Effects of follistatin and BMP4 proteins on early dorso-ventral patterning in chick

In Xenopus and zebrafish certain bone morphognetic proteins (BMPs), and proteins that antagonise these by preventing their interaction with receptors, constitute a morphogen system in primary dorso-ventral patterning. This system may be directly involved in the parallel processes, within mesoderm and ectoderm, whereby the boundaries of the dorsal (paraxial) mesoderm and the neural plate are established. The bird blastoderm, amenable to grafting techniques and to direct exposure to specific proteins, has provided an opportunity to explore the phylogenetic conservation of such antagonistic system. We have grafted the gastrular organiser (node) into hosts, testing the effects of prior exposure of either grafted or host tissue to Follistatin (a known antagonist of TGFbeta superfamily ligands including BMP4) or to BMP4 protein. Strong, converse effects are seen from the two agents, the most consistent being on the sizes of new dorsalised areas (second neural plates) induced in host epiblast. Follistatin also enhances extension movements due to grafts, though without clear effect upon the rostro-caudal completeness of new patterns. Neural induction in chick epiblast by grafted mouse nodes are also more extensive, after their pre-incubation in Follistatin. Follistatin potentiates other, unknown but distinctive signals coming from the node, being unable to convert other non-inducing pieces of blastoderm into organisers on grafting. Pre-incubation of early blastoderms in BMP4 has such profound effects on normal dorsal axial development that host responsiveness of these blastoderms as hosts to node grafts is difficult to assess. Follistatin has no such overt effect on host development, but greatly enhances the competence of host epiblast to grafts of untreated nodes. Early chick BMP4 and BMP7 expressions are consistent with the proposed roles, though Follistatin is probably an experimental tool only in the present study.

Gene interference using antisense oligodeoxynucleotides on whole chick embryos. Optimal ring and roller-bottle culture technique

Details are given of an advanced version of the ring method of chick embryo culture. This ensures good development from early blastoderm stages even when the culturing procedure is interrupted by the extended periods required for collecting matched embryo samples and for preparing antisense treatment. Antisense oligodeoxynucleotide treatment, in short-term incubation before return of blastoderms to their ring cultures, is then described. An alternative, roller-bottle, culture method for continued development after treatment is also described. Criteria for the validity and success of this gene interference method are given. While the text is meant to be of detailed practical help to those inexperienced in embryo culture, a preliminary reading, and familiarity with its sectional (Subheading) structure, is recommended before work is undertaken.

Effects of a pharmacist's medication review in nursing homes. Randomised controlled trial

BACKGROUND

Older people in nursing and residential homes often have complex disabilities and behavioural disturbances. Recent publicity has highlighted the dangers of medication in this group, and controls over prescribing have been suggested.

AIMS

To investigate the effect of a review of medication by a pharmacist.

METHOD

An 8-month prospective trial of an active medication review by a pharmacist was carried out on 330 residents in nursing homes in Manchester.

RESULTS

The intervention group experienced greater deterioration in cognitive function and behavioural disturbance than the control group, but the changes in depression and quality of life were similar for both groups. The number of drugs prescribed fell in the intervention group, but not in the control group, with a corresponding saving in drug costs. The number of deaths was significantly smaller in the intervention homes during the intervention period (4 v. 14) but not overall during the study period as a whole (26 v. 28).

CONCLUSION

This clinical intervention reduced the number of medicines prescribed to elderly people in nursing homes, with minimal impact on their morbidity and mortality.

Prescribing costs. Braking point

A joint hospital, health authority and PCG initiative to improve prescribing has produced significant savings in the PCG involved. The venture included the appointment of a medicines management pharmacist to work with practices, and a survey to ascertain GPs' prescribing needs. GPs considered the most important issues to be developing local disease management guidelines, education and repeat prescribing. Guidelines on dyspepsia management have resulted in a 4.9 per cent reduction in the cost of prescribing gastrointestinal drugs. Antibiotic prescribing has also fallen.

FGF and genes encoding transcription factors in early limb specification

SnR, twist and Fgf10 are expressed in presumptive limb territories of early chick embryos. When FGF-2/FGF-8 beads are implanted in chick flank, an ectopic limb develops and SnR is irreversibly activated as early as 1 h. Ectopic Fgf10 and twist expression are activated much later at 17 and 20 h, respectively. FGF-10 can also induce SnR, but much later, and in this case activation occurs simultaneously with that of twist and Fgf10 via the Fgf8- expressing ridge. Tbx-4 and Tbx-5 are expressed in leg and wing forming regions, respectively, in a similar pattern to SnR and twist. FGF-2 leads to ectopic expression of Tbx-4 and Tbx-5 as rapidly as ectopic expression of SnR, but the patterns of ectopic transcripts suggest that induction of SnR and Tbx gene expression occur via different pathways.

Skin edge perception in mammograms: a comparison of two film-screen combinations

The entire skin edge is not always seen on mammograms. The importance of demonstrating the full extent of the breast on a mammogram is uncertain, but there are implications for optimizing film design and use. The new Agfa HDR film has been designed to improve visualization of the skin edge without compromising overall contrast. A quantitative and qualitative comparison between Agfa HDR and the Fuji UMMA film has been performed. A total of 216 mammograms from 54 symptomatic women were analysed. For each view on each woman, one breast was imaged using Fuji UMMA film and the other using Agfa HDR film. The target density achieved on quality control films of PMMA blocks was 1.70 +/- 0.10 for both film types. A radiologist graded the skin edges of all the films as visible, just visible or dark. Measurements were made of the optical densities in the skin edge region and on the fully exposed black part of the film, adjacent to the skin line. 70% of the HDR films had visible skin edges compared with 43% of the UMMA films. 2% of the HDR films had dark skin edges compared with 26% of the UMMA films. Optical densities at the skin edge were broadly similar for the two films and in the range 3.6 +/- 0.3. However, the density of the black part of the Agfa film was about 0.5 higher than with the Fuji film and it appears that this was the main reason the skin edge region was better visualized with the Agfa film.

Flik, a chick follistatin-related gene, functions in gastrular dorsalisation/neural induction and in subsequent maintenance of midline Sonic hedgehog signalling

We have targetted the chick gene Flik with antisense oligodeoxynucleotide treatment at gastrular stages, when it is expressed in organiser-derived structures of the midline (K. Patel et al., 1996, Dev. Biol. 178, 327-342). A specific syndrome of deficient axial patterning and holoprosencephaly is produced. Most aspects of this syndrome can be understood as due to attenuation of dorsalising and neural-inducing signals during gastrulation, followed by failure to maintain the later signals from chordamesoderm/neural midline that pattern the mesodermal and neural cross sections during subsequent stages. Anatomical effects are first apparent at early neurula stages and correspond with what might be expected from a reduced counteraction of the ventralising Bone morphogenetic protein (BMP) pathway at the earlier stages, coupled with inadequate Sonic hedgehog (Shh) signalling subsequently. Delay in the clearing of BMP-4 RNA expression from the presumptive neural region at gastrulation is indeed seen, though chordin RNA expression within organiser derivatives remains normal. Subsequently, specific attenuation of chordamesoderm and neural midline Shh expression is observed. Brief preincubation of stage 4 chick blastoderms in supernatant from Xenopus oocytes that have been injected with Flik RNA prolongs and enhances the competence of their peripheral epiblast to respond to neural inductive signals from grafted Hensen's nodes. This effect specifically mimics that recently observed using microg/ml solutions of recombinant Follistatin (D. J. Connolly et al., 1999, Int. J. Dev. Biol., in press), further suggesting that Flik protein might act in vivo by somehow modulating activity of signalling pathways through BMP or other TGFbeta-related ligands. We discuss the significance of the observations in relation to recent ideas about neural induction, about possible redundancy in gene action, and about subsequent patterning of the axial cross section, suggesting that a Flik function in autocrine/paracrine maintenance of later midline Shh signalling represents a role of the gene separate from that in primary dorsalisation/neural induction.

Secretory immunoglobulin A and cardiovascular activity during mental arithmetic and paced breathing

The role of the autonomic nervous system in secretory immunoglobulin A (sIgA) responses to laboratory challenge was explored in a study in which sIgA and cardiovascular activity were recorded at rest and during mental arithmetic and paced breathing. These tasks were selected to preferentially engage the sympathetic and parasympathetic nervous systems, respectively. Mental arithmetic elicited a mixed pattern of increased alpha- and beta-adrenergic activity and a reduction in parasympathetic activity; diastolic blood pressure, total peripheral resistance, and systolic blood pressure increased, preejection period shortened, and heart rate variability decreased. In contrast, paced breathing primarily elicited an increase in parasympathetic activity; heart rate variability increased. Mental arithmetic also provoked an increase in sIgA concentration but no change in saliva volume, whereas paced breathing affected neither sIgA concentration nor saliva volume. These data suggest that sIgA responses to laboratory challenges are mediated by sympathetic rather than parasympathetic processes.

Analysis of optical density and contrast in mammograms

The objective of this project is the development of tools for the UK NHSBSP to assess image quality quantitatively in clinical films, for the purposes of optimizing imaging procedures and audit. As an initial step, 120 mammograms of 46 women on a single day of screening were digitized and analysed to produce indices of optical density (OD) and contrast. Analysis was performed on three regions of interest (ROI): pectoral muscle, main breast and skin edge. Two radiologists independently graded the quality of information in the different parts of each mammogram, and categorized breast type as either "dense", "mixed density" or "fatty". Measurements of contrast and OD generally correlated well with the opinions of the radiologists. For the oblique mammograms, the mean OD in the main breast ranged between films from 1.25 to 2.24 with a mean of 1.69 +/- 0.02. In the craniocaudal mammograms, the mean OD in the main breast ROI ranged from 1.14 to 1.94 with a mean of 1.61 +/- 0.05. The OD for a quality control film of a 40 mm block of PMMA exposed on the same day with this system was 1.53. A contrast index (CI) was calculated for each mammogram as the difference between the points of maximum and minimum OD in the main breast. Mean CI was 1.02 +/- 0.09 for fatty breasts, 1.50 +/- 0.10 for mixed density breasts and 2.05 +/- 0.23 for dense breasts. A review of the radiologist assessments indicated that the main breast was satisfactorily displayed when glandular and fatty tissues were displayed within the OD range 0.8-2.9. An analysis of the dynamic range requirements showed that 17% of films had a dynamic range that lay above that calculated using the suggested OD limits.

Nodal signalling and the roles of the transcription factors SnR and Pitx2 in vertebrate left-right asymmetry

Left-specific mesodermal expression of the homeobox gene Pitx2 links a gastrula-stage intercellular signalling cascade to the later development of vertebrate left-right organ asymmetry through the Nodal signalling pathway [1] [2][3] [4][5] [6]. SnR (Drosophila snail-related), a gene conserved in vertebrates and encoding a zinc-finger protein, appears to function in a similar manner to Pitx2, but through right-specific mesodermal expression [7] [8]. Here, we present direct evidence for an earlier proposal [7] that Nodal signalling specifically represses expression of SnR in left lateral mesoderm, and thus ensures its normal confinement to the right, while activating Pitx2 on the left. We addressed the relationship between Pitx2 and SnR using antisense disruption of SnR. Relatively severe antisense-SnR treatment led to massive ectopic expression of Pitx2 on the right, accompanied by randomisation of situs with embryos showing aspects of left-cardiac isomerism. This indicates a gene cascade relationship in the propagation of left-right information, whereby nodal activates Pitx2 on the left through a double-negative mechanism involving the repression of SnR's repressor role on Pitx2. Milder antisense-SnR treatment reversed heart-loop direction and embryo torsion at significant incidence, although Pitx2 expression remained normally left-confined throughout. This reversed morphology following SnR disruption alone appeared different from that in which additional ectopic right-hand Pitx2 expression was seen. Therefore, in addition to their regulatory gene cascade relationship, these two transcription factors appear to have further, parallel but non-redundant, roles in directly controlling normally right- and left-specific morphogenetic processes.

Do anaemia co-ordinators have to be nurses?

The role of the anaemia co-ordinator has developed subsequent to the introduction of erythropoietin therapy for renal anaemia, and posts have been established at an increasing number of hospitals in the UK. While co-ordinators have previously tended to come from a nursing background, the post at our hospital has been held jointly by a pharmacist and a clinical nurse specialist since July 1997. This paper presents an informal evaluation of our experience of joint working, and has drawn on diary entries to outline the components of the service provided. The main focus is on the boundary negotiated between pharmacist and nurse responsibilities and expertise, involving as it does areas of potential conflict and complementarity. Through a critical examination of the assumptions and expectations associated with 'generic' pharmacist and nurse roles, we begin to clarify the respective contributions which the disciplines make to anaemia management.

The significance of spontaneous resolution of breast calcification

Spontaneously resolving breast microcalcification is a rarely reported occurrence. A retrospective review was carried out on 33 cases of resolving benign and indeterminate microcalcification identified from 108,000 screening mammograms from the South West London Breast Screening Service. Four further cases are reported from The Jarvis Breast Screening Centre. No interval cancers were identified in women with microcalcification which initially showed benign appearances. However, 36.4% of the group with resolving indeterminate microcalcification subsequently developed cancers. It is recommended that this change should prompt full investigation and close follow-up or excision. While the majority of spontaneously resolving microcalcification is associated with benign processes, it is concluded that a significant proportion of disappearing indeterminate microcalcification is associated with malignancy.

Eph signaling is required for segmentation and differentiation of the somites

Somitogenesis involves the segmentation of the paraxial mesoderm into units along the anteroposterior axis. Here we show a role for Eph and ephrin signaling in the patterning of presomitic mesoderm and formation of the somites. Ephrin-A-L1 and ephrin-B2 are expressed in an iterative manner in the developing somites and presomitic mesoderm, as is the Eph receptor EphA4. We have examined the role of these proteins by injection of RNA, encoding dominant negative forms of Eph receptors and ephrins. Interruption of Eph signaling leads to abnormal somite boundary formation and reduced or disturbed myoD expression in the myotome. Disruption of Eph family signaling delays the normal down-regulation of her1 and Delta D expression in the anterior presomitic mesoderm and disrupts myogenic differentiation. We suggest that Eph signaling has a key role in the translation of the patterning of presomitic mesoderm into somites.

Cost issues in sequential therapy

Pharmacoeconomics is starting to be employed in strategic therapeutic decision making. Costs associated with antimicrobials included: (i) acquisition costs; (ii) preparation, administration and consumables costs; (iii) monitoring costs; (iv) costs of unwanted drug effects; (v) costs of resistance and therapeutic failures and (vi) costs of duration of stay. Most hospitals have a Drug and Therapeutics Committee but acquisition costs are still the most important economic criterion for acceptance for use, even though medicines only consume between 3 and 5% of total revenue costs, of which antibiotics account for around 15%. In any sequential programme acquisition costs and consumables are immediately realizable. Staff time and monitoring tests are less realizable but require changes in the way budgets are handled. Microbial resistance and risk management are difficult to quantify but are increasingly becoming important in strategic decision-making. The educational needs of health care decision makers in economic need addressing and mechanisms need to be put in place to enable the putative savings reported in the pharmacoeconomic literature to be realized.

A Cascade of Gene Action Controlling Heart Asymmetry and Torsion in Embryonic Development

Lateralized looping of the heart tube, with associated torsion of the embryo axis, is the first structural sign of the consistent left-right asymmetrical organization that characterizes all vertebrate embryos. Rare failures or reversals of this asymmetry in humans lead to clinically important syndromes of malformation in heart and great blood vessels. Recently, elements of the genetic control sequence underlying this left-right aspect of development have been uncovered. The normal sequence of transmission for asymmetry information can now be traced to a point close to the actual execution of right-hand looping in the heart tube, with the hope that the further sequence of gene activity, within the heart itself and directing these events, may soon be uncovered.

Great medicine--pity about the cost

Images

Noggin acts downstream of Wnt and Sonic Hedgehog to antagonize BMP4 in avian somite patterning

In the vertebrate embryo, the lateral compartment of the somite gives rise to muscles of the limb and body wall and is patterned in response to lateral-plate-derived BMP4. Activation of the myogenic program distinctive to the medial somite, i.e. relatively immediate development of the epaxial muscle lineage, requires neutralization of this lateral signal. We have analyzed the properties of molecules likely to play a role in opposing lateral somite specification by BMP4. We propose that the BMP4 antagonist Noggin plays an important role in promoting medial somite patterning in vivo. We demonstrate that Noggin expression in the somite is under the control of a neural-tube-derived factor, whose effect can be mimicked experimentally by Wnt1. Wnt1 is appropriately expressed in the neural tube. Furthermore, we show that Sonic Hedgehog is able to activate ectopic expression of Noggin resulting in the blocking of BMP4 specification of the lateral somite. Our results are consistent with a model in which Noggin activation lies downstream of the SHH and Wnt signaling pathways.

Effect of automatic kV selection on dose and contrast for a mammographic X-ray system

The effect of automatic tube potential (kV) selection on breast dose and contrast has been assessed using a Philips MammoDiagnost 3000 mammography X-ray set. The performance of the X-ray set using automatic kV selection has been compared with that found using a fixed kV of 28. The AUTOKV mode selected 25 kV for breasts with thickness up to about 50 mm, which increased the contrast by 5-10%, and increased the mean glandular dose (MGD) per film by, on average, 30-40%. For large breasts with a compressed thickness of 70 mm and above, kVs up to 30 were selected so that the average MGD per film was reduced by 19% from 3.62 to 2.94 mGy, with an estimated loss in contrast of about 4-8%. For all breasts the mean MGD per film was 1.85 +/- 0.05 mGy where AUTOKV was used, and 1.74 +/- 0.08 mGy per film when 28 kV was used. The overall image quality of the mammograms was found to be higher when AUTOKV was used. Overall, the AUTOKV facility on this X-ray set generally worked well and resulted in slightly higher contrast and slightly better image quality at the price of a small increase in the average dose for this patient group when compared with the usual UK procedure of using a fixed 28 kV.

Left/right patterning signals and the independent regulation of different aspects of situs in the chick embryo

Recently, a pathway of genes which are part of a cascade regulating the side on which the heart forms during chick development was characterized (M. Levin et al., 1995, Cell 82, 1-20). Here we extend these previous studies, showing that manipulation of at least one member of the cascade, Sonic hedgehog (Shh), can affect the situs of embryonic rotation and of the gut, in addition to the heart. Bilateral expression of Shh, which is normally found exclusively on the left, does not result in left isomerism (a bilaterally symmetrical embryo having two left sides) nor in a complete situs inversus phenotype. Instead, misexpression of Shh on the right side of the node, which in turn leads to bilateral nodal expression, produces a heterotaxia-like condition, where different aspects of laterality are determined independently. Heart situs has previously been shown to be altered by ectopic Shh and activin. However, the most downstream gene identified in the LR pathway, nodal, had not been functionally linked to heart laterality. We show that ectopic (right-sided) nodal expression is able to affect heart situs, suggesting that the randomization of heart laterality observed in Shh and activin misexpression experiments is a result of changes in nodal expression and that nodal is likely to regulate heart situs endogenously. The first defined asymmetric signal in the left-right patterning pathway is Shh, which is initially expressed throughout Hensen's node but becomes restricted to the left side at stage 4(+). It has been hypothesized that the restriction of Shh expression may be due to repression by an upstream activin-like factor. The involvement of such an activin-like factor on the right side of Hensen's node was suggested because ectopic activin protein is able to repress Shh on the left side of the node, as well as to induce ectopic expression of a normally right-sided marker, the activin receptor cAct-RIIa. Here we provide further evidence in favor of this model. We find that a member of this family, Activin betaB, is indeed expressed asymmetrically, only on the right side of Hensen's node, at the correct time for it to be the endogenous asymmetric activin signal. Furthermore, we show that application of follistatin-loaded beads eliminates the asymmetry in Shh expression, consistent with an inhibition of an endogenous member of the activin-BMP superfamily. This combined with the previous data on exogenous activin supports the model that Activin betaB functions in the chick embryo to initiate Shh asymmetry. While these data extend our understanding of the early signals which establish left-right asymmetry, they leave unanswered the interesting question of how the bilateral symmetry of the embryo is initially broken to define a consistent left-right axis. Analysis of spontaneous chick twins suggests that, whatever the molecular mechanism, left-right patterning is unlikely to be due to a blastodermal prepattern but rather is initiated in a streak-autonomous manner.