A genome-wide screen for linkage disequilibrium in Australian HLA-DRB1*1501 positive multiple sclerosis patients

The association of multiple sclerosis with alleles/haplotypes from the HLA region on chromosome 6p21 is well established although the remainder of the genome remains relatively unexplored. We have completed a genome-wide screen for linkage disequilibrium in a cohort of Australian multiple sclerosis patients positive for HLA-DRB1*1501. A total of 4346 microsatellite markers provided through the "Genetic Analysis of Multiple sclerosis in EuropeanS" (GAMES) collaborative were analysed in DNA separately pooled from cases (n=217) and controls (n=187). Associations were found in four genomic regions (12q15, 16p13, 18p11 and 19q13) previously identified in linkage genome screens. Three additional regions of novel association were also identified (11q12, 11q23 and 14q21). Further analysis of these regions is required to establish whether the associations observed are due to epistatic interaction with the HLA locus.

Histological assessment after different methods of reperfusion following liver transplantation

INTRODUCTION

Preservation-reperfusion injury is a major cause of graft failure after liver transplantation. This injury refers to a variety of insults after reperfusion of the graft, independent of technical errors, vascular problems, immunological reactions or infection. Significant injuries occur during the period of cold preservation. Loss of sinusoidal endothelial attachments to the underlying extracellular matrix results in loss of the normal antithrombogenic milieu. Reperfusion with recipient blood results in platelet aggregation and neutrophil sludging in all areas of denudation, preventing adequate reoxygenation. Early histopathological findings in biopsy specimens can predict poor graft outcome.

OBJECTIVE

To analyse the effect of early rearterialisation on histological findings of the liver biopsies after liver transplantation.

METHODS

Twenty young Large White X Landrace pigs (weight 22-28 kg) were subjected to orthotopic liver transplantation. Livers were stored in Eurocollins solution for 3 hours on ice and the animals were randomised into four different groups of increasingly early arterialisation. Groups were aligned from delayed rearterialisation (group 1) to early rearterialisation (group 4). Biopsies were taken before and after cold storage, as well as 1 hour post transplantation.

RESULTS

Results show that both hepatocyte vacuolisation and neutrophil infiltration were significantly reduced in group 4 (early rearterialisation), compared with groups 1, 2 and 3. Single cell necrosis and group cell necrosis of the hepatocytes were both significantly reduced in groups 3 and 4 compared with groups 1 and 2 (early venous reperfusion).

CONCLUSION

This study demonstrates that early rearterialisation is associated with a decrease in early histopathological changes in the transplanted pig liver.

Meeting patient expectations of care: the major determinant of satisfaction with out-of-hours primary medical care?

BACKGROUND

Client or consumer expectation is considered to influence their satisfaction with the service provided, but its importance has not been quantified in health care.

OBJECTIVE

The aim of this study was to determine the effect of "patient expectations of care" on satisfaction with care provided by out-of-hours services.

METHODS

We surveyed 3457 patients who requested out-of-hours care from five practices, two general practice out-of-hours co-operatives and a deputizing service in an English health authority during late 1997. The independent variables were: the service providing the care (service type), where out-of-hours care was given (location of care) and whether the care met the patient's expectations. The independent variable was overall patient satisfaction with out-of-hours care.

RESULTS

Patients who received the care they hoped for (their idealized expectation was met) were more satisfied than those who did not. Patients who attended centres were more satisfied with the care received than those who had had home visits. Patients were more satisfied if they received care from the co-operative which did not employ assistants than from the deputizing service. Idealized expectation (care which was hoped for) match, location of care and service type explained 34, 2 and 4% of the variance, respectively. Age, sex, ethnicity, access to a car, normative/comparative expectation (care which was expected) and whether patients expected and received telephone advice, a home visit or domiciliary care, and the delay between request for care and care provision were not independently associated with satisfaction.

CONCLUSIONS

Meeting or failing to meet the care patients hoped for is an important predictor of patient satisfaction with out-of-hours care. Purchasers and providers of out-of-hours care should consider whether and how patient expectation of service can be managed. This may reduce patient dissatisfaction with the service they provide. These findings also have important implications for the design of studies which use patient satisfaction as an outcome variable.

Fatal donor-derived Epstein-Barr virus-associated post-transplant lymphoproliferative disorder following reduced intensity volunteer-unrelated bone marrow transplant for myelodysplastic syndrome

Post-transplant lymphoproliferative disorders (PTLD) are a well recognised complication of conventional haemopoietic stem cell transplantation (HSCT). Reduced intensity HSCT involves intensive immunosuppression to permit engraftment. Thirty reduced intensity transplants with the FBC (fludarabine 150 mg/m2, busulphan 8 mg/m2, CAMPATH-1H 100 mg) protocol have been performed at our centre, with one confirmed EBV-positive PTLD. The female recipient developed a perforated viscus day +191 following HSCT from a volunteer unrelated male donor. A large caecal mass and a retroperitoneal abscess were excised, revealing an EBV-positive diffuse large B cell lymphoma confirmed by FISH to be of donor origin. More experience is required before the risk of PTLD in this setting can be assessed.

Magnetic resonance imaging in the diagnosis of Fournier's gangrene

Magnetic resonance imaging and ultrasound are the imaging modalities recommended in the early diagnosis of Fournier's gangrene. Because of the high mortality of this inflammatory disease early diagnosis is essential to initiate adequate surgical and medical treatment. In the clinical literature only a handful of cases, in which diagnosis of Fournier's gangrene is based on MRI findings, have been reported; therefore, we report another case which shows the ability of MRI especially to determine the point of origin and extension of disease.

Partially mismatched related donor bone marrow transplantation as salvage for patients with AML who failed autologous stem cell transplant

Treatment options for patients who relapse are limited and the outcome is dismal. Between August 1993 and January 1999, 17 patients, median age 26 (4-44) years, underwent T cell depleted bone marrow transplant from partially mismatched related donors (PMRD), as a salvage for AML relapsing after an autograft. The median time from auto-transplant to relapse was 7 months (1.5-24) and the interval between transplants was 10 months (3-30). All patients had active leukemia at time of transplant. Donors were siblings (n = 8), parents (n = 2), daughters (n = 4) and others (n = 3), and 82% were > or = 2 major HLA antigen mismatched with the recipient. The conditioning therapy included total body irradiation in 14 patients and was busulfan-based in three. Graft-versus-host disease (GVHD) prophylaxis consisted of partial T cell depletion along with post-transplant immunosuppression. Median day to engraftment was 16 days (12-20). Acute GVHD was seen in six patients, and chronic GVHD in four of 13 surviving beyond 100 days. Ten patients died of non-relapse causes, at 1-588 (median 77) days. Two patients relapsed at 3 and 4 months. Five patients (29%) are surviving leukemia-free 42-84 months post transplant (median 68 months). A short interval between transplants was predictive of early relapse but not mortality. Age <18 and <2 organ toxicities were marginally predictive of better survival. We conclude that BMT from PMRD is a reasonable option for patients with refractory AML post autograft.

Validation of a commercially available monoclonal antibody-based competitive-inhibition enzyme-linked immunosorbent assay for detection of serum antibodies to Neospora caninum in cattle

A previously described monoclonal antibody (MAb)-based competitive-inhibition enzyme-linked immunosorbent assay (cELISA) was modified to optimize performance, and the assay was validated in various defined cattle populations for detection of serum antibody to Neospora caninum, a major cause of bovine abortion. Modifications to the cELISA included capturing native N. caninum antigen with a parasite-specific MAb (MAb 5B6-25) and directly conjugating the competitor MAb (MAb 4A4-2), with both MAbs binding different epitopes of a conserved, immunodominant 65-kDa tachyzoite surface antigen. The assay was validated using three serum sets, a "gold standard" set of 184 cow sera defined by fetal histopathology and N. caninum immunohistochemistry and by maternal N. caninum indirect fluorescence assay (IFA) at a 1:200 serum dilution, a relative standard set of 330 cow sera defined by IFA alone, and a set of 4,323 cow sera of unknown N. caninum status. A test cutoff of 30% inhibition was identified. The diagnostic sensitivity was 97.6%, and diagnostic specificity was 98.6% for the gold standard abortion-defined sera. The diagnostic sensitivity was 96.4%, and diagnostic specificity was 96.8% for the relative standard IFA-defined sera. Testing of the 4,323 bovine sera of unknown N. caninum status revealed a distinct bimodal distribution and steep sigmoid frequency curve with only 1.8% of samples within 5% of the test cutoff, indicating a sharp discrimination between test-positive and test-negative samples. In summary, the modified N. caninum cELISA provided a simple, rapid, and versatile method to accurately identify N. caninum infection status in cattle using a single cutoff value.

Therapeutic vaccination (p24-VLP) of patients with advanced HIV-1 infection in the pre-HAART era does not alter CD4 cell decline

In a randomized placebo controlled trial 304 HIV infected patients with CD4 cell counts below 350 cells/microL received therapeutic vaccination with: alum placebo (Group I, n = 102), p24-VLP 500 microg (Group II, n = 101) or p24-VLP 1000 microg (Group III, n = 101) p24-VLP monthly for six months. Over one year the average change in CD4 cell count did not differ significantly between groups (-32, -40 and -52 cells per microL respectively). There was also no difference between groups in progression to CDC category B or C events, or in adverse events. Therapeutic vaccination with p24-VLP does not affect CD4 cell decline in patients with advanced HIV infection.

Mechanisms of pH regulation in the regulated secretory pathway

A precise pH gradient between organelles of the regulated secretory pathway is required for sorting and processing of prohormones. We studied pH regulation in live endocrine cells by targeting biotin-based pH indicators to cellular organelles expressing avidin-chimera proteins. In AtT-20 cells, we found that steady-state pH decreased from the endoplasmic reticulum (ER) (pH(ER) = 7.4 +/- 0.2, mean +/- S.D.) to Golgi (pH(G) = 6.2 +/- 0.4) to mature secretory granules (MSGs) (pH(MSG) = 5.5 +/- 0.4). Golgi and MSGs required active H(+) v-ATPases for acidification. ER, Golgi, and MSG steady-state pH values were also dependent upon the different H(+) leak rates across each membrane. However, neither steady-state pH(MSG) nor rates of passive H(+) leak were affected by Cl(-)-free solutions or valinomycin, indicating that MSG membrane potential was small and not a determinant of pH(MSG). Therefore, our data do not support earlier suggestions that organelle acidification is primarily regulated by Cl(-) conductances. Measurements of H(+) leak rates, buffer capacities, and estimates of surface areas and volumes of these organelles were applied to a mathematical model to determine the H(+) permeability (P(H+)) of each organelle membrane. We found that P(H+) decreased progressively from ER to Golgi to MSGs, and proper acidification of Golgi and MSGs required gradual decreases in P(H+) and successive increases in the active H(+) pump density.

Reactive carbonyl formation by oxidative and non-oxidative pathways

The spectrophotometric protein carbonyl assay is used as an indicator of protein damage by free radical reactions in vitro and in a variety of pathologies. We investigated model proteins and a variety of oxidative and non-oxidative reactions, as well as what effects hemoglobin, myoglobin, and cytochrome c might have on levels of protein carbonyls. We show that oxidative as well as non-oxidative mechanisms introduce carbonyl groups into proteins, providing a moiety for quantification with 2,4-dinitrophenylhydrazine (DNPH). Bovine serum albumin exposed to oxidative scenarios, such as hypochlorous acid, peroxynitrite, and metal-catalyzed oxidation exhibited variable, but increased levels of carbonyls. Other non-oxidative modification systems, in which proteins are incubated with various aldehydes, such as malondialdehyde, acrolein, glycolaldehyde, and glyoxal also generated significant amounts of carbonyls. Furthermore, purified myoglobin, hemoglobin, and cytochrome c show high absorbance at the same wavelengths as DNPH. The high levels observed are due to the innate absorbance of hemoglobin, myoglobin, and cytochrome c near the assay spectra of DNPH. These studies show that carbonyl content could be due to oxidative as well as non-oxidative mechanisms and that heme-containing compounds may effect carbonyl quantification.

The -590C/T and -34C/T interleukin-4 promoter polymorphisms are not associated with atopic eczema in childhood

Susceptibility to the development of asthma and other atopic diseases is known to have a genetic component. To date, several studies have linked chromosome 5q31 to asthma and atopy in human beings. This region harbors a cluster of cytokine and growth factor genes, IL-4 presenting as a prime atopy candidate gene, inasmuch as it plays a pivotal role in the atopy pathway. Our approach was to identify polymorphisms within the promoter regions of IL-4 and test their association with atopic eczema. Polymorphisms were typed in a cohort of 76 small nuclear families and 25 triads with childhood atopic eczema. The genotypes were used to test for linkage in the presence of association with atopic eczema. A new polymorphism, -34C/T, was identified and studied with a known polymorphism, -590C/T. On its own, each polymorphism showed no association with atopic eczema. The 2 polymorphisms were used to generate haplotypes, and a significant result was found for the -590C/-34C haplotype. However, after Bonferroni correction for multiple testing, the association became nonsignificant. Neither polymorphism predisposes to early-onset atopic eczema by itself, but suggestive linkage was found for the -590C/-34C haplotype in this study.

Radioisotope-guided surgery in patients with pheochromocytoma and recurrent medullary thyroid carcinoma: a comparison of preoperative and intraoperative tumor localization with histopathologic findings

BACKGROUND

The objective of this study was to appraise the detection of metastases of medullary thyroid carcinoma (MTC) and pheochromocytoma using radioguided surgery (RGS) and to compare the results with external imaging modalities, surgical palpation, and histopathologic findings.

METHODS

Twenty-five patients with recurrent MTC underwent preoperative scintigraphic imaging with 500 megabecquerels (MBq) of technetium 99m(V)-dimercaptosuccinic acid [(99m)Tc(V)-DMSA] and 222 MBq of indium 111 ((111)In)-pentetreotide. The radiopharmaceutical that showed the greatest preoperative tumor uptake was selected for intraoperative RGS. Surgery was performed 24 hours after the administration of (111)In-pentetreotide or 4 hours after the injection of (99m)Tc(V)-DMSA. Furthermore, three male patients underwent surgery who suffered from recurrent pheochromocytoma (injection of 180 MBq iodine 123-labeled metaiodobenzylguanidine [(123)I-MIBG] 4--5 hours before surgery).

RESULTS

Overall, lesion detection sensitivities in patients with MTC for computed tomography, (111)In-pentetreotide, and (99m)Tc(V)-DMSA were 32%, 34%, and 65%, respectively. Surgical palpation identified lymph node metastases of recurrent MTC with a sensitivity of 65%, whereas RGS localized 64 malignant lesions (sensitivity, 97%). Altogether, 71 lesions could be excised, 5 of which were adjudged false positive with respect to MTC metastases. Both surgical palpation and RGS localized all paravertebral subdiaphragmatic lesions (size > or = 2 cm) of recurrent pheochromocytoma seen in the preoperative MIBG scan.

CONCLUSIONS

RGS was capable of localizing more and smaller metastases of MTC compared with conventional imaging modalities and surgical palpation. However, the relatively high radioligand accumulation in the kidneys ((111)In-pentetreotide) and the dense hepatic and biliary signals using MIBG limited their use for intraoperative detection of tumors in the area of the adrenal gland.

Role of the medial and lateral caudate-putamen in mediating an auditory conditional response association

Rats with quinolinic acid lesions of the medial or lateral caudate-putamen (CPu) and controls were tested for performance of a previously learned auditory conditional response association task. The task involved the selection of two possible responses when presented with one of two different tones. Results indicated that lesions of either the medial or the lateral CPu produced a sustained deficit in the auditory conditional response association task. Only the lateral CPu lesioned rats exhibited transient motor problems immediately following surgery, but these problems did not interfere with the execution of the appropriate responses. It is suggested that both the medial and the lateral CPu are involved in response selection and response separation within egocentric space.

A comparative study of CT fluoroscopy combined with fluoroscopy versus fluoroscopy alone for percutaneous transhepatic biliary drainage

PURPOSE

We compared CT fluoroscopy (CTF) for the initial puncture of bile ducts with conventional fluoroscopic guidance in patients with malignant jaundice in whom percutaneous transhepatic biliary drainage (PTBD) was planned.

METHODS

Forty consecutive patients were randomized to two study groups: group A underwent PTBD under CTF and fluoroscopic guidance, group B underwent PTBD under fluoroscopic guidance alone. CTF-guided PTBD was performed using a combination of a helical CT scanner of the latest generation and a mobile C-arm; conventional PTBD was performed under fluoroscopic guidance in the angiographic unit. End points of the study were the success (a puncture that enabled safe placement of a guidewire in a suitable bile duct) and the complication rate (hemobilia, bile fistula, biliary peritonitis), the number of punctures required, the time needed for successful puncture of a suitable bile duct, and the patient's radiation exposure.

RESULTS

CTF-guided puncture of peripheral bile ducts suitable for PTBD was successful at the first attempt in 16 cases, under conventional fluoroscopic guidance, in only two cases. We found a significantly different number of punctures (1.2 in group A vs 2.9 in group B), a significantly shorter time for puncture in group A (mean 39 sec), but also a significantly higher skin exposure dosage in group A (mean 49.5 mSv surface dosage). There was no significant difference regarding the total procedure time. Only one complication occurred in group B (portobiliary fistula).

CONCLUSION

CTF-guided initial puncture of bile ducts allowed a significantly reduced number of punctures and puncture times compared with puncture under conventional fluoroscopic guidance for placement of percutaneous transhepatic biliary drainage catheters.

Nephrostomy tube or 'JJ' ureteric stent in ureteric obstruction: assessment of patient perspectives using quality-of-life survey and utility analysis

INTRODUCTION

Upper urinary tract obstruction is often relieved by either a percutaneous nephrostomy tube (PCN) or a ureteric stent. Both can cause considerable morbidity and reduce patient's health-related quality of life (QoL). We have compared the QoL in these 2 groups.

PATIENTS AND METHODS

34 patients (21 stent and 13 PCN) with unilateral ureteric obstruction were prospectively studied. Each patient completed a questionnaire, which included a common single health index (EuroQol EQ-5D) and intervention-specific questions to assess pain, urinary symptoms and day-to-day problems.

RESULTS

There were 22 male and 12 female patients [mean age 56+/-9 years (PCN) and 55+/-14 years (stent)]. The mean duration between the intervention and conduct of the survey was 12+/-5 days for PCN and 28+/-14 days for stent. There was no different in the mean EuroQol score (p = 0.199) and analogue score (p = 0.596) indicating no differences in the gross defects in physical and psychosocial function and the utility between the 2 groups. There was a significant difference in the urinary symptoms (p<0.0001) with patients who had a stent experiencing significantly more irritative urinary symptoms. This group also suffered discomfort for a greater duration and in various postures requiring more analgesia (although not significant with Bonferroni correction). Patients with PCN required more help in the daily care of the nephrostomy tube. There was no difference in the incidence of infections and the need for antibiotics.

CONCLUSIONS

Patients with 'JJ' stents have significantly more irritative urinary symptoms and a high chance of local discomfort than patients with nephrostomy tubes (PCN). However, based on the EuroQol analysis, there is no significant difference in the gross impact on the health-related QoL or the utility between these groups indicating no patient preference for either modality of treatment.

Relationship between bond valence and bond softness of alkali halides and chalcogenides

Established bond-valence parameter tables rely on the assumption that the bond-valence sum of a central atom is fully determined by interactions to atoms in its first coordination shell. In this work the influence of higher coordination shells is tested in detail for bonds between lithium and oxygen. It is demonstrated that the sum of the weak interactions with atoms of the second coordination shells significantly contributes to the valence sum and should therefore not be neglected. Since the independent refinement of the two parameters R(0) and b is hardly possible from the limited range of bond lengths occurring in the first coordination shell, the restriction of bond-valence sums to contributions from nearest neighbours implicated another far-reaching simplification: the postulation of a universally fixed value of the bond-valence parameter b which characterizes the shape of the bond-valence pseudopotential for the respective atom pair. However, recent more sophisticated applications of the bond-valence concept, e.g. to model ion-transport pathways in solid electrolytes, demand sensible estimates of the bond-valence sums for mobile ions not only at their equilibrium sites but also at interstitial sites and bottle-necks of transport pathways. Calculations of bond valences at these non-equilibrium sites require the knowledge of the actual shape of the bond-valence pseudopotential. A systematic route to a more realistic estimate of b for alkali halides and chalcogenides is developed in this work from an empirical correlation between b and the absolute softnesses of the interacting particles.

Successful treatment of intimal hyperplasia in renal arteries by endovascular brachytherapy

PURPOSE

The present study shows the possibility of preventing restenosis of renal arteries by endovascular brachytherapy.

METHODS AND MATERIALS

We present a patient suffering from rapid restenosis of both renal arteries with decreasing renal function. Percutaneous transluminal angioplasty (PTA) and stent implantation were unable to stop hypertension and to stabilize renal function. Both renal arteries and the right pole artery were treated by endovascular brachytherapy in one session.

RESULTS

Six months after intervention, intraarterial digital subtraction angiography (DSA) showed no evidence of recurrence, and the blood pressure remained normal without medical treatment.

CONCLUSION

Endovascular brachytherapy can help to prevent restenosis in renal arteries. It is possible to treat both renal arteries and one pole artery in one session without any disadvantage.