteal Osteochondromatous Proliferation) of the sesamoid. A 32-year-old woman presented with a painless, enlarging mass of two years duration on the plantar aspect of the first metatarsophalangeal joint of the left foot. Radiographs, Computerized Tomographs and Magnetic Resonance images, initially suggested a parosteal osteosarcoma arising from the tibial sesamoid. The mass was excised, and a histological diagnosis of Bizarre Parosteal Osteochondromatous Proliferation of bone (Nora's lesion) was made. The aggressive growth of this lesion may suggest a neoplasm clinically. Histological features, however, are those of a reactive lesion.

The quantitative measurement of autoantibodies to thyroglobulin and thyroid peroxidase by automated microparticle based immunoassays in Hashimoto's disease, Graves' disease and a follow-up study on postpartum thyroid disease

The aim of this study was to investigate the association between various autoimmune thyroid diseases and the presence of anti-TPO and anti-Tg antibodies using two novel automated microparticle based immunoassays developed for the AxSYM analyzer. Serum samples from 65 individuals with Hashimoto's Disease, 38 with Graves' Disease and 80 UK blood donors were assayed. In addition, samples were taken from 50 women known to be positive for TPO antibodies, for up to 24 weeks following delivery. Precision for both assays ranges from 5.7-9.1% CV, while analytical sensitivity was determined to be 1.0 IU/ml for Anti-Tg and 0.3 IU/ml for Anti-TPO. The Anti-TPO test showed positive results in 86% of Hashimoto's Disease and 87% of Graves' Disease. The figures obtained for Anti-Tg were 58% and 73% respectively. Specificity was 94% with Anti-TPO and 99% with Anti-Tg. The postpartum women were divided into 2 groups, group A remained symptomless while group B developed thyroid dysfunction. Within the 2 groups, medians calculated at each time point were compared between and within groups using the Mann-Whitney Rank Sum Test or the Kruskal-Wallis One Way ANOVA on Ranks. Anti-TPO baseline levels (week 6) were statistically different between both groups (median 36 vs. 167 IU/ml, p = 0.002). In group A, the median values increased from 36 to 87 IU/ml within the observation period, although the difference was not statistically significant. In group B, antibody titres showed a statistically significant increase from 168 IU/ml (week 6) up to 676 IU/ml after 20 weeks (p < 0.001). Anti-Tg baseline levels were not statistically different between the two groups. In group A, the median values did not change significantly over time (range: 47-86 IU/ml) whereas antibody titres in group B showed a statistically significant increase from 79 IU/ml (week 6) to 276 IU/ml after 24 weeks (p = 0.002). Results obtained indicate that these assays provide useful tools for the quantitative determination of autoantibodies in both primary diagnosis as shown with the Hashimoto's disease and Graves' disease samples and patient follow-up as demonstrated with the postpartum samples. The automation and high precision of the assays make them perfectly suited to routine diagnostic use.

Transgenic approaches to model Alzheimer's disease

Two transgenic mouse lines were generated which express human APP751 containing familial Alzheimer's disease (AD) mutations in brain neurons. These mice develop pathological features reminiscent of AD. The degree of pathology depends on both expression levels and specific mutations. In mice with more advanced pathology (APP 23), typical plaques appear at six months which increase with age and are Congo Red positive at first detection. These congophilic plaques are accompanied by neuritic changes and dystrophic cholinergic fibers. Furthermore, inflammatory processes indicated by a massive glial reaction are apparent. Most notably, plaques are immunoreactive for hyperphosphorylated tau, reminiscent of early tau pathology. A quantitative analysis of degenerative changes by state-of-the-art unbiased stereological methods revealed a significant reduction in neuronal cell bodies of the CA1 field of the hippocampus when compared to controls. This reduction is directly related to plaque load. When subjected to analysis in the Morris water maze, 18 month old APP 23 mice show a significant increase in platform finding latency throughout the entire trial when compared to non-transgenic littermates.

Permanent transfemoral pacemaker implantation is the technique of choice for patients in whom the superior vena cava is inaccessible

We describe transfemoral pacemaker implantation in three patients in whom pacing via the superior vena cava was not possible or suboptimal. The first was an 88-year-old man with superior vena cava obstruction presenting with fractured epicardial pacing leads. Recent pneumonia increased the risks of a general anesthetic. The second patient was a 57-year-old man who was intolerant of a pectorally sited pacemaker because of the thinness of his anterior chest wall. The third patient was a 69-year-old woman who presented with an infected eroding pectorally sited pacemaker. Scarring secondary to a previous pacemaker infection rendered the contralateral pectoral site inaccessible. Since the subclavian route was inaccessible (case 1) or suboptimal (case 2 and 3), we implanted transvenous pacemakers via the femoral route, which was safe, and effective, during a 6-month follow-up period.

Microvascular decompression for trigeminal neuralgia: report of outcome in patients over 65 years of age

Microvascular decompression (MVD) is now recognized as an effective operation for the cure of trigeminal neuralgia (TN), and is far superior to the other surgical procedures utilized in the treatment of TN. TN is common in the elderly, but there is debate concerning MVD in 'elderly' patients. Some clinicians have a policy of not offering patients over a certain age the choice of MVD, yet the recurrence rate is inversely related to the age of the patient. Previous failed procedures and a long period of pain before MVD, also affect the outcome negatively. This study is a retrospective review of the outcome in elderly patients following MVD. Forty-two patients over the age of 65 years are reviewed after undergoing MVD for TN. The results indicate that there was no serious morbidity or mortality that could be ascribed to old age and the length of stay in the hospital was not influenced by the age of the patient. The results are compared with the outcome in a younger age group and the literature on MVD for TN reviewed.

Efficient gene transfer into human cord blood CD34+ cells and the CD34+CD38- subset using highly purified recombinant adeno-associated viral vector preparations that are free of helper virus and wild-type AAV

Recombinant adeno-associated viral (rAAV) vectors have been evaluated for their ability to transduce primitive hematopoietic cells. Early studies documented rAAV-mediated gene expression during progenitor derived colony formation in vitro, but studies examining genome integration and long-term gene expression in hematopoietic cells have yielded conflicting results. Such studies were performed with crude vector preparations. Using improved methodology, we have generated high titer, biologically active preparations of rAAV free of wild-type AAV (less than 1/107particles) and adenovirus. Transduction of CD34+ cells from umbilical cord blood was evaluated with a bicistronic rAAV vector encoding the green fluorescent protein (GFP) and a trimetrexate resistant variant of dihydrofolate reductase (DHFR). Freshly isolated, quiescent CD34+ cells were resistant to transduction (less than 4%), but transduction increased to 23 +/- 2% after 2 days of cytokine stimulation and was further augmented by addition of tumor necrosis factor alpha (51 +/- 4%) at a multiplicity of infection of 106. rAAV-mediated gene expression was transient in that progenitor derived colony formation was inhibited by trimetrexate. Primitive CD34+ and CD34+, CD38- subsets were sequentially transduced with a rAAV vector encoding the murine ecotropic receptor followed by transduction with an ecotropic retroviral vector encoding GFP and DHFR. Under optimal conditions 41 +/- 7% of CD34+ progenitors and 21 +/- 6% of CD34+, CD38- progenitors became trimetrexate resistant. These results document that highly purified rAAV transduce primitive human hematopoietic cells efficiently but gene expression appears to be transient. Gene Therapy (2000) 7, 183-195.

Isolation and stigma: the experience of patients with active tuberculosis

Tuberculosis treatment is an important component of community health programs. Understanding how different groups of patients experience tuberculosis can influence the completion of drug therapy. This study explored how a sample of patients with active tuberculosis experienced their illness. Guided by questions from Kleinman's (1980) explanatory model, 28 semistructured interviews were conducted in public health clinics. The analysis suggested that patients understood tuberculosis through the medical model and perceived themselves as disease vectors. After their diagnosis became known, almost all patients felt that their family and friends avoided or shunned them. Patients responded to these attitudes by isolating themselves and becoming secretive about their illness. An awareness of patients' experiences can help nurses to understand behaviors that may be labeled as noncompliant and design interventions that address these behaviors. Modifying community attitudes and behaviors poses a longer term challenge to the elimination of tuberculosis.

Genetic influences on F cells and other hematologic variables: a twin heritability study

To assess the relative contribution of genetic factors in the variation of F cells (FC) and other hematologic variables, we conducted a classical twin study in unselected twins. The sample included 264 identical (monozygotic [MZ]) twin pairs and 511 nonidentical (dizygotic [DZ]) same-sex twin pairs (aged 20 to 80 years) from the St. Thomas' UK Adult Twin Register. The FC values were distributed continuously and positively skewed, with values ranging from 0.6% to 22%. FC values were higher in women than in men and decreased with age, with the variables accounting for 2% of the total FC variance. The intraclass correlations of FC values were higher in MZ (rMZ = 0.89) than in DZ (rDZ = 0.49) twins. The XmnI-(G)gamma polymorphism in the beta-globin gene cluster had a significant effect on FC levels, accounting for approximately 13% of the total FC variance. Variance components analysis showed that the FC values were accounted for predominantly by additive genetic and nonshared environmental influences, with an estimate of heritability of 0.89. Hemoglobin levels and red blood cell, white blood cell, and platelet numbers were also substantially heritable, with heritability estimates of 0.37, 0.42, 0.62, and 0.57, respectively. Previously, studies of sib pairs with sickle cell disease and isolated family studies showed that high levels of Hb F and FC tend to be inherited. Here, our classical twin study demonstrated that the variance of FC levels in healthy adults is largely genetically determined. (Blood. 2000;95:342-346)

Expression of apoptosis-associated genes by human dermal scar fibroblasts

The purpose of this study was to determine if aberrant apoptosis plays a role in pathologic wound healing as manifested by hypertrophic scarring and keloid formation. Apoptosis has recently been found to participate in the transition between granulation tissue and the development of definitive scar. The question that remains to be answered is what stimuli initiate apoptosis during wound healing. Hitherto, regulatory factors and pathways involved have been largely undefined. We investigated heterogeneity among fibroblasts derived from normal skin and keloid scar, by examining apoptotic profiles and pathways for these cells. Quantitative analysis of apoptotic cells using an Annexin-V-FITC binding assay showed that normal skin fibroblast cultures were found to have a two-fold higher percentage of apoptotic cells than did keloid fibroblast cultures. To study apoptotic pathways and related death-associated genes, a ribonuclease protection assay was performed for fibroblasts exposed to anti-Fas antibody and tumor necrosis factor-alpha to activate the Fas/TNF receptor apoptotic pathway. Compared with normal skin fibroblasts, keloid fibroblasts exhibited decreased expression of apoptosis-associated genes.

Ceramide glycanase activities in human cancer cells

Ceramide glycanase (CGase) activities have been detected in different human tumor cells (colon, carcinoma Colo-205; neuroblastoma, IMR-32; breast cancer lines, SKBr3 and MCF7). However, the level of enzymatic activity is lower in these cells compared to that present in other mammalian tissues reported before (Basu, M., Kelly, P., Girzadas, M. A., Li, Z., and Basu, S. Methods Enzymol. (in press)). The majority of CGase activity was found in the 100,000 g soluble supernatant fraction isolated from all these cell lines and tissues. Using the soluble enzyme, the requirement for optimum CGase activity was found to be consistent with previous observations found for rat and rabbit tissues (Basu, M., Dastgheib, S., Girzadas, M. A., O'Donnell, P. H., Westervelt, C. W., Li, Z., Inokuchi, J. I., and Basu, S. (1998) Acta Pol. Biochim. 42:327). The CGase activities from both Colo-205 and IMR-32 cells are optimum at a protein to detergent ratio of one. All the mammalian CGases, including human cancer cells, show an optimum pH between 5.5 and 5.8 in sodium acetate buffer. The CGase activities from cancer cells are found to be cation-independent; however, mercury, zinc, and copper ions seem to inhibit the enzyme activity substantially in both tumor cells lines. The mercury ion inhibition of CGase activities from all different sources indicates a possible structural homology in the CGase proteins. Radiolabeled substrates, labeled at the sphingosine double bond or at the 3-position of sphingosine without modifying double bond of sphingosine were used in this investigation. Both were active substrates with all enzyme preparations isolated from different cancer cells (apparent Km, 500 microM for nLcOse5[3H-DT]Cer and 350 microM for GgOse4[sph-3-3H]Cer with Colo-205 enzyme). Structural analogues of ceramide and sphingosine (L-PPMP. L-PDMP, alkylamines, and Tamoxifen) inhibited cancer cell CGase activities in vitro.

Laparoscopic extraperitoneal inguinal hernia repair in the day-care setting

BACKGROUND

Totally extraperitoneal (TEP) laparoscopic inguinal hernia repair is gaining popularity, and our preference is to perform this procedure as a day case. This study evaluates the suitability of TEP repair in the day-care setting.

METHODS

A policy of day-care TEP repair, unless contraindicated, was adopted for inguinal hernia repair, and the outcome was prospectively evaluated. Of 87 consecutive inguinal hernia repairs, day-care TEP was possible in 54 (62%); 17 (20%) were in-patient TEP, 14 (16%) were open repairs, and 2 (2%) were converted from TEP to open repairs.

RESULTS

Among day-care TEP repairs, median visual analog pain score at discharge was 2.3/10, and 43% of patients had no pain. Complications included cord hematoma 2 (4%) and seroma 3 (6%). Median times for stopping analgesia, resumption of full activity, and return to work were 3, 3, and 6 days respectively. Complete satisfaction with day-care TEP was expressed by 91% of patients; 9% were moderately satisfied, and none expressed dissatisfaction.

CONCLUSIONS

Day-care TEP repair is feasible in the majority of patients with inguinal hernias, and it is associated with minimal complications, excellent recovery, and a high degree of patient satisfaction.

Prolactin blocks glucocorticoid induced cell death by inhibiting the disruption of the mitochondrial membrane

Prolactin (PRL) has been reported to inhibit dexamethasone (Dex) induced cell death. Nevertheless, the mechanism through which PRL exerts its protective effect is still not unravelled. Here, we analyse the effect of PRL at different stages of the glucocorticoid (GC) apoptotic pathway in PRL dependent cells (Nb2 cells). PRL blocks completely the GC induced loss of the mitochondrial transmembrane potential (delta psi(m)) and consequently phosphatidylserine (PS) exposure and loss of DNA content. Although PRL promotes an upregulation of the bcl-2 expression, simultaneous addition of PRL to GC fails to maintain even the normal levels of this anti-apoptotic protein. This finding excludes a critical role for bcl-2 in the PRL protective effect against GC. GC induced delta psi(m) disruption can be inhibited by the ICE-like inhibitor zVAD-fmk but not by ICE inhibitor tetrapeptide acetyl-Tyr-Val-Ala-Asp.chloromethylketone (YVAD-cmk) nor by caspase-3 inhibitor zDEVD. It can be speculated that PRL blocks delta psi(m) disruption by inhibiting an unknown caspase activated by GC.

Efficient transduction of human lymphocytes and CD34+ cells via human immunodeficiency virus-based gene transfer vectors

The development of gene transfer systems for the efficient transduction of human primary cells including lymphocytes and CD34+ cells is a significant step in the advancement of gene therapy and cell marking protocols. Efficient gene transfer systems also represent useful tools for basic research. Here we show that human primary lymphocytes and CD34+ cells can be efficiently transduced using a VSV-G pseudotyped HIV-1-based gene transfer system. The enhanced green fluorescent protein (EGFP) was chosen as the marker transgene, because it can be easily visualized and quantitated using fluorescence microscopy and flow cytometry, thus eliminating the need for selection or PCR to score transduction. Vectors produced with this system did not generate replication-competent retroviruses (RCRs) and efficiently transduced human cell lines (40-90%), PBMCs (60%), mobilized CD34+ cells (39%), and CD34+ cells from umbilical cord blood (60%) as measured by flow cytometry. Cells treated with AZT prior to infection did not express EGFP, ruling out passive protein or plasmid DNA transfer. This was further confirmed in methylcellulose cultures, where expression in myeloid and erythroid colonies was maintained for at least 3 weeks. In addition, this HIV-based vector was able to efficiently transduce freshly isolated, not-prestimulated CD34+ cells (70% EGFP positive) in serum-free medium. Under these same conditions, a Moloney murine leukemia virus-based vector failed to transduce not-prestimulated CD34+ cells. These characteristics make this gene transfer system an excellent choice for both basic science and possible gene therapy applications.

Micronutrient supplementation in the AIDS diarrhoea-wasting syndrome in Zambia: a randomized controlled trial

OBJECTIVE

As HIV has spread through sub-Saharan Africa, persistent diarrhoea has emerged as a major problem in hospitals and in the community in severely affected areas. We have previously demonstrated that antiprotozoal therapy with albendazole reduces diarrhoea in AIDS patients in urban Zambia. This trial was designed to test the hypothesis that the clinical response to albendazole might be improved by oral micronutrient supplementation.

DESIGN

Randomized, placebo-controlled trial.

SETTING

Home care service of Ndola Central Hospital, Zambia.

PATIENTS

HIV-seropositive patients with persistent diarrhoea.

INTERVENTION

Patients were randomized to albendazole plus vitamins A, C and E, selenium and zinc orally or albendazole plus placebo, for 2 weeks.

MAIN OUTCOME MEASURES

Time with diarrhoea following completion of treatment; mortality; adverse events.

RESULTS

Serum vitamin A and E concentrations before treatment were powerful predictors of early mortality, but supplementation did not reduce time with diarrhoea or mortality during the first month, even after taking into account initial vitamin A or E concentrations, CD4 cell count or clinical markers of illness severity. Serum concentrations of vitamins A and E did not increase significantly in supplemented patients compared with those given placebo, and there were no changes in CD4 cell count or haematological parameters. No adverse events were detected except those attributable to underlying disease.

CONCLUSIONS

Although micronutrient deficiency is predictive of early death in Zambian patients with the diarrhoea-wasting syndrome, short-term oral supplementation does not overcome it nor influence morbidity or mortality.

Irritable bowel syndrome, gastro-oesophageal reflux, and bronchial hyper-responsiveness in the general population

BACKGROUND

Associations have been shown between irritable bowel syndrome (IBS) and gastro-oesophageal reflux, between gastro-oesophageal reflux and asthma, and more recently between IBS and bronchial hyper-responsiveness (BHR).

AIMS

To explore the inter-relations between these conditions.

SUBJECTS

A randomly selected community sample of 4432 adults.

METHODS

A validated postal symptom questionnaire investigating the associations between IBS, gastro-oesophageal reflux symptoms, and symptomatic BHR.

RESULTS

3169 questionnaires (71.7% response) returned by 1451 men and 1718 women were analysed. One year prevalences, in men and women respectively, of IBS were 10.5% and 22.9%, of dyspepsia 26.3% and 25. 25%, of gastro-oesophageal reflux symptoms 29.4% and 28.2%, of BHR 13.2% and 14.6%, and of chronic bronchitis 8.3% and 4.9%. Logistic regression showed independent associations between IBS and BHR, gastro-oesophageal reflux symptoms, and dyspepsia. There was no significant independent association between IBS and chronic bronchitis. In men and women the odds ratio with 95% confidence interval (CI) for IBS and gastro-oesophageal reflux symptoms was 2.6 (2.1-3.1; p<0.001) and for IBS and BHR 2.1 (1.7-2.7; p<0.001). These associations held on stratifying for sex and consultation behaviour. IBS, gastro-oesophageal reflux symptoms, and bronchial hyper-responsiveness occurred more frequently together than expected, 2.5% (95% CI 2.41-2.57) of the sample having all three conditions compared with an expected prevalence of 0.7% (95% CI 0.66-0.71). The conditions were independently associated with each other.

CONCLUSIONS

These observations may indicate the presence of an underlying disorder producing symptoms in gastrointestinal and respiratory systems.

Purification and characterization of avian glycolipid: beta-galactosyltransferases (GalT-4 and GalT-3): cloning and expression of truncated betaGalT-4

Acidic glycolipid of ganglio-(containing sialic acid) and sialyl-lactofucosyl-type, SA-Lex (containing sialic acid and fucose) are developmentally regulated and appear to be ubiquitous on neuronal and cancer cell surfaces of animals. Two glycolipid: beta-galactosyltransferases, GalT-3 and GalT-4, were characterized in embryonic chicken brain (ECB). Based on substrate competition experiments, these two activities were believed to be due to expression of two gene products. A cDNA fragments (about 600 bp) encoding the catalytic domain of the GalT-4 (UDP-Gal:LcOse3Cer beta1,4galactosyltransferase) from ECB and human Colo-204 were isolated. These cDNAs were expressed as a soluble glutathione-S-transferase fusion protein (48 kDa) in Escherichia coli. Interactions between GlcNAc-, UDP-hexanolamine-, and alpha-lactalbumin were studied with the purified fusion protein (recombinant and truncated). Functionally it was similar to that of native GalT-4 purified (40000-fold) from 11-day-old ECB. GalT-3 (UDP-Gal:GM2beta1,3galactosyltransferase) was purified from 19-day-old ECB, and a polyclonal antibody was produced against the peptide backbone for immunoscreening of a lambdaZAP ECB cDNA expression library. Each of the GalT-3 peptides (62 and 65 kDa was analyzed by protein fingerprinting analysis indicating a similar peptide mapping pattern.

Can academic radiology departments become more efficient and cost less?

PURPOSE

To determine how successful two large academic radiology departments have been in responding to market-driven pressures to reduce costs and improve productivity by downsizing their technical and support staffs while maintaining or increasing volume.

MATERIALS AND METHODS

A longitudinal study was performed in which benchmarking techniques were used to assess the changes in cost and productivity of the two departments for 5 years (fiscal years 1992-1996). Cost per relative value unit and relative value units per full-time equivalent employee were tracked.

RESULTS

Substantial cost reduction and productivity enhancement were realized as linear improvements in two key metrics, namely, cost per relative value unit (decline of 19.0% [decline of $7.60 on a base year cost of $40.00] to 28.8% [$12.18 of $42.21]; P < or = .001) and relative value unit per full-time equivalent employee (increase of 46.0% [increase of 759.55 units over a base year productivity of 1,651.45 units] to 55.8% [968.28 of 1,733.97 units]; P < .001), during the 5 years of study.

CONCLUSION

Academic radiology departments have proved that they can "do more with less" over a sustained period.

Variable distribution of Cryptosporidium parvum in the intestine of AIDS patients revealed by polymerase chain reaction

OBJECTIVE

Cryptosporidium parvum is associated with persistent diarrhoea and malnutrition in children, with large waterborne outbreaks and with the diarrhoea-wasting syndrome in AIDS. However, pathophysiology of infection remains to be defined and the reasons for the variability of clinical features are uncertain. The polymerase chain reaction (PCR) is valuable for the analysis of infections with non-culturable organisms because of its high sensitivity, so we compared PCR and microscopy as tools for the analysis of the distribution of infection.

DESIGN

PCR was compared with light microscopy (LM) and electron microscopy (EM) in duodenal biopsies from a well characterized series of 75 Zambian AIDS patients. PCR and LM were then used to define the distribution of infection in biopsies from duodenum, ileum, right colon and left colon in eight South African patients with persistent AIDS-related cryptosporidiosis.

RESULTS

PCR specifically detected 10 fg of genomic C. parvum DNA. When applied to duodenal biopsies from 75 Zambian AIDS patients, infection was detected in all seven cases of duodenal cryptosporidiosis that were identified by LM or EM and in six additional cases which appeared to be negative by microscopy. Distribution of infection was defined in six of eight South African AIDS patients. Two had pan-enteric infection, three had small bowel infection and one had purely ileo-colonic infection. In two cases infection could not be localized despite using PCR, suggesting that infection was confined to the inaccessible mid-small intestine.

CONCLUSIONS

PCR detection of C. parvum DNA demonstrated that infection is highly variable in distribution, which must be taken into account when designing and interpreting studies of pathophysiology.

Local understandings of adult diarrhoeal disease and its treatment in an area of high HIV-seroprevalence in Zambia

We set out to investigate the extent to which cultural constructs might determine treatment-seeking for diarrhoea in the poorer populations of Lusaka, Zambia. This paper describes these concepts and perceptions and outlines a classification of such illnesses, together with an analysis of its implications for understanding treatment choice. Data were derived from focus group discussions, a household survey, a survey of practitioners of traditional medicine and interviews with local residents attending an urban health centre with persistent diarrhoea. The classification is based on symptoms and perceptions of aetiology. While resulting categories convey imperatives for treatment choice, it is clear that individuals with diarrhoeal illnesses seek treatment from multiple sources. This may be because any single illness may fit more than once category, or because unrelenting ill-health engenders desperate behaviour. The cultural constructs do not fully explain treatment choice and attitudes to prevention, but could be used to improve communication regarding public health and treatment strategies.

Bacterial infections of the gut (excluding enteric fever)

Bacterial enteric infections are still a major cause of morbidity and mortality, and many challenges lie ahead in understanding and managing these conditions. Clostridium difficile remains the most important nosocomial infection. Antibiotic resistance makes the treatment of shigella infections increasingly difficult. Molecular and cellular techniques are, however, rapidly expanding our understanding of the complexity of the pathogenesis of established and newly recognized pathogens.

Expression of the ErbB-neuregulin signaling network during human cerebellar development: implications for the biology of medulloblastoma

The four receptor tyrosine kinase I receptors, ErbB-1, ErbB-2, ErbB-3, and ErbB-4, which have been implicated in the development of a variety of normal and malignant tissues, are activated through ligand mediated homo- and heterodimerization. We have previously reported the frequent coexpression, heterodimerzation, and prognostic significance of ErbB-2 and ErbB-4 in childhood medulloblastoma, an embryonal tumor of the cerebellar external granule cell layer (EGL). In the present study, we have used immunohistochemistry and Western blotting analysis to analyze the expression of the ErbB receptors and neuregulin (NRG) 1-alpha and NRG1-beta ligands during normal human cerebellar development. We demonstrate that ErbB-1, ErbB-3, ErbB-4, and NRG1-beta display specific temporal and topographical distribution in the cerebellum during intrauterine and postnatal life, and that normal ErbB-NRG signaling in the EGL multiplying zone is likely to be mediated by ErbB-4 and NRG1-beta. In contrast, ErbB-2, which is expressed in 86% of medulloblastomas, could not be detected at any stage of cerebellar development. Therefore, we propose that positive deregulation of ErbB-2 expression in the cerebellar EGL, leading to the formation of a NRG41-beta-driven ErbB-2/ErbB-4 autocrine loop, is an important factor in medulloblastoma tumorigenesis. In further support of this hypothesis, we provide evidence using reverse transcription-PCR analysis that expression of the ErbB-2 and ErbB-4 receptors, but not ErbB-1 or ErbB-3, is deregulated in medulloblastoma compared with normal developing cerebellum. We also demonstrate NRG1-beta expression in 87% (n = 46 of 48) of medulloblastoma primary tumors, with the greatest expression levels occurring in tumors with high ErbB-2 and ErbB-4 receptor coexpression. Furthermore, the expression of all three components of the proposed autocrine loop (ie., ErbB-2, ErbB-4, and NRG1-beta) was significantly related to the presence of metastases at diagnosis (P < 0.05).

Cryptosporidiosis in urban Zambian children: an analysis of risk factors

In four crowded townships of Lusaka, Zambia, the prevalence of cryptosporidiosis in 222 children with diarrhea was 18%, with marked temporal and geographic variation over the course of one rainy season. Using data on the finding of oocysts of Cryptosporidium parvum in urban water supplies, the areas under study were categorized as high or low risk. Prevalence of cryptosporidiosis in children with diarrhea was higher in high risk areas after stratification by early/late stage of the rains (Mantel-Haenszel odds ratio [OR] = 2.9, 95% confidence interval [CI] = 1.3, 6.7; P = 0.008). Cryptosporidiosis was not associated with keeping animals, nutritional status, or parental education, but was apparently more common in breast fed children (OR = 2.7, 95% CI = 1.1, 6.9; P = 0.01), although the proportion of exclusively breast fed children was not measured. Since most of these infections were of short duration, we conclude that transmission of C. parvum can vary dynamically within one city and over short periods of time, and that water-borne contamination may be a substantial influence.

A randomized controlled trial of extraperitoneal bupivacaine analgesia in laparoscopic hernia repair

BACKGROUND

The limited space developed in totally extraperitoneal laparoscopic inguinal hernia repair (TEP) provides the ideal setting for direct instillation of local anesthetic. This study evaluates the efficacy of extraperitoneal bupivacaine analgesia in patients undergoing day-care TEP.

METHODS

Fifty-six consecutive patients were randomized to intraoperative extraperitoneal instillation of bupivacaine (n = 29) or normal saline control (n = 27). Patients were blindly assessed on discharge from hospital, at 24 hours, 1 week, and 1 month postoperatively.

RESULTS

Compared with controls, patients treated with bupivacaine had lower median (range) visual analogue pain scores on discharge (1.5 [0 to 5.9] versus 3.7 [0.2 to 6.9], P = 0.03), and were more frequently pain free (54% versus 31%, P = 0.078). Although this difference had gone by 24 hours, the bupivacaine group continued to recover faster; stopping analgesia earlier (2 [0 to 7] days versus 3 [0 to 21] days, P = 0.01) and returning to full activity earlier (2.5 [1 to 14] days versus 5 [1 to 21] days, P = 0.013). Of bupivacaine patients 100% were completely satisfied with the procedure compared with 81% of controls (P = 0.02).

CONCLUSION

Extraperitoneal bupivacaine minimizes pain following day-care TEP repair, facilitates recovery, and increases patient satisfaction. Benefits persist beyond the pharmacological action of bupivacaine.

Comparative study of electric and manual toothbrushes in patients with fixed orthodontic appliances

The objective of this three treatment, three period, single blind, cross-over trial was to evaluate the efficacy of three toothbrushes in a cohort of children undergoing fixed appliance orthodontic therapy. The brushes used were: (1) Dental Logic HP550 with regular brush head HP5924 (Philips, U.K.); (2) Braun Oral B Plaque Remover (D7) with dedicated orthodontic brush head OD5-1 (Braun AG, Germany); and (3) a manual dedicated orthodontic toothbrush (P35, Oral B Laboratories, Calif.). Sixty orthodontic patients, aged 10 to 16 years and wearing upper and lower fixed appliances, were screened and recruited with parental consent. After an oral soft tissue examination at baseline, the percentage of plaque-covered tooth surfaces and gingival bleeding sites were recorded using visible plaque and gingival bleeding indexes. Each subject was randomly allocated to one of three groups (n = 20) with brushing sequences 1-2-3, 2-1-3, 3-2-1. The first brush was given 2 weeks after baseline (visit 1). The time interval for using each brush was 4 weeks at the end of which visible plaque and gingival bleeding indexes were recorded and a further prophylaxis given. Statistical analysis was undertaken with analysis of variance. Data were analyzed on a site-specific basis; buccal smooth and interproximal surfaces, lingual smooth and interproximal surfaces. At baseline the mean visible plaque index for all subjects were; buccal smooth, 52.5% (+/- 22.5%); buccal interproximal, 70.5% (+/- 18.5%); lingual smooth, 68.5% (+/- 21%); lingual interproximal, 76% (+/- 16%). At visit 1, the plaque scores at all surfaces had reduced significantly compared to baseline, but there had been no active treatment. This was attributed to a Hawthorne effect. Subsequently, there were no significant effects on visible plaque (or gingival bleeding) indexes with any toothbrush at any tooth surfaces. This suggests that the new HP550 is equally effective as specifically designed orthodontic toothbrushes in removing plaque from patients with fixed orthodontic appliances.

Purification and characterization of avian glycolipid: beta-galactosyltransferases (GalT-4 and GalT-3): cloning and expression of truncated betaGalT-4

Acidic glycolipid of ganglio-(containing sialic acid) and sialyl-lactofucosyl-type, SA-Lex (containing sialic acid and fucose) are developmentally regulated and appear to be ubiquitous on neuronal and cancer cell surfaces of animals. Two glycolipid: beta-galactosyltransferases, GalT-3 and GalT-4, were characterized in embryonic chicken brain (ECB). Based on substrate competition experiments, these two activities were believed to be due to expression of two gene products. A cDNA fragments (about 600 bp) encoding the catalytic domain of the GalT-4 (UDP-Gal:LcOse3Cer beta1,4galactosyltransferase) from ECB and human Colo-204 were isolated. These cDNAs were expressed as a soluble glutathione-S-transferase fusion protein (48 kDa) in Escherichia coli. Interactions between GlcNAc-, UDP-hexanolamine-, and alpha-lactalbumin were studied with the purified fusion protein (recombinant and truncated). Functionally it was similar to that of native GalT-4 purified (40000-fold) from 11-day-old ECB. GalT-3 (UDP-Gal:GM2beta1,3galactosyltransferase) was purified from 19-day-old ECB, and a polyclonal antibody was produced against the peptide backbone for immunoscreening of a lambdaZAP ECB cDNA expression library. Each of the GalT-3 peptides (62 and 65 kDa was analyzed by protein fingerprinting analysis indicating a similar peptide mapping pattern.

Combining the clinical signs improves diagnosis of scaphoid fractures. A prospective study with follow-up

This is a prospective study evaluating the efficacy of four clinical signs believed to be useful in the diagnosis of scaphoid fracture. Two hundred and fifteen consecutive patients with suspected scaphoid fracture were examined on two separate occasions to evaluate tenderness in the anatomical snuff box (ASB), tenderness over the scaphoid tubercle (ST), pain on longitudinal compression of the thumb (LC) and the range of thumb movement (TM). At the initial examination ASB, ST and LC were all 100% sensitive for detecting scaphoid fracture with specificities of 9%, 30% and 48% respectively. These clinical signs used in combination, within the first 24 hours following injury, produced 100% sensitivity and an improvement in the specificity to 74%. TM had 69% sensitivity and 66% specificity. Our results suggest that these clinical signs are inadequate indicators of scaphoid fracture when used alone and should be combined to achieve a more accurate clinical diagnosis.

Tuberculosis incidence in Northern Ireland and the Republic of Ireland--a collaborative study

We examined the incidence of tuberculosis in the Republic of Ireland and Northern Ireland for 1991 using the Census of Population for both jurisdictions, data from a National Survey of Tuberculosis for 1991 for the Republic and examination of nominal notification data for Northern Ireland. We showed that there is a significantly higher incidence of TB in the Republic of Ireland. More cases were reported (p < 1.0 x 10(-7)) as were more bacteriologically proven cases (p < 1.0 x 10(-7)). The difference was true for each of the following age groups (< 15 years, 15-35 years, 35-54 years and > 55 years) but it is noteworthy that areas in the Republic which make use of neonatal BCG vaccine did not have a significantly different rate of tuberculosis for individuals less than 15 years (p = 0.34) compared to Northern Ireland.

An update on British medical students' lifestyles

Information about medical students' lifestyles was obtained from 785 second-year students from seven medical schools in Great Britain by a personally administered questionnaire. Fifteen per cent of the students were non-drinkers. Among those who drank, 48% of the men and 38% of the women exceeded sensible weekly limits of alcohol consumption, and high-risk levels of consumption were reported by 12% of men and 7% of women. Cannabis had been used at least once or twice by more than half the men and 40% of the women, and 10% reported regular use (weekly or more often). Experience with other illicit drugs was also reported: amphetamines (8% of students), LSD (7%), ecstasy (4%), amyl/butyl nitrate (10%) and magic mushrooms (7%). Nineteen per cent of the students had used two or more different drugs. Experience with illicit drugs started before entering university in more than a third of those who used them. Comparison of the results with other student surveys suggests that the lifestyles of medical students differ little from those of other student groups, but that alcohol and illicit drug consumption is increasing in university students generally. Prospective studies are under way to establish whether medical students change their lifestyles at later stages of their course and after qualification.

Plasma leptin in chronic inflammatory bowel disease and HIV: implications for the pathogenesis of anorexia and weight loss

1. Leptin inhibits food intake and is an important regulator of long-term energy balance. In rodents, plasma concentrations of leptin are increased by administration of interleukin-1 and tumour necrosis factor. Hyperleptinaemia may mediate the anorexia and weight loss which is observed in chronic infections and inflammatory conditions. 2. Plasma leptin and soluble tumour necrosis factor receptor (sTNF-r55) concentrations were measured in patients with inflammatory bowel disease and acquired immunodeficiency syndrome (AIDS), and healthy controls. 3. The patients with AIDS were severely wasted [% body fat 12 (9-16); median (interquartile range)] compared with those with inflammatory bowel disease [25.1 (19-31.5)] and control subjects [29.4 (23.6-37.8)]. Leptin concentrations were highly correlated with percentage body fat in controls (r = 0.74, P < 0.001) and patients with IBD (r = 0.73, P < 0.001) but not in the patients with AIDS (r = -0.024). Leptin concentrations were similar in the inflammatory bowel disease [4.8 (2.6-10.1) ng/ml] and control groups [8.0 (3.1-14.1) ng/ml] but were significantly lower (P < 0.05) in patients with AIDS [1.8 (1.5-2.3) ng/ml] after 23 patients were matched for sex and percentage body fat in patients with inflammatory bowel disease [2.4 (1.8-4.1) ng/ml]. Plasma concentrations of sTNF-r55 were higher in both the patients with inflammatory bowel disease [0.19 (0.16-0.23) ng/ml] and those with AIDS [4.8 (2.8-7.3) ng/ml] compared with controls [0.14 (0.09-0.16) ng/ml] but were not correlated with either percentage body fat or plasma leptin concentrations. 4. Hyperleptinaemia does not appear to mediate the anorexia and weight loss associated with inflammatory bowel disease and AIDS. In patients with AIDS with extreme wasting there was no relationship between body fat and leptin and this may be related to the rapid weight loss which occurs in these patients.

Predictors of quality of life and adjustment after lung transplantation

STUDY OBJECTIVE

Few studies have examined predictors of quality of life and adjustment after lung transplantation. This study determined whether pretransplant psychological measures predicted physical health, quality of life, and overall adjustment posttransplant. Cross-sectional analyses also examined differences in adjustment and quality of life for lung transplant candidates and recipients.

DESIGN AND PARTICIPANTS

Seventeen transplant candidates and 60 transplant recipients completed questionnaires measuring adjustment and quality of life. In addition, we examined archival data on 107 transplant candidates who had received pretransplant psychological assessments, and posttransplant physical health status data were collected on these patients. Of the 107 patients who provided a pretransplant psychological assessment, 32 completed the questionnaires measuring posttransplant adjustment and quality of life.

SETTING

University medical center transplant service.

RESULTS

Cross-sectional analyses indicated significantly better adjustment and quality of life posttransplant. Pretransplant psychological variables were not associated with measures of posttransplant physical health. Hierarchical multiple regression analyses found that pretransplant anxiety and psychopathology predicted posttransplant adjustment (beta's ranging from 0.32 to 0.68) and greater pretransplant anxiety also predicted worse posttransplant quality of life (beta's ranging from 0.29 to 0.62). Subjective sleep disturbances were associated with poorer adjustment and quality of life (beta's ranging from 0.36 to 0.75), and were found to mediate the relationship between presurgical anxiety and posttransplant adjustment and quality of life.

CONCLUSIONS

This study found that psychological status pretransplant predicted adjustment and quality of life posttransplant. Moreover, increased anxiety levels pretransplant predicted subsequent subjective sleep disturbances, which were, in turn, associated with poorer adjustment and quality of life. The benefits of pretransplant stress management interventions are discussed.

Induction of CYP2E1 activity in liver transplant patients as measured by chlorzoxazone 6-hydroxylation

OBJECTIVE

To examine the phenotypic expression of CYP2E1 in liver transplant patients, as measured by the in vivo probe chlorzoxazone, and to evaluate CYP2E1 activity over time after transplantation.

METHODS

Thirty-three stable liver transplant patients were given 250 mg chlorzoxazone within 1 year after transplantation as part of a multiprobe CYP cocktail; urine and blood were collected for 8 hours. Chlorzoxazone and 6-hydroxychlorzoxazone concentrations were determined by HPLC. Twenty-eight healthy control subjects, eight patients with moderate to severe liver disease, and four patients who had not received liver transplants were also studied for comparison. The chlorzoxazone metabolic ratio, calculated as the plasma concentration of 6-hydroxychlorzoxazone/chlorzoxazone at 4 hours after chlorzoxazone administration, was used as the phenotypic index. In a subgroup of patients and control subjects, additional blood samples were obtained to allow for the calculation of chlorzoxazone pharmacokinetic parameters by noncompartmental methods.

RESULTS

The chlorzoxazone metabolic ratio for the liver transplant patients in the first month after transplantation (mean +/- SD, 6.4 +/- 5.1) was significantly higher than that after 1 month after surgery (2.1 +/- 2.0), when the chlorzoxazone metabolic ratio was not different from control subjects (0.8 +/- 0.5). The chlorzoxazone metabolic ratios in the patients who had not received liver transplants (1.1 +/- 0.7) were equivalent to those of healthy control subjects. The maximum observed 6-hydroxychlorzoxazone plasma concentration was 3046 +/- 1848 ng/ml in seven liver transplant patients in the first month after surgery compared with 1618 +/- 320 ng/ml in 16 healthy control subjects (p < 0.05). The maximum observed concentration of chlorzoxazone, the chlorzoxazone apparent oral clearance, and the formation clearance of 6-hydroxychlorzoxazone were also significantly different between the groups.

CONCLUSIONS

We conclude that significant induction of CYP2E1, as indicated by the chlorzoxazone metabolic ratio, occurs in the first month after surgery in liver transplant patients and that drugs that are substrates for CYP2E1 may require dosage alteration during that period. Contrary to expectations, drug metabolism is not uniformly depressed after liver transplantation.

Recovery rates, serotypes, and antimicrobial susceptibility patterns of salmonellae isolated from cloacal swabs of wild Nile crocodiles (Crocodylus niloticus) in Zimbabwe

Samples from the cloaca and the ventral skin surface of 67 Nile crocodiles (Crocodylus niloticus) captured in four uninhabited areas at Lake Kariba, Zimbabwe, were cultured for Salmonella. All the skin samples tested negative for Salmonella, whereas 18 of 67 (26.9%) cloacal samples grew Salmonella. Significantly more males than females yielded Salmonella, but no statistically significant correlation among salmonella carriage, body size, and age was recorded. Ten different serotypes of S. enterica belonging to the subspecies enterica, salamae, and diarizonae were isolated. All isolates belonging to subspecies enterica displayed invasive properties in an experimental mouse model and thus exhibited pathogenic potential, whereas none of the other isolates were invasive. In general, isolates were sensitive to a number of commonly used antimicrobials, except for three isolates that were resistant to streptomycin.

Enteropathy in Zambians with HIV related diarrhoea: regression modelling of potential determinants of mucosal damage

BACKGROUND

AIDS is characterised by small intestinal mucosal damage, but its aetiopathogenesis is poorly understood. Enteric infections in Africa differ from those in northern countries, where protozoan infections have been associated with severe enteropathy in AIDS patients.

AIMS

To characterise enteropathy in Zambian AIDS patients compared with local controls, and to assess relative contributions of enteric infection, nutritional impairment, and immune dysfunction.

METHODS

Computer aided mucosal morphometry of small intestinal biopsy specimens from 56 HIV infected Zambians with persistent diarrhoea and 26 diarrhoea free controls, followed by regression modelling.

RESULTS

Patients with HIV related diarrhoea had reduced villous height and increased crypt depth compared with controls. There was no difference between HIV positive and negative controls. In regression models applied to AIDS mucosal measurements, villous height and crypt depth were related to nutritional parameters and to serum soluble tumour necrosis factor receptor p55 concentration. Crypt depth was also related to lamina propria plasma cell count. Intestinal infection was found in 79%, which consisted predominantly of microsporidia in 34%, Isospora belli in 24%, and Cryptosporidium parvum in 21%, but detection of these enteropathogens was not related to severity of enteropathy.

CONCLUSIONS

Nutritional and immune disturbances were associated with enteropathy, accounting for over one third of the variation in mucosal morphometric parameters.

Sclerosing cholangitis, race and sex

BACKGROUND

Primary sclerosing cholangitis develops in 3-10% of patients with ulcerative colitis, and may be associated with an increased cancer risk. Ulcerative colitis is probably less common in people of African origin than in populations of European descent.

AIMS AND METHODS

To review the records of all patients under regular follow up for ulcerative colitis at St Bartholomew's Hospital (London, UK), a tertiary referral centre, prompted by discovering a cluster of cases with common features.

RESULTS AND CONCLUSIONS

Among 166 patients with ulcerative colitis under regular follow up, only four (all women) are of African or Caribbean genetic origin, and three of these have developed sclerosing cholangitis within three years of presentation with colitis, compared with four of 162 patients of European or Asian descent (odds ratio 119, 95% confidence interval 8-3837; p = 0.0002). This cluster, which is not explained by common HLA DR or DQ type, suggests that Africans and Afro-Caribbeans, especially women, may be at increased risk of sclerosing cholangitis. This may reflect genetic influences on the development of enteric and hepatobiliary inflammatory disease.