Preliminary results of carotid artery stenting in a non-academic hospital

INTRODUCTION

A review of our experience with CAS in a non-academic hospital is presented.

MATERIALS AND METHODS

A consecutive series of 18 CAS-interventions between 2003 and 2005 is studied retrospectively. Indication, medical history, preoperative carotid imaging, operative technique and results were studied for each patient.

RESULTS

CAS was used 12 times in men and six (33.3%) times in women between 2003 and 2005. Five (27.8%) symptomatic stenoses, 12 (66.6%) asymptomatic stenoses and one (5.6%) arterio-venous fistula were treated. One permanent postoperative ipsilateral ischaemic neurologic deficit occurred (5.6%). The mean duration of hospital stay was 4.9 days (range : 2-9 days).

CONCLUSIONS

Our study shows that CAS is feasible in non-academic hospital settings, with acceptable early results. Participating in larger studies should confirm our results.

Anthropometry and body composition of south Indian babies at birth

OBJECTIVES

To assess the consequences on body composition of increasing birth weight in Indian babies in relation to reported values in Western babies, and to assess the relationship between maternal and neonatal anthropometry and body composition.

DESIGN

Prospective observational study.

SETTING

Bangalore City, India.

SUBJECTS

A total of 712 women were recruited at 12.5+/-3.1 weeks of gestation (mean+/-standard deviation, SD) and followed up until delivery; 14.5% were lost to follow-up. Maternal body weight, height, mid upper-arm circumference and skinfold thicknesses were measured at recruitment. Weight and body composition of the baby (skinfold thicknesses, mid upper-arm circumference, derived arm fat index and arm muscle index; AFI and AMI, respectively) were measured at birth in hospital.

RESULTS

The mean+/-SD birth weight of all newborns was 2.80+/-0.44 kg. Birth weight was significantly related to the triceps and subscapular skinfold thickness of the baby. In a small number of babies with large birth weight for gestational age, there was a relatively higher normalised AFI relative to AMI than for babies with lower or appropriate birth weight for gestational age. Maternal height and fat-free mass were significantly associated with the baby's length at birth.

CONCLUSIONS

Skinfold thicknesses in Indian babies were similar to those reported in a Western population with comparable birth weights, and the relationship of AFI to birth weight appeared to be steeper in Indian babies. Thus, measures to increase birth weight in Indian babies should take into account possible adverse consequences on body composition. There were no significant relationships between maternal anthropometry and body composition at birth on multivariate analysis, except for sum of the baby's skinfold thicknesses and maternal fat-free mass (P<0.02).

Preserved Bone Health in Adolescent Elite Rhythmic Gymnasts despite Hypoleptinemia

BACKGROUND/AIMS

Leptin is linked to hormonal disturbances occurring in anorexia and positively linked with bone mineral density. The aim of this study was to determine whether hypoleptinemia occurring in rhythmic gymnasts may affect bone health.

METHOD

Leptin, insulin, cortisol, IGF1 levels and bone markers were determined in 36 rhythmic gymnasts (EG) and 20 controls (C). Body composition, BMD at the whole body (WBBMD), lumbar spine (LSBMD) and bone ultrasound properties (SOS, BUA) were measured.

RESULTS

The rhythmic gymnasts had lower fat mass and leptin level than the controls. There was no difference for IGF1, cortisol and insulin levels. Bone turnover rate was higher in elite gymnasts. The uncoupling index showed that remodeling favored the bone formation. LSBMD, WBBMD, SOS and BUA were higher in elite gymnasts after adjustment for fat mass. Leptin correlated positively with fat mass and negatively with physical activity.

CONCLUSION

High impact training is able to counterbalance bone effects usually encountered in hormonally disturbed subjects. Our results suggest that hypoleptinaemia might be related to direct osteogenic effects and indirect hormonal mechanisms including preservation of IGF and cortisol levels.

Efficacy and safety of leflunomide alone and in combination with methotrexate in the treatment of refractory rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis patients who develop refractoriness are left with no alternatives other than leflunomide and costly biological response modifiers. Leflunomide, though effective, was associated with adverse events and has not been extensively studied in the Indian population.

AIMS

Determination of safety and efficacy of leflunomide alone and if not useful, in combination with methotrexate in patients refractory to conventional disease-modifying agents.

SETTING AND DESIGN

Open labeled clinical trial with leflunomide [100 mg, OD x 3 days followed by 20 mg, OD x 6 months], if no improvement at three months, combined with methotrexate [5-7.5 mg, OD x 3 months] at a tertiary care hospital.

MATERIALS AND METHODS

The primary endpoint in the improvement in EULAR criteria and secondary endpoints were patient and physician global evaluation, incidence of remission and biochemical and clinical adverse events.

STATISTICAL ANALYSIS

Chi square test or Fisher's exact test and parametric and non-parametric repeat measure ANOVA were used for analysis.

RESULTS

Among 84 patients who were included in the study, leflunomide showed improvement and remission in 52 [62%] and 6 [7%] in six months, by intention to treat analysis. Adverse events were observed in 15, discontinuation in 5 and 24 dropped out. With combination in 11 patients, there was improvement and remission in nine [91%] and one [9%] after three months. Adverse events were observed in six and one discontinued.

CONCLUSIONS

If regular monitoring of hepatic function and hematological parameters are performed, leflunomide is an effective and safe drug in the Indian population in resistant rheumatoid arthritis patients, especially if used alone.

[Risk factors for hepatitis C virus transmission to Health Care Workers after occupational exposure: a European case-control study]

BACKGROUND

Factors that influence the risk for HCV infection after occupational exposure to hepatitis C virus (HCV) have not yet been determined. The objective of this study was to assess potential risk factors for Hepatitis C seroconversion after occupational exposure to HCV.

METHODS

We conducted a European matched case-control study from 01/01/1991 through 31/12/ 2002. Cases were Health Care Workers (HCWs) who were HCV seronegative at the time of exposure, sustained a documented exposure to HCV, and present documented HCV seroconversion temporally associated with the exposure. Controls-HCWs had a documented exposure to HCV, were HCV seronegative at the time of exposure, and remained so at least 6 months later. Controls were matched to cases for the center and the time period of the exposure occurrence.

RESULTS

60 cases and 204 controls were included. All cases were exposed to HCV-infected materials through percutaneous injuries. Those for whom information was available (61.6%) were exposed to viremic source patients. Multivariate conditional logistic regression analysis, in which HCV viral load was not introduced because of missing values, identified needle placed in the source patient's vein or artery (Odds Ratio [OR]=100.1; 95% Confidence Interval [CI]=7.3-1365.7), deep injury (OR=155.2; 95%CI=7.1-3417.2), and HCW's gender (M vs. F: OR=3.1; 95%CI=1.0-10.0) as risk factors for HCV infection. In univariate unmatched analysis the risk of HCV transmission was increased 11-fold (C195%=1.1-114.1) in HCWs exposed to sources with a viral load>6 log10 copies/mL when compared to sources with a HCV viral load<4 log10 copies/mL.

CONCLUSION

The risk of HCV transmission after percutaneous exposure increases with a larger volume of blood, and, a higher titer of HCV in the source patient's blood. The role of HCW's gender need to be further investigated. The results of this study have important implications for counselling and follow-up of HCWs after exposure.

Two mutations in the HSN2 gene explain the high prevalence of HSAN2 in French Canadians

BACKGROUND

Hereditary sensory and autonomic neuropathy type 2 (HSAN2; MIM 201300) is a rare recessive neuropathy typically diagnosed in the first decade. The 1973 study of a French Canadian family led to the definition of HSAN2.

OBJECTIVES

To demonstrate that the apparent higher prevalence of HSAN2 in Quebec is due to the presence of two HSN2 mutations and that carriers of different mutations appear to have a similar phenotype.

METHODS

Through attending physicians, the authors recruited French Canadian patients with HSAN2. Exclusion of linkage to the known HSAN loci and linkage to the HSAN2 was performed using standard methods. Sequencing of the HSN2 gene was used to uncover the causal mutations.

RESULTS

A large cluster of HSAN2 patients comprising 16 affected individuals belonging to 13 families was identified. The mode of inheritance is clearly autosomal recessive. All patients originated from southern Quebec, and 75% are from the Lanaudière region. Whereas linkage to the HSAN1, 3, and 4 loci was excluded, linkage to the 12p13.33 HSAN2 locus was confirmed. Sequencing of the HSN2 gene uncovered two French Canadian mutations and a novel nonsense mutation in a patient of Lebanese origin, all predicted to lead to truncations of the HSN2 protein. The comparison of clinical variables between patients with different genotypes does not suggest any difference in phenotype.

CONCLUSIONS

Two founder mutations are responsible for the apparently higher prevalence of HSAN2 in French Canadians. Genotype-phenotype correlation does not suggest any significant clinical variability.

Risk factors for hepatitis C virus transmission to health care workers after occupational exposure: a European case-control study

BACKGROUND

Additional studies are required to identify risk factors for hepatitis C virus (HCV) transmission to health care workers after occupational exposure to HCV.

METHODS

We conducted a matched case-control study in 5 European countries from 1 January 1991 through 31 December 2002. Case patients were health care workers who experienced seroconversion after percutaneous or mucocutaneous exposure to HCV. Control subjects were HCV-exposed health care workers who did not experience seroconversion and were matched with case patients for center and period of exposure.

RESULTS

Sixty case patients and 204 control subjects were included in the study. All case patients were exposed to HCV-infected fluids through percutaneous injuries. The 37 case patients for whom information was available were exposed to viremic source patients. As risk factors for HCV infection, multivariate analysis identified needle placement in a source patient's vein or artery (odds ratio [OR], 100.1; 95% confidence interval [CI], 7.3-1365.7), deep injury (OR, 155.2; 95% CI, 7.1-3417.2), and sex of the health care worker (OR for male vs. female, 3.1; 95% CI, 1.0-10.0). Source patient HCV load was not introduced in the multivariate model. In unmatched univariate analysis, the risk of HCV transmission increased 11-fold for health care workers exposed to source patients with a viral load >6 log(10) copies/mL (95% CI, 1.1-114.1), compared with exposures to source patients with a viral load < or =4 log10 copies/mL.

CONCLUSION

In this study, HCV occupational transmission was found to occur after percutaneous exposures. The risk of HCV transmission after percutaneous exposure increased with deep injuries and procedures involving hollow-bore needle placement in the source patient's vein or artery. These results highlight the need for widespread adoption of needlestick-prevention devices in health care settings, together with other preventive measures.

European recommendations for the management of healthcare workers occupationally exposed to hepatitis B virus and hepatitis C virus

Exposure prevention is the primary strategy to reduce the risk of occupational bloodborne pathogen infections in healthcare workers (HCW). HCWs should be made aware of the medicolegal and clinical relevance of reporting an exposure, and have ready access to expert consultants to receive appropriate counselling, treatment and follow-up. Vaccination against hepatitis B virus (HBV), and demonstration of immunisation before employment are strongly recommended. HCWs with postvaccinal anti-HBs levels, 1-2 months after vaccine completion, &gt;10 mIU/mL are considered as responders. Responders are protected against HBV infection: booster doses of vaccine or periodic antibody concentration testing are not recommended. Alternative strategies to overcome non-response should be adopted. Isolated anti-HBc positive HCWs should be tested for anti-HBc IgM and HBV-DNA: if negative, anti-HBs response to vaccination can distinguish between infection (anti-HBs &gt;50 mUI/ml 30 days after 1st vaccination: anamnestic response) and false positive results(anti-HBs &gt;10 mUI/ml 30 days after 3rd vaccination: primary response); true positive subjects have resistance to re-infection. and do not need vaccination The management of an occupational exposure to HBV differs according to the susceptibility of the exposed HCW and the serostatus of the source. When indicated, post-exposure prophylaxis with HBV vaccine, hepatitis B immunoglobulin or both must be started as soon as possible (within 1-7 days). In the absence of prophylaxis against hepatitis C virus (HCV) infection, follow-up management of HCV exposures depends on whether antiviral treatment during the acute phase is chosen. Test the HCW for HCV-Ab at baseline and after 6 months; up to 12 for HIV-HCV co-infected sources. If treatment is recommended, perform ALT (amino alanine transferase) activity at baseline and monthly for 4 months after exposure, and qualitative HCV-RNA when an increase is detected.

European recommendations for the management of healthcare workers occupationally exposed to hepatitis B virus and hepatitis C virus

Exposure prevention is the primary strategy to reduce the risk of occupational bloodborne pathogen infections in healthcare workers (HCW). HCWs should be made aware of the medicolegal and clinical relevance of reporting an exposure, and have ready access to expert consultants to receive appropriate counselling, treatment and follow-up. Vaccination against hepatitis B virus (HBV), and demonstration of immunisation before employment are strongly recommended. HCWs with postvaccinal anti-HBs levels, 1-2 months after vaccine completion, >or=10 mIU/mL are considered as responders. Responders are protected against HBV infection: booster doses of vaccine or periodic antibody concentration testing are not recommended. Alternative strategies to overcome non-response should be adopted. Isolated anti-HBc positive HCWs should be tested for anti-HBc IgM and HBV-DNA: if negative, anti-HBs response to vaccination can distinguish between infection (anti-HBs >or=50 mUI/ml 30 days after 1st vaccination: anamnestic response) and false positive results(anti-HBs >or=10 mUI/ml 30 days after 3rd vaccination: primary response); true positive subjects have resistance to re-infection. and do not need vaccination The management of an occupational exposure to HBV differs according to the susceptibility of the exposed HCW and the serostatus of the source. When indicated, post-exposure prophylaxis with HBV vaccine, hepatitis B immunoglobulin or both must be started as soon as possible (within 1-7 days). In the absence of prophylaxis against hepatitis C virus (HCV) infection, follow-up management of HCV exposures depends on whether antiviral treatment during the acute phase is chosen. Test the HCW for HCV-Ab at baseline and after 6 months; up to 12 for HIV-HCV co-infected sources. If treatment is recommended, perform ALT (amino alanine transferase) activity at baseline and monthly for 4 months after exposure, and qualitative HCV-RNA when an increase is detected.

Conformational dynamics of estrogen receptors alpha and beta as revealed by intrinsic tryptophan fluorescence and circular dichroism

Estrogen receptors (ER alpha and ER beta) are ligand-activated nuclear receptors that mediate the action of estrogens. These receptors activate transcription by similar mechanism(s), although the overall amino acid sequence identity is only 47%. In order to compare the structural and conformational features of ER alpha and ER beta, we monitored their intrinsic tryptophan fluorescence during thermal unfolding. The 50% unfolding temperatures (T(M)) of ER alpha and ER beta were 39+/-1 and 40+/-2 degrees C, respectively. Estradiol had no significant effect on the T(M) of ER alpha or ER beta. In contrast, binding of the estrogen-response element increased the T(M) of ER alpha and ER beta by 10 degrees C. Thermal unfolding of estradiol-bound ER alpha and ligand-free ER beta showed two-step transitions, with the formation of intermediates that were stable between 36-48 and 34-42 degrees C, respectively. We confirmed the presence of intermediate states during thermal unfolding by circular dichroism spectroscopy. Atomic force microscopy showed that the ER beta intermediate consisted of discrete globular particles, whereas the ER alpha intermediate showed a speckled appearance, with sparse well-defined particles. Fluorescence-quenching studies showed the presence of two classes of tryptophan in unliganded ER alpha and ER beta. Binding of estradiol to ER beta exposed its tryptophans, whereas estradiol reduced the accessibility of the tryptophans of ER alpha. Our results illustrate the differential effects of ligands on the unfolding of ER alpha and ER beta, and identify partially unfolded intermediates. Differences in the conformational flexibility and stability of ER alpha and ER beta may represent functional differences of ligand-bound ERs in recruiting coactivator proteins and initiating transcription.

Are we increasing serious maternal morbidity by postponing termination of pregnancy in severe pre-eclampsia/eclampsia?

The objective of this study was to evaluate the impact of admission--delivery interval on maternal morbidity in patients with severe pre-eclampsia/eclampsia. This was a retrospective study, which involved review of case sheets of 188 women (admitted to St John's Medical College Hospital during the year 2000--2001 with the above diagnosis). The incidence of severe pre-eclampsia and eclampsia was 5.18% (188/3,627) with 119 primigravida and 69 multigravida. The incidence of serious maternal complications in the post partum period was 17% (11/68) in the category of women who delivered within 12 hours of admission compared with 40.6% (28/69) in the 12--48-h category and 60.8% (31/51) in the>48-h category. The incidence of serious maternal complications in the subset with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome was 33.4% (7/21) in the<or=12-h category compared with 90.9% (20/22)in the>12-h. We concluded that termination of pregnancy within 12 hours of admission in severe pre-eclampsia/eclampsia especially in patients with HELLP syndrome helps to prevent avoidable serious maternal morbidity.

[Incidents of blood donation]

In France, more than two million blood donations are needed for transfusion each year. The rules and requirements for blood donors selection are strict and aim to protect the donors' health as well as the patients'security. However, the review of the literature shows that adverse effects of blood withdrawal occur quite frequently. They can be classified in immediate or delayed events, or local (hematoma, nerve injury, arterial puncture injury, allergy, veinitis, thrombosis) and general reactions (vasovagal reaction, citrate toxicity, cardiovascular failure, allergy to ethylene oxide, adverse effects of drugs used for some types of donation). This article reviews the principal adverse events described in the literature and concludes with the necessity to set up hemovigilance for donors, as defined in directive 2002/98/EC of the European parliament and of the council.

Practice variability in the management of infrarenal arterial stenoses in seven Belgian hospitals

This multicentre retrospective study describes the variation of therapeutic options, treatment outcomes and costs for treating infrarenal arterial stenoses as observed in daily practice in 1997-99 in seven Belgian hospitals. Data were obtained from clinical record review and from the sickness fund claims database, and included preoperative functional state, presence of acute ischaemia, diabetes and polyvascular disease, state of the lower-leg run-off arteries, anatomical site and type of lesion, type of treatment, result at 30 days and up to 4 years. A total of 442 episodes were studied, but most analyses dealt with a subgroup of 240 lesions in the common iliac up to the superficial femoral artery. The proportion of surgical treatments (as compared to an endovascular or mixed approach) varied from 15% to 81% between the hospitals. In univariate survival analysis, relapse or failure rates at 4 years ranged from 5% for the common iliac artery to 35% for the superficial femoral artery. Polyvascular disease, a poor run-off, multiple stenoses and chronic occlusion were significant risk factors; age and diabetes were not. In the multivariate (stratified Cox regression) analysis, only a location in the superficial femoral artery and a poor preoperative clinical stage were significant risk factors, but type of therapeutic approach was not. The total average cost of treatment was 5300 Euro, of which 15% was contributed by the patient. Surgery was associated with longer stays (median at 12 days) than endovascular treatments (median 2 d), and was 1.9 times more expensive. In conclusion, the results of the present study suggest that a multidisciplinary approach, orienting the patient to the most appropriate therapeutic pathway could increase both the quality and the cost-effectiveness of the care. In many clinical situations, the endovascular approach appears to offer similar long-term results as surgery, but at a substantially lower cost, both for the patient and for society, especially when performed in a (semi-)ambulatory radiology setting.

Practice variability in the management of subrenal arterial stenoses in seven Belgian hospitals

This multicentre retrospective study describes the variation of therapeutic options, treatment outcomes and costs for treating subrenal arterial stenoses as observed in daily practice in 1997-99 in seven Belgian hospitals. Data were obtained from clinical record review and from the sickness fund claims database, and included preoperative functional state, presence of acute ischaemia, diabetes and polyvascular disease, state of the lower-leg run-off arteries, anatomical site and type of lesion, type of treatment, result at 30 days and up to 4 years. A total of 442 episodes were studied, but most analyses dealt with a subgroup of 240 lesions in the common iliac up to the superficial femoral artery. The proportion of surgical treatments (as compared to an endovascular or mixed approach) varied from 15% to 81% between the hospitals. In univariate patency analysis, relapse or failure rates at 4 years ranged from 5% for the common iliac artery to 35% for the superficial femoral artery. Polyvascular disease, a poor run-off, multiple stenoses and chronic occlusion were significant risk factors; age and diabetes were not. In the multivariate (stratified Cox regression) analysis, only a location in the superficial femoral artery and a poor preoperative clinical stage were significant risk factors, but type of therapeutic approach was not. The total average cost of treatment was 5,300 Euros, of which 15% was contributed by the patient. Surgery was associated with longer stays (median at 12 days) than endovascular treatments (median 2 days), and was 1.9 times more expensive. In conclusion, the results of the present study suggest that a multidisciplinary approach, orienting the patient to the most appropriate therapeutic pathway, could increase both the quality and the cost-effectiveness of the care.

High-grade dysplasia in Barrett's oesophagus: natural history and review of clinical practice

BACKGROUND

Management of high-grade dysplasia in Barrett's oesophagus is controversial: surgery carries an appreciable morbidity/mortality, high-grade dysplasia may not progress to cancer and endoscopic ablation is an emerging option.

AIM

To review Barrett's oesophagus-related high-grade dysplasia management and outcome over a 10-year period.

METHODS

This was a retrospective case note review of 36 patients identified from a pathology database.

RESULTS

There were 31 men of mean age 67 years. Endoscopic surveillance identified nine. Median follow-up was 21 months. Seven patients had no further intervention because of age/comorbidity. The other 29 had repeat endoscopic biopsies, nine showing cancer (six oesophagectomized). Of the 20 remaining patients with persisting high-grade dysplasia, eight had surgery (histology showed cancer in six), seven continued endoscopic surveillance (high-grade dysplasia regressed in four) and five had 'curative' argon ablation. An intensive biopsy protocol was not followed in 55% of endoscopies. Prevalent cancers occurred in 44% with an annual incidence of 5% over 5 years. All cause mortality was 39% (14 of 36, eight of 14 from cancer).

CONCLUSIONS

Management of high-grade dysplasia was not uniform. Unsuspected cancer was common in high-grade dysplasia patients undergoing surgery but 13% regressed under surveillance. High-grade dysplasia patients have a high mortality but 43% did not die from cancer.

Community outreach for untreated schizophrenia in rural India: a follow-up study of symptoms, disability, family burden and costs

BACKGROUND

In resource-poor countries, there remains an alarming treatment gap for people with schizophrenia, particularly those living in rural areas. Decentralization of mental health services, including community-based outreach programmes, represents one obvious strategy for bringing appropriate care to these communities. This study set out to assess the costs and effects of such a programme in rural Karnataka in India.

METHOD

Eight rural communities were visited by an outreach team, who identified cases of drug-naive or currently untreated schizophrenia. Recruited cases were provided with appropriate psychotropic medication and psychosocial support, and after obtaining informed consent were assessed every 3 months over one and a half years on symptomatology, disability, family burden, resource use and costs. A repeated-measures analysis was carried out to test for significant change in these outcome measures over this period.

RESULTS

A total of 100 cases of untreated schizophrenia were recruited, of whom 28% had never received antipsychotic medication and the remaining 72% had not been on medication for the past 6 months. Summary scores for psychotic symptoms, disability and family burden were all reduced significantly, with particular improvement observed at the first follow-up assessment. Increases in treatment and community outreach costs over the follow-up period were accompanied by reductions in the costs of informal-care sector visits and family care-giving time.

CONCLUSIONS

Efforts to organize community-based care such as outreach services for people with schizophrenia living in more remote areas of resource-constrained countries can bring substantial benefits to patients and families alike.

Tolerance and short term efficacy of rituximab in 43 patients with systemic autoimmune diseases

OBJECTIVE

To assess the tolerance and efficacy of rituximab in patients with various autoimmune diseases seen in daily rheumatological practice.

METHODS

866 rheumatology and internal medicine practitioners were contacted by e-mail to obtain the files of patients treated with rituximab for systemic autoimmune diseases. Patients with lymphoma were analysed if the evolution of the autoimmune disease could be evaluated.

RESULTS

In all, 43 of 49 cases could be analysed, including 14 with rheumatoid arthritis (RA), 13 with systemic lupus erythematosus (SLE), six with primary Sjogren's syndrome (pSS), five with systemic vasculitis, and five with other autoimmune diseases. Rituximab was prescribed for lymphoma in two patients with RA and two with pSS. In the 39 other cases, rituximab was given because of the refractory character of the autoimmune disease. The mean follow up period was 8.3 months (range 2 to 26). There were 11 adverse events in 10 patients and treatment had to be discontinued in six. Efficacy was observed in 30 patients (70%): RA 11, SLE 9, pSS 5, vasculitis 2, antisynthetase syndromes 2, sarcoidosis 1. The mean decrease in corticosteroid intake was 9.5 mg/d (range 0 to 50) in responders. Seven patients experienced relapse after mean 8.1 months (5 to 15). Three patients died because of refractory autoimmune disease.

CONCLUSIONS

Despite absence of marketing authorisation, rituximab is used to treat various refractory autoimmune diseases in daily rheumatological practice. This study showed good tolerance and short term clinical efficacy, with marked corticosteroid reduction in patients with SLE, pSS, vasculitis, and polymyositis.

Proposed recommendations for the management of HIV post-exposure prophylaxis after sexual, injecting drug or other exposures in Europe

Post-exposure prophylaxis (PEP) is the standard of care for a healthcare worker (HCW) accidentally exposed to an HIV infected source person (occupational exposure), but this is not the case for non-occupational exposures. Very few national guidelines exist for the management of non-occupational exposures to HIV in Europe, contrarily to the occupational ones. The administration of non-occupational post-exposure prophylaxis (NONOPEP) for HIV may be justified by: a biological plausibility, the effectiveness of PEP in animal studies and occupational exposures in humans, efficacy in the prevention of mother to child HIV transmission, and cost effectiveness studies. These evidences, the similar risk of HIV transmission for certain non-occupational exposures to occupational ones, and the conflicting information about attitudes and practices among physicians on NONOPEP led to the proposal of these European recommendations. Participant members of the European project on HIV NONOPEP, funded by the European Commission, and acknowledged as experts in bloodborne pathogen transmission and prevention, met from December 2000 to December 2002 at three formal meetings and a two day workshop for a literature review on risk exposure assessment and the development of the European recommendations for the management of HIV NONOPEP. NONOPEP is recommended in unprotected receptive anal sex and needle or syringe exchange when the source person is known as HIV positive or from a population group with high HIV prevalence. Any combination of drugs available for HIV infected patients can be used as PEP and the simplest and least toxic regimens are to be preferred. PEP should be given within 72 hours from the time of exposure, starting as early as possible and lasting four weeks. All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure. NONOPEP seems to be a both feasible and frequent clinical practice in Europe. Recommendations for its management have been achieved by consensus, but some remain controversial, and they should be updated periodically. NONOPEP should never be considered as a primary prevention strategy and the final decision for prescription must be made on the basis of the patient-physician relationship. Finally, a surveillance system for these cases will be useful to monitor NONOPEP practices in Europe.

Proposed recommendations for the management of HIV post-exposure prophylaxis after sexual, injecting drug or other exposures in Europe

Post-exposure prophylaxis (PEP) is the standard of care for a healthcare worker (HCW) accidentally exposed to an HIV infected source person (occupational exposure), but this is not the case for non-occupational exposures. Very few national guidelines exist for the management of non-occupational exposures to HIV in Europe, contrarily to the occupational ones. The administration of non-occupational post-exposure prophylaxis (NONOPEP) for HIV may be justified by: a biological plausibility, the effectiveness of PEP in animal studies and occupational exposures in humans, efficacy in the prevention of mother to child HIV transmission, and cost effectiveness studies. These evidences, the similar risk of HIV transmission for certain non-occupational exposures to occupational ones, and the conflicting information about attitudes and practices among physicians on NONOPEP led to the proposal of these European recommendations. Participant members of the European project on HIV NONOPEP, funded by the European Commission, and acknowledged as experts in bloodborne pathogen transmission and prevention, met from December 2000 to December 2002 at three formal meetings and a two day workshop for a literature review on risk exposure assessment and the development of the European recommendations for the management of HIV NONOPEP. NONOPEP is recommended in unprotected receptive anal sex and needle or syringe exchange when the source person is known as HIV positive or from a population group with high HIV prevalence. Any combination of drugs available for HIV infected patients can be used as PEP and the simplest and least toxic regimens are to be preferred. PEP should be given within 72 hours from the time of exposure, starting as early as possible and lasting four weeks. All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure. NONOPEP seems to be a both feasible and frequent clinical practice in Europe. Recommendations for its management have been achieved by consensus, but some remain controversial, and they should be updated periodically. NONOPEP should never be considered as a primary prevention strategy and the final decision for prescription must be made on the basis of the patient-physician relationship. Finally, a surveillance system for these cases will be useful to monitor NONOPEP practices in Europe.

Étude comparative entre technique isocinétique et kinésithérapie classique chez le lombalgique chronique. Résultats préliminaires

OBJECTIVE

To determine if the use of an isokinetic device for trunk exercise is more effective than standard physiotherapy in promoting motor disinhibition for patients with chronic low back pain.

POPULATION

chronic low back pain outpatients who are treated in a Rheumatology or PM & R unit within an academic hospital.

METHODOLOGY

This is a prospective, controlled, randomized study, with two groups of treatment: one treated with isokinetic techniques and the other with standard physiotherapy, six sessions for each treatment during 2 weeks. Outcome measures include pain (VSA), trunk mobility (Schöber index, distance from fingers to floor), muscle extensibility and muscle strength (Biering-Sorensen and Shirado-Ito test), and functional capacity (Quebec scale).

RESULTS

Seventeen subjects were enrolled. The results suggest that both isokinetic exercise and physiotherapy result in improved range of motion, extensibility, muscle strength, and pain, without any significant superiority of one technique over the other. However, each technique has specific advantage.

DISCUSSION

Despite methodologic limitations, this study shows that isokinetic exercise is not better than physiotherapy in reversing motor inhibition in chronic low back pain. Our results are consistent with those of other studies in the literature, with regard to the absence of established overall superiority of one exercise technique or program over the other in this population, and with regard to partial benefits of specific exercise techniques.

CONCLUSION

The non-specific benefit of one technique indicates that further studies are needed to evaluate the benefit of combining exercise techniques in chronic low back pain, in order to address the multiple factors involved in this pathology.

Progestins initiate adverse events of menopausal estrogen therapy

OBJECTIVE

Recent report, particularly the Women's Health Initiative, demonstrated that hormone therapy with combined estrogen plus progestin increased the incidence of heart attacks, stroke, blood clots, breast cancer and dementia in women over 65 years old. We investigated the role of synthetic progestins in initiating the adverse events associated with estrogen therapy.

METHODS

We used a fluorescence imaging technique, which allows video microscopic recordings of blood flow, blood vessel morphology and activities of various blood cells in a live animal. The acute peripheral and cerebrovascular responses were measured following intraperitoneal (5 or 10 mg) or intravenous (10 or 100 microg) administration of progesterone, synthetic progestins (medroxyprogesterone acetate and norethindrone) or estrogens (conjugated equine estrogens and 17 beta-estradiol).

RESULTS

In both peripheral and cerebral vasculature, synthetic progestins caused endothelial disruption, accumulation of monocytes in the vessel wall, platelet activation and clot formation, which are early events in atherosclerosis, inflammation and thrombosis. Natural progesterone or estrogens did not show such toxicity.

CONCLUSION

The risk associate with combined estrogen plus progestin therapy may be a consequence of vascular actions of progestins. Using progestins with minimal vascular toxicity may lead to safer estrogen preparations for menopausal women.

Measurement of TG synthesis and turnover in vivo by 2H2O incorporation into the glycerol moiety and application of MIDA

A method is presented for measurement of triglyceride (TG) synthesis that can be applied to slow-turnover lipids. The glycerol moiety of TG is labeled from 2H2O, and mass isotopomer distribution analysis (MIDA) is applied. Mice and rats were given 4-8% 2H2O in drinking water; TG-glycerol was isolated from adipose and liver during < or =12-wk of 2H2O labeling. Mass isotopomer abundances in the glycerol moiety of TG were measured by GC-MS. The combinatorial pattern of isotopomers revealed the number of H atoms in glycerol incorporating label from 2H2O (n) to be 3.8-4.0 of a possible 5 for adipose tissue and 4.6-4.8 for liver TG. Hepatic TG-glycerol in fact reached 97% predicted maximal value of label incorporation (4.4-4.6 x body 2H2O enrichment), indicating near-complete replacement of the liver TG pool. Label incorporation into adipose tissue revealed turnover of mesenteric TG to be faster (k = 0.21 day-1) than other depots (k = 0.04-0.06 day-1) in mice. TG isolated from subcutaneous depots of growing adult rats plateaued at 85-90% of calculated maximal values at 12 wk (k = 0.05 day-1), excluding significant dilution by unlabeled alpha-glycerol phosphate. Turnover of plasma TG, modeled from 2H incorporation over 60 min, was 0.06 min-1 (half-life 11.5 min). In summary, use of 2H2O labeling with MIDA of TG-glycerol allows measurement of new alpha-glycerol phosphate-derived TG synthesis and turnover. The hypothesis that mesenteric TG is more lipolytically active than other depots, previously difficult to prove by isotope dilution techniques, was confirmed by this label incorporation approach.

Enhanced two-photon biosensing with double-clad photonic crystal fibers

A double-clad photonic crystal fiber was used to improve detection efficiency over a standard single-mode fiber in a two-photon fluorescence detection scheme in which the dye was excited and the fluorescence was detected back through the same fiber.

[Value of percutaneous core needle biopsy in the investigation of a suspected bone tumor]

PURPOSE

To Determine the value of percutaneous core needle biopsy in the investigation of a suspected bone neoplasm.

MATERIAL AND METHODS

We performed a retrospective study of 91 core needle biopsies performed between May 1995 and October 2001. Patients were excluded if they had a known primary carcinoma or if an infection was suspected by clinical, physical or laboratory findings. The results were correlated to the analysis of the surgical piece or, for the 28 patients who did not undergo surgery, to the clinical evolution over more than 12 months.

RESULTS

The final diagnosis was metastasis in 29 cases, primary bone tumor in 36 cases and benign lesions in 25 cases. Sensitivity was 92.3% and specificity was 97.4%. For primary malignant bone tumors, results respected histology features and grade in 79.2%. In cases of mistake, because of the correlation of these results to the clinical and radiological context, the treatment of the bony malignant lesions were adapted in 95.8% of cases. Only one major complication was reported in these 91 biopsies.

CONCLUSION

First intention core needle biopsy, confronted with radio-clinical context seems to have a place in the evaluation of bone lesions when a tumor is suspected. This technique, less expensive than an open biopsy and with fewer complications, is best performed as part of a multidisciplinary approach with the surgeon's collaboration.

CML leukapheresis products can be enriched for CD34+ cells and simultaneously depleted of CD15+ cells using a simple Ab cocktail

BACKGROUND

CML progenitor-cell studies would be greatly facilitated if samples could be repeatedly accessed from a source of well-characterized cells. The present study was designed to develop a simple, inexpensive Ab cocktail that would provide subpopulations of cells enriched for CD34+ cells and simultaneously depleted of CD15+ mature myeloid cells.

METHODS

Cells from leukapheresis products from CML patients at diagnosis were incubated with each of two Ab cocktails. The standard cocktail (debulking, DB), containing 11 Abs, is recommended for obtaining a highly enriched population of CD34+ cells. The efficacy of an alternative, simpler cocktail (CML custom, CC), containing only four Abs was tested. The recoveries of CD34+ cells, CD15+ cells, colony-forming unit granulocyte-macrophage, and LTCIC were monitored. The samples were then cryopreserved, thawed, and the recoveries remeasured.

RESULTS

The purity of CD34+ cells was significantly superior using the DB cocktail than with the CC cocktail. Conversely, using the CC cocktail, the yield of CD34+ cells was significantly higher compared to the DB cocktail. These results were maintained even when the amount of Ab was reduced 10-fold. Both Ab cocktails consistently removed > 99% of the CD15+ cells. Consistent with the CD34+ cell-enrichment data, higher colony-forming cell (CFC) frequencies were obtained with the DB cocktail, although superior yields of CFC were obtained with the CC cocktail. After cryopreservation and thawing the yield of CD34+ cells remained high, and a further reduction in the number of CD15+ cells was obtained.

DISCUSSION

A method is described that allows the rapid and efficient debulking of large CML samples. This strategy will provide a source of well-characterized CML stem/progenitor cells that can be repeatedly accessed.

Role of cytoskeletal elements in the recruitment of Cx43-GFP and Cx26-YFP into gap junctions

Cytoskeletal elements may be important in connexin transport to the cell surface, cell surface gap junction plaque formation and/or gap junction internalization. In this study, fluorescence recovery after photobleaching was used to examine the role of microfilaments and microtubules in the recruitment and coalescence of green fluorescent protein-tagged Cx43 (Cx43-GFP) or yellow fluorescent tagged-Cx26 (Cx26-YFP) into gap junctions in NRK cells. In untreated cells, both Cx26-YFP and Cx43-GFP were recruited into gap junctions within photobleached areas of cell-cell contact within 2 hrs. However, disruption of microfilaments with cytochalasin B inhibited the recruitment and assembly of both Cx26-YFP and Cx43-GFP into gap junctions within photobleached areas. Surprisingly, disruption of microtubules with nocodazole inhibited the recruitment of Cx43-GFP into gap junctions but had limited effect on the transport and clustering of Cx26-YFP into gap junctions within the photobleached regions of cell-cell contact. These results suggest that the recruitment of Cx43-GFP and Cx26-YFP to the cell surface or their lateral clustering into gap junctions plaques is dependent in part on the presence of intact actin microfilaments while Cx43-GFP was more dependent on intact microtubules than Cx26-YFP.

Aspirin and diabetes: inhibition of amylin aggregation by nonsteroidal anti-inflammatory drugs

Islet amyloid polypeptide (amylin), cosecreted with insulin by the pancreatic beta-cells, has an important role in the regulation of islet cell hormone homeoastasis. Deposition of beta-sheet polypeptide fibrils into amyloid deposits is considered to be central to the pathology of a number of amyloidogenic disorders, including type-2 diabetes. Amyloid deposits comprised of beta-sheet fibrillar amylin observed in type-2 diabetics are cytotoxic and may have a prominent role in causing beta-cell dysfunction. The amyloidogenic process may impair beta-cell function before cell death and replacement by amyloid. Preservation of beta-cell viability and insulin secretion is a major objective in diabetic care. Using circular dichroism and Congo red absorption techniques we found that clinically relevant doses of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDS) prevented and also reversed the beta-sheet conformation of human amylin. The specific COX-2 inhibitors were less effective. The anti-inflammatory steroid prednisolone or the analgesic acetaminophen had no effect on amylin fibrillogenesis. This action of NSAIDS was similar to their inhibition of beta-sheet conformation of the Alzheimer protein, amyloid-beta. Aspirin, currently recommended for the prevention of cardiovascular complications in diabetic patients, may also ameliorate the disease process in diabetes by preserving the beta-cell function.

Cell separation improves the sensitivity of detecting rare human normal and leukemic hematopoietic cells in vivo in NOD/SCID mice

BACKGROUND

This report describes a novel cell-separation procedure developed to improve detection and analysis of rare human hematopoietic populations, obtained from NOD/SCID mice engrafted with normal and/or leukemic stem cells.

METHODS

In preliminary experiments, artificial mixtures of murine and human BM cells were labeled with a combination of Abs specific for murine hematopoietic cells, prior to immunomagnetic negative selection using StemSep. In subsequent experiments, BM was harvested from individual NOD/SCID mice transplanted 6-12 weeks earlier with either human cord blood or primary CML cells and a similar immunomagnetic selection procedure was applied to enrich human cells present.

RESULTS

Application of this selection procedure to mixtures of murine and human hematopoietic cells using anti-mouse CD45 and Ter-119 allowed a > 1000-fold depletion of murine cells with > 50% recovery of human cells, including progenitors. This level of depletion and recovery were found to be reproducible for NOD/SCID mice transplanted and engrafted with human cord blood stem cells, thus facilitating detection of human progenitors, including colony-forming cells (CFC) and LTCIC. For NOD/SCID mice previously transplanted with CML cells, this procedure increased the sensitivity of detecting rare human cell subsets by up to > 100-fold. This, in turn, improved the sensitivity of RT-PCR for BCR-ABL and made possible the identification by FACS of various minor subsets of human cells, including CD34(-)CD19/20(+) B-lineage cells, CD34(+) progenitors, mature CD15(+) myeloid cells and CD3(+) T cells present in the mice.

DISCUSSION

This simple cell-depletion procedure should facilitate future investigations of normal and CML stem cell populations in vitro and in NOD/SCID mice.

Effects of aminooxy analogues of biogenic polyamines on aggregation and stability of calf thymus DNA

The effect of a series of aminooxy analogues of the biogenic polyamines spermidine and spermine on the conformation of calf thymus DNA is studied. These new molecules are isosteric and charge insufficient analogues that are suitable to study the roles of both charge distribution and structural requirements in the molecular physiology of the biogenic polyamines. They are also evidenced as useful tools to inhibit polyamine biosynthesis and cell growth. Circular dichroism (CD) spectra of solutions containing DNA and the aminooxy analogues at different concentrations (100-1000 microM) and different pH values, (5-7.5) are recorded. We use both sonicated and highly polymerized calf thymus DNA. The CD spectra of sonicated DNA showed the formation of Psi-DNA, a highly ordered aggregated structure similar to liquid crystals, in the presence of the aminooxy analogues. Aggregation induced by an aminooxy derivative of spermine is followed by DNA collapse when increasing the polyamine concentration. The features of Psi-DNA are not detected for highly polymerized DNA. Temperature melting measurements support a high degree of structural order of the aggregates. The CD experiments indicate that dications are unable to induce major changes on the macromolecular structure of DNA. In addition, aggregation is only observed when the trimethylene moiety is present between two adjacent positive charges. The observed differences among the CD spectra of DNA solutions with different aminooxy derivatives of spermidine indicate different roles for different amino groups of this biogenic polyamine when interacting with DNA. Our results support the idea that aminooxy analogues can be used as good models in studying the physiological functions of biogenic polyamines.

Synchrotron radiation microtomography allows the analysis of three-dimensional microarchitecture and degree of mineralization of human iliac crest biopsy specimens: effects of etidronate treatment

Quantitative microcomputed tomography using synchrotron radiation (SR microCT) was used to assess the effects of a sequential etidronate therapy on both three-dimensional (3D) microarchitecture and degree of mineralization of bone (DMB) in postmenopausal osteoporosis. Thirty-two iliac crest biopsy specimens were taken from 14 patients with osteoporosis (aged 64 +/- 1.8 years) before (baseline) and after 1 year of etidronate treatment, and after 2 years of treatment for four of the patients. The samples were imaged at high spatial resolution (voxel size = 10 microm) using the microtomography system developed at the European Synchrotron Radiation Facility (ESRF), Grenoble, France. Three-dimensional microarchitecture parameters were calculated and compared with those obtained from conventional histomorphometry. In addition, the DMB was evaluated also in 3D. No significant statistical changes regarding bone mass and structural parameters were observed in histomorphometry or 3D analyses. The distribution of the DMB in cortical and trabecular bone showed a trend to a shift toward highest mineralization values after 1 year of etidronate treatment (3.88% and 1.24% in cortical and trabecular bone, respectively). This trend was more evident after 2 years. The study also showed that SR microCT is an accurate technique and the only one for quantifying both the mineralization and the microarchitecture of bone samples at the same time in 3D.

Overexpression of White Collar-1 (WC-1) activates circadian clock-associated genes, but is not sufficient to induce most light-regulated gene expression in Neurospora crassa

Many processes in fungi are regulated by light, but the molecular mechanisms are not well understood. The White Collar-1 (WC-1) protein is required for all known blue-light responses in Neurospora crassa. In response to light, WC-1 levels increase, and the protein is transiently phosphorylated. To test the hypothesis that the increase in WC-1 levels after light treatment is sufficient to activate light-regulated gene expression, we used microarrays to identify genes that respond to light treatment. We then overexpressed WC-1 in dark-grown tissue and used the microarrays to identify genes regulated by an increase in WC-1 levels. We found that 3% of the genes were responsive to light, whereas 7% of the genes were responsive to WC-1 overexpression in the dark. However, only four out of 22 light-induced genes were also induced by WC-1 overexpression, demonstrating that changes in the levels of WC-1 are not sufficient to activate all light-responsive genes. The WC proteins are also required for circadian rhythms in dark-grown cultures and for light entrainment of the circadian clock, and WC-1 protein levels show a circadian rhythm in the dark. We found that representative samples of the mRNAs induced by over-expression of WC-1 show circadian fluctuations in their levels. These data suggest that WC-1 can mediate both light and circadian responses, with an increase in WC-1 levels affecting circadian clock-responsive gene regulation and other features of WC-1, possibly its phosphorylation, affecting light-responsive gene regulation.

Hepatic stellate cells: role in microcirculation and pathophysiology of portal hypertension

Accumulating evidence suggests that stellate cells are involved in the regulation of the liver microcirculation and portal hypertension. Activated hepatic stellate cells have the necessary machinery to contract or relax in response to a number of vasoactive substances. Because stellate cells play a role in both fibrosis and portal hypertension, they are currently regarded as therapeutic targets to prevent and treat the complications of chronic liver disease.

Evidence for the involvement of purinergic signalling in the control of respiration

The ventrolateral medulla has a critical role in the generation and patterning of respiration via an extensive network of respiratory neurones. We have investigated the effects of activating purinergic P2 receptors within the ventrolateral medulla of the anaesthetised rat on the overall pattern of respiratory activity. In addition, using immunohistochemical techniques, we have identified the subtypes of P2X receptors in the ventrolateral medulla. Unilateral microinjection of ATP into the ventrolateral medulla reduced in a dose-dependent manner, or abolished, resting phrenic nerve discharge recorded as an indication of central inspiratory drive. ATP also elicited increases in blood pressure and variable changes in heart rate. These effects were mimicked by microinjection of the P2X receptor agonist alpha,beta-methylene ATP into the ventrolateral medulla. Whilst microinjection of suramin, a P2 receptor antagonist, had no effect on resting cardiorespiratory variables it blocked the respiratory and cardiovascular effects of ATP microinjected into the ventrolateral medulla. Immunohistochemical staining using IgG antibodies showed that P2X1, P2X2, P2X5 and P2X6, but not P2X3, P2X4 or receptor subunits were localised in the rostral ventrolateral medulla.Our results indicate that several P2X receptor subtypes are localised within areas of the ventrolateral medulla that are important for cardiorespiratory control (including the pre-Bötzinger and Bötzinger complexes), and that activation of these receptors can have profound effects on both the cardiovascular and the respiratory networks. Our pharmacological data suggest that different P2X subunits in this region may co-assemble to form hetero-oligomeric assemblies as well as homomultimers within this region.

Self-assembly of an oligodeoxyribonucleotide harboring the estrogen response element in the presence of polyamines: ionic, structural, and DNA sequence specificity effects

Estrogenic regulation of gene expression is mediated by the binding of the hormone to its specific receptor, estrogen receptor (ER), which undergoes structural and conformational alterations to recognize specific DNA sequences, estrogen response elements (ERE), in responsive genes to trigger a series of events culminating in the transcription of these genes. Polyamines are ubiquitous cellular cations that are important for cell growth and differentiation, and have been shown to participate in estrogenic regulation of gene expression. Polyamine-mediated DNA condensation/aggregation has been studied to understand the ionic and structural requirements for the compaction of DNA. DNA condensation/decondensation may also play a role in transcription and replication. We studied the aggregation of a 38-mer oligonucleotide duplex (ODN) in the presence of natural and synthetic polyamines under different ionic conditions (NaCl, KCl, and K glutamate). Our results showed that an ODN harboring the consensus ERE (ODN1) was 2-fold more susceptible to precipitation by spermine compared to ODN2 containing scrambled sequences, or a mutant ODN (ODN3). The nature of the monovalent cations (Na+ vs K+), and anions (Cl- vs glutamate) also played an important role in the efficacy of a polyamine to precipitate ODNs: potassium glutamate being the least effective in suppressing the ability of spermine to precipitate ODNs. The concentration of polyamines required for precipitating the ODNs increased with monovalent ion concentration in the buffer. With ODN1, a plot of log[spermine4+] at the 50% precipitation concentrations against log[Na+/K+] yielded a straight line, with a slope of 1.8 +/- 0.18, a value comparable to that predicted by the counterion condensation theory (1.85). We also observed significant structural specificity effects of spermine and its analogues [NH2(CH2)3NH(CH2)nNH(CH2)3NH2, where n = 2-9; n = 4 for spermine] on aggregating the ODN1. These results demonstrate DNA sequence and polyamine structural specificity effects on the aggregation of ODNs, and suggest that the gene regulatory function of ERE may be linked to its ability to undergo facile condensation/decondensation in the presence of biological cations, such as polyamines.