959 A Double Case Review: Arteria Comitans Nervi Ischiadici, Two Rare Presentations of Persistent Sciatic Artery Aneurysm

Background

In the embryo, the blood flow of the lower limb bud originates from the umbilical artery and becomes the sciatic artery following the course of the sciatic nerve. By the 12th week, the sciatic will involute, in rare instances that this fails it is referred to as ‘arteria comitans nervi ischiadici’. This variant is rare with an incidence of 0.01%-0.05% is of the utmost surgical significance as failure to accurately diagnose and treat can ultimately threaten limb loss.

Cases

1. A middle aged gentleman who presented with a 9-month history of posterior thigh pain with sensations of pressure related to posture and back pain following heavy lifting. Initially this patient was managed conservatively for claudication symptoms until they represented to clinic 4 years later with a 5month history of left buttock discomfort when sitting in the absence of claudication. An endovascular intervention with coil embolisation was undertaken reasons with a satisfactory outcome.

2. A young female with AVM to the left thigh and bilateral PSA's, presented with a painful swelling of the upper inner aspect of the mid-thigh, with a normal venous examination. On representing, despite repeated sclerotherapy, the patient had developed increasingly severe discomfort at the site of the thigh malformation, posterior aspect of the left leg. The patient was referred to a tertiary centre for reassessment.

Conclusion

Due to the variety and evolving nature of clinical presentations, a high degree of clinical suspicion is an important factor in providing a diagnosis. We also highlight the advantages of endovascular intervention.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

“I see my culture starting to disappear”: Anishinaabe perspectives on the socioecological impacts of climate change and future research needs

Climate change disproportionately affects Indigenous Peoples because of strong connections between environmental, cultural, and spiritual well-being. While much of the global discourse surrounding climate change is founded in Western science, the holistic, place-based knowledge of Indigenous Peoples offers a complementary way of understanding and mitigating climate change impacts. The goal of this research was to elevate Anishinaabe concerns, observations, and perspectives about climate change impacts and future research needs. We organized a workshop called “Connecting Guardians in a Changing World” where participants shared concerns about animal and plant life cycles, water cycles and water quality, and impacts to ways of life, including reduced capacity to perform cultural practices and erosion of their knowledge. Participants highlighted the challenge of prioritizing a single impact of climate change, emphasizing that impacts to the environment and ways of life are interconnected. Participants also expressed the need for research and policy that move beyond interdisciplinarity to include intercultural philosophy and research that better reflects Indigenous worldviews and incorporates Indigenous methodologies. Moving forward, meaningful partnerships and opportunities for knowledge sharing should be prioritized in climate change discourse to ensure solutions are generated together, with all of the tools and knowledge available.

Faecal immunochemical testing and blood tests for prioritization of urgent colorectal cancer referrals in symptomatic patients: a 2-year evaluation

BACKGROUND

A novel pathway incorporating faecal immunochemical testing (FIT) for rapid colorectal cancer diagnosis (RCCD) was introduced in 2017. This paper reports on the service evaluation after 2 years of pathway implementation.

METHODS

The RCCD protocol was based on FIT, blood results and symptoms to stratify adult patients in primary care. Two-week-wait (2WW) investigation was indicated for patients with rectal bleeding, rectal mass and faecal haemoglobin (fHb) level of 10 µg Hb/g faeces or above or 4 µg Hb/g faeces or more in the presence of anaemia, low ferritin or thrombocytosis, in all other symptom groups. Patients with 100 µg Hb/g faeces or above had expedited investigation . A retrospective audit of colorectal cancer detected between 2017 and 2019 was conducted, fHb thresholds were reviewed and critically assessed for cancer diagnoses.

RESULTS

In 2 years, 14788 FIT tests were dispatched with 13361 (90.4 per cent) completed returns. Overall, fHb was less than 4 µg Hb/g faeces in 9208 results (68.9 per cent), 4-9.9 µg Hb/g in 1583 (11.8 per cent), 10-99.9 µg Hb/g in 1850 (13.8 per cent) and 100 µg Hb/g faeces or above in 720 (5.4 per cent). During follow-up (median 10.4 months), 227 colorectal cancers were diagnosed. The cancer detection rate was 0.1 per cent in patients with fHb below 4 µg Hb/g faeces, 0.6 per cent in those with fHb 4-9.9 µg Hb/g faeces, 3.3 per cent for fHb 10-99.9 µg Hb/g faeces and 20.7 per cent for fHb 100 µg Hb/g faeces or above. The detection rate in the cohort with 10-19.9 µg Hb/g faeces was 1.4 per cent, below the National Institute for Health and Care Excellence threshold for urgent referral. The colorectal cancer rate in patients with fHb below 20 µg Hb/g faeces was less than 0.3 per cent.

CONCLUSION

Use of FIT to "rule out" urgent referral from primary care misses a small number of cases. The threshold for referral may be adjusted with blood results to improve stratification .

Opinions and experiences of a national smokefree prison policy: evidence from the TIPs study

Background

Removal of tobacco from prisons poses distinct challenges, as prisons are 'homes' and smoking rates are high. TIPs is unique in comprehensively studying a smoking ban using data collected before, during and after the ban. This paper presents opinions and experiences of people in custody (PiC) and staff in Scotland, and identifies implementation success factors and lessons that are highly relevant for other jurisdictions and areas of public health.

Methods

Surveys of staff and PiC (response rates) were conducted in Nov-Dec 2016 (27%, 34%), May-Jul 2018 (31%, 26%) and May-Jul 2019 (16%, 18%), with questions on smoking, smoking cessation/abstinence and smoking restrictions in the prison context. Topics were also explored qualitatively with staff/PiC at similar time points (34 focus groups, 99 interviews). Survey responses were analysed using descriptive statistics and logistic regression analyses. Qualitative data were thematically analysed to identify the diversity of views and experiences.

Results

Smokefree policy is widely accepted as the new 'norm', but support was higher among staff than PiC before, during and after implementation. Surveys and qualitative data suggest perceptions of some of the potential difficulties (e.g. 'hard to enforce') and negative consequences (e.g. 'cause a lot of trouble') of smokefree policy reduced post implementation. Participants identified several implementation success factors relating to: planning and communication, smoking abstinence/cessation products/services, and partnership working.

Conclusions

Smokefree prison polices can be successfully implemented, providing the removal of tobacco is well managed and support measures are available for smokers. Some factors shaping the successful introduction of smokefree prisons in Scotland are relevant to other areas of public health transformation e.g. setting clear objectives and timescales; collaboration and teamwork; and involving staff at all levels and end-users.

Assessing people with dementia: the role of the aged care assessment team and memory clinics

BACKGROUND

A cross-sectional survey of all patients reviewed by the aged care assessment team (ACAT) service and memory clinics between 1 January and 31 December 2012. The ACAT catchment included an estimated 14 325 people over the age of 70.

AIMS

To determine the numbers and outcomes of assessments for cognitive problems by the ACAT and hospital memory clinics for patients within a single ACAT catchment area.

METHODS

Data collected included patient demographics, diagnoses, referral and pharmacological treatment. Flow of referrals to the services that diagnose and manage dementia, and the number of incident dementia cases diagnosed in 2012 were determined.

RESULTS

The ACAT service assessed 1005 patients from the catchment, of which 241 patients already had a diagnosis of dementia. When compared with the estimated dementia prevalence in Australia, 19% of prevalent dementia cases (n = 1260) within the catchment were reviewed by the ACAT. The two memory clinics saw a combined 186 new referrals (91 and 95 respectively) from within the catchment, with a total of 82 patients (22 and 60 respectively) receiving a new diagnosis of dementia. Using Australian estimates of dementia incidence, this would suggest 29% of 286 incident cases were managed through these memory clinics.

CONCLUSIONS

Geriatric services are responsible for the assessment and management of a large proportion of the estimated number of patients with dementia in this catchment area. Further resourcing and standardisation of the pathways to dementia assessment is required in Australia in order to diagnose and manage effectively people with dementia.

Test-retest reliability of high angular resolution diffusion imaging acquisition within medial temporal lobe connections assessed via tract based spatial statistics, probabilistic tractography and a novel graph theory metric

This study examined the reliability of high angular resolution diffusion tensor imaging (HARDI) data collected on a single individual across several sessions using the same scanner. HARDI data was acquired for one healthy adult male at the same time of day on ten separate days across a one-month period. Environmental factors (e.g. temperature) were controlled across scanning sessions. Tract Based Spatial Statistics (TBSS) was used to assess session-to-session variability in measures of diffusion, fractional anisotropy (FA) and mean diffusivity (MD). To address reliability within specific structures of the medial temporal lobe (MTL; the focus of an ongoing investigation), probabilistic tractography segmented the Entorhinal cortex (ERc) based on connections with Hippocampus (HC), Perirhinal (PRc) and Parahippocampal (PHc) cortices. Streamline tractography generated edge weight (EW) metrics for the aforementioned ERc connections and, as comparison regions, connections between left and right rostral and caudal anterior cingulate cortex (ACC). Coefficients of variation (CoV) were derived for the surface area and volumes of these ERc connectivity-defined regions (CDR) and for EW across all ten scans, expecting that scan-to-scan reliability would yield low CoVs. TBSS revealed no significant variation in FA or MD across scanning sessions. Probabilistic tractography successfully reproduced histologically-verified adjacent medial temporal lobe circuits. Tractography-derived metrics displayed larger ranges of scanner-to-scanner variability. Connections involving HC displayed greater variability than metrics of connection between other investigated regions. By confirming the test retest reliability of HARDI data acquisition, support for the validity of significant results derived from diffusion data can be obtained.

Incidental findings on positron emission tomography/CT scans performed in the investigation of lung cancer

OBJECTIVES

This study aimed to clarify the number and cause of incidental findings detected on positron emission tomography (PET)/CT in patients undergoing investigation for presumed lung cancer.

METHODS

The scan reports from PET/CT studies performed for patients with lung cancer under National Institute for Clinical Evidence guidelines from January 2006 until March 2008 were retrospectively reviewed. Incidental findings were followed up by a combination of case note review, clinician feedback, colonoscopy database, histopathology and follow-up imaging.

RESULTS

818 patients were investigated for lung cancer in the study period. 197 incidental findings were found in 175 (21%) patients. The subsequent investigation of 108 lesions confirmed a pathological correlation in 71 (66%) cases. A second primary malignancy was found in 10 patients within the bowel (6), breast (2), tongue (1) and stomach (1). A pre-malignant lesion was confirmed in 25 cases (24 large bowel tubulovillous adenomas and a follicular thyroid lesion). A further 41 (5%) benign abnormalities were detected at multiple sites; the thyroid gland was the single most frequently affected site (14 abnormalities). There were 36 (4.4%) false-positive reported findings, including 17 in the region of the pharynx and larynx and 12 within the large bowel.

CONCLUSIONS

Overall, 9.2% of patients with suspected or known lung cancer having PET/CT had a confirmed incidental finding. A malignant or pre-malignant lesion was found in 1.2% and 3.0%, respectively. These were mostly located within the gastrointestinal tract. The majority of false-positive incidental findings were located in the larynx and pharynx. Uptake in these regions is unlikely to be significant in the absence of a CT morphological correlation.

Incidental focal colonic lesions found on (18)Fluorodeoxyglucose positron emission tomography/computed tomography scan: further support for a national guideline on definitive management

AIM

(18)Fluorodeoxyglucose ((18)FDG) positron emission tomography/computed tomography (PET/CT) is an established part of staging in a wide variety of malignancies. Incidental abnormal uptake of (18)FDG of unknown significance is frequently encountered. Therefore, we investigated patients with abnormal colonic uptake of (18)FDG, determined by PET/CT images, using colonoscopy.

METHOD

The radiology reports of all patients referred to a tertiary referral centre for a PET/CT scan were reviewed retrospectively. Patients with abnormal colonic uptake of (18)FDG were identified and the PET/CT findings were correlated with colonoscopic findings.

RESULTS

Of 555 consecutive patients identified over a 26-month period, 53 had abnormal colonic uptake of (18)FDG, as determined by PET/CT images. Twenty-nine were not investigated following discussion in a specialist multidisciplinary (MDT) meeting, according to local protocol. Twenty out of 24 patients investigated by endoscopy had a colonic lesion correlating to the site identified on the PET/CT image: 16 patients had tubulovillous adenomas (nine of which were > 10 mm), two had invasive adenocarcinomas, two had diverticular disease and one had collagenous colitis; no colonic lesion was detected in three. These findings were incidental and not related to the primary diagnosis for which the scan was being performed. Accordingly, a positive predictive value of 83% is associated with the finding of abnormal uptake of (18)FDG on PET/CT images.

CONCLUSION

Incidental abnormal colonic uptake of (18)FDG, determined by a PET/CT scan requires definitive colonic investigation in patients suitable for further treatment because significant colonic pathology is frequently identified. The benefit of this approach should be discussed in specialist MDT meetings and tailored to each patient; however, national guidelines for management are required.

Self-assessment of morbidity following radical hysterectomy for cervical cancer

The aim of this study was to assess the magnitude of the morbidity following radical surgery for early stage cervical cancer. We performed a retrospective survey of all women who had undergone a radical hysterectomy and lymphadenectomy between the months of July 1995 and December 1996 inclusive at either the Royal Marsden or St George's Hospital (n =38), using a detailed questionnaire on bladder, ano-rectal and sexual function, both before and after treatment. Sixteen women (44.4%) received adjuvant radiotherapy. The mean interval between surgery and inquiry was 16.4% months (range 8-25 months). The mean age at the time of surgery was 40.5 years. Thirty-six out of 38 women contacted responded (94.7%). Overall 33 women (91.7%) reported new bladder, ano-rectal or sexual symptoms. Complaints of urinary incontinence, particularly of urge incontinence, and of voiding difficulties increased significantly after surgery (P <0.05). However, only 5.3% of women had sought treatment. Tenesmus increased significantly (P <0.05), while increases in diarrhoea and faecal incontinence were not statistically significant (P =0.051). Although 12.9% of women stated an improvement in their sex lives, 54.8% thought that their sex life was worse after treatment, and 12.9% of women had ceased sexual activity altogether. Of women of childbearing age 53.8% felt adversely affected by their loss of fertility. Bladder, ano-rectal and sexual symptoms are very common following radical hysterectomy for cervical cancer, with adverse effect on quality of life, and persist into the second year after treatment.

Skin conductance as a means to predict hypotension following spinal anaesthesia

BACKGROUND AND OBJECTIVE

Hypotension following spinal anaesthesia (SA) is common, especially in the elderly. Elevated sympathetic tone has been shown to correlate with severe hypotension after SA. The aim of this prospective trial was to investigate skin conductance (SC), as a measure of sympathetic tone, to predict hypotension after SA.

METHODS

After ethical approval and written informed consent, 30 patients undergoing SA were included. Baseline measurements of SC [number of fluctuations per second (reflecting the firing rate of skin sympathetic nerves), area under the curve (AUC) A and B (reflecting the magnitude of the sympathetic impulse)], blood pressure and heart rate were recorded. After administration of SA, all parameters were assessed every 2.5 min for a total of 15 min. Baseline readings of SC were compared with the lowest blood pressure within the study period.

RESULTS

Data from 30 subjects [73 (8) years] were analysed. After SA, the mean arterial blood pressure declined an average of 21.3 (11.3) mmHg. A cut-off value of 0.35 microSs for baseline AUC B allowed prediction of more than mild hypotension (>15% from baseline) after SA with a sensitivity of 72.5% and a specificity of 77.5%.

CONCLUSIONS

AUC B, as a parameter of SC, may predict severe arterial hypotension after SA in the elderly.

New parameters of skin conductance compared with bispectral index ® monitoring to assess emergence from total intravenous anaesthesia

BACKGROUND

Arousal after total i.v. anaesthesia (TIVA) has been reported to be detectable by monitoring the number of fluctuations per second (NFSC), a parameter of skin conductance (SC). However, compared with monitoring of the bispectral index (BIS), the predictive probability of NFSC was significantly lower. The aim of this study was to determine the value of the two new, not yet published parameters of SC, area under the curve (AUC) methods A and B, for monitoring emergence from TIVA compared with monitoring of NFSC and BIS.

METHODS

Twenty-five patients undergoing surgery were investigated. NFSC, AUC A, AUC B, BIS, and haemodynamic parameters (mean arterial pressure and heart rate) were recorded simultaneously. The performance of the monitoring devices in distinguishing between the clinical states 'steady-state anaesthesia', 'first clinical reaction', and 'extubation' were compared using the method of prediction probability (Pk) calculation.

RESULTS

BIS showed the best performance in distinguishing between 'steady-state anaesthesia' vs 'first reaction' (Pk BIS 0.95; NFSC 0.73; AUC A 0.54; AUC B 0.62) and 'steady-state anaesthesia' vs 'extubation' (Pk BIS 0.99; NFSC 0.73; AUC A 0.71; AUC B 0.67). However, the time from first BIS>60/SC>0 to a first clinical reaction was significantly shorter for BIS (median BIS((R)) 180 s; NFSC 780 s; AUC A 750 s; AUC B 690 s; P < 0.001).

CONCLUSIONS

AUC A and AUC B did not improve accuracy of SC monitoring in patients waking after TIVA.

Eradication therapy for peptic ulcer disease in Helicobacter pylori positive patients

BACKGROUND

Peptic ulcer disease is the cause for dyspepsia in about 10% of patients. 95% of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori. Eradication of H pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain.

OBJECTIVES

The primary outcomes were the proportion of peptic ulcers healed initially and proportion of patients free from relapse following successful healing. Eradication therapy was compared to placebo or pharmacological therapies in H. pylori positive patients. Secondary aims included symptom relief and adverse effects.

SEARCH STRATEGY

A search was undertaken according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group module using CCTR, MEDLINE, EMBASE and CINAHL databases. Experts in the field and pharmaceutical companies were contacted. Abstract books between 1994 and 2003 were hand-searched.

SELECTION CRITERIA

Randomised controlled trials of short and long-term treatment of peptic ulcer disease in H. pylori positive adults were analysed. Patients received at least one week of H pylori eradication compared with ulcer healing drug, placebo or not treatment. Trials were included if they reported assessment from 2 weeks onwards.

DATA COLLECTION AND ANALYSIS

Data were collected on ulcer healing, recurrence, relief of symptoms and adverse effects.

MAIN RESULTS

60 trials were eligible. Data extraction was not possible in 7 trials, and 53 trials were included. In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 patients, relative risk [RR] of ulcer persisting = 0.66; 95% confidence interval [CI] = 0.58, 0.76) and no treatment (2 trials, 207 patients, RR = 0.37; 95% CI 0.26, 0.53). In gastric ulcer healing, no significant differences were detected between eradication therapy and UHD (13 trials, 1469 patients, RR = 1.32; 95% CI = 0.92, 1.90). In preventing duodenal ulcer recurrence no significant differences were detected between eradication therapy and maintenance therapy with UHD (4 trials, 319 patients, relative risk [RR] of ulcer recurring = 0.73; 95% CI = 0.42, 1.25), but eradication therapy was superior to no treatment (27 trials 2509 patients, RR = 0.20; 95% CI = 0.15, 0.26). In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (10 trials, 1029 patients, RR = 0.28; 95% CI 0.18, 0.43).

REVIEWERS' CONCLUSIONS

A 1 to 2 weeks course of H. pylori eradication therapy is an effective treatment for H. pylori positive peptic ulcer disease.

Eradication therapy for peptic ulcer disease in Helicobacter pylori positive patients

BACKGROUND

Peptic ulcer disease is the cause for dyspepsia in about 10% of patients. 95% of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori. Eradication of H pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain.

OBJECTIVES

The primary outcomes were the proportion of peptic ulcers healed initially and proportion of patients free from relapse following successful healing. Eradication therapy was compared to placebo or pharmacological therapies in H. pylori positive patients. Secondary aims included symptom relief and adverse effects.

SEARCH STRATEGY

A search was undertaken according to the Cochrane Upper Gastrointestinal and Pancreatic Diseases Review Group module using CCTR, MEDLINE, EMBASE and CINAHL databases. Experts in the field and pharmaceutical companies were contacted. Abstract books between 1994 and 2002 were hand-searched.

SELECTION CRITERIA

Randomised controlled trials of short and long-term treatment of peptic ulcer disease in H. pylori positive adults were analysed. Patients received at least one week of H pylori eradication compared with ulcer healing drug, placebo or not treatment. Trials were included if they reported assessment from 2 weeks onwards.

DATA COLLECTION AND ANALYSIS

Data were collected on ulcer healing, recurrence, relief of symptoms and adverse effects.

MAIN RESULTS

59 trials were eligible. Data extraction was not possible in 7 trials, and 52 trials were included. In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 patients, relative risk [RR] of ulcer persisting = 0.66; 95% confidence interval [CI] = 0.58, 0.76) and no treatment (2 trials, 207 patients, RR = 0.37; 95% CI 0.26, 0.53). In gastric ulcer healing, no significant differences were detected between eradication therapy and UHD (13 trials, 1469 patients, RR = 1.32; 95% CI = 0.92, 1.90). In preventing duodenal ulcer recurrence no significant differences were detected between eradication therapy and maintenance therapy with UHD (4 trials, 319 patients, relative risk [RR] of ulcer recurring = 0.73; 95% CI = 0.42, 1.25), but eradication therapy was superior to no treatment (26 trials 2434 patients, RR = 0.19; 95% CI = 0.15, 0.26). In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (9 trials, 774 patients, RR = 0.31; 95% CI 0.19, 0.48).

REVIEWER'S CONCLUSIONS

A 1 to 2 weeks course of H. pylori eradication therapy is an effective treatment for H. pylori positive peptic ulcer disease.

Congenital bowel perforation in twin-to-twin transfusion syndrome

Two unrelated survivors of twin-to-twin transfusion syndrome (TTTS) presented with intestinal perforation at birth. Both were localised perforations without any suggestion of widespread ischaemic disease to the splanchnic bed. Histopathology from the perforation site showed evidence of focal ischaemic necrosis, presumably from a vascular accident. One infant later died of multiple organ failure with major brain damage, but the other survived without long-term sequelae. These two cases appear to represent an unreported variation of the ischaemic intestinal complications of TTTS.

Integrating behavioral and pharmacological interventions in treating clients with psychiatric disorders and mental retardation

While the literature on treatment of dually diagnosed individuals continues to grow, few studies have examined the potential interactions between behavioral interventions and pharmacological interventions in treating persons with a developmental disability and a concurrent psychiatric disorder. The current theoretical paper discusses different manners in which psychotropic medications and behavioral interventions can interact, including the potential for facilitative or inhibitory effects of one treatment modality on the other. Possible permutations of these interactions are discussed. Case examples, including objective measures of psychiatric and behavioral symptoms over time, representing possible illustrations of these permutations, are presented. The authors argue that in many cases the potential effect of one treatment procedure on the efficacy of another may be an important consideration in treating dually diagnosed individuals.

Capsaicin receptor VR1 and ATP-gated ion channel P2X3 in human urinary bladder

OBJECTIVES

To determine the presence, distribution and molecular forms of the vanilloid receptor VR1, and confirm the presence and distribution of the ATP-gated ion channel P2X3 in the human urinary bladder. Materials and methods Normal urinary bladder tissues were obtained at postmortem from four subjects. Eight urinary bladder biopsies were also taken from patients with detrusor hyper-reflexia treated with intravesical resiniferatoxin. The specimens were studied using affinity-purified specific antibodies to VR1 and P2X3 by Western blotting and immunocytochemistry, and compared with immunostaining using antibodies to the pan-neuronal marker PGP 9.5 and Schwann cell marker S-100.

RESULTS

VR1- and P2X3-immunoreactive fine nerve fibres were scattered throughout the suburothelium of the normal bladder and cystoscopic biopsies, and traversed the muscle layer. They had a similar distribution to PGP 9.5-immunoreactive fibres, but there were fewer, suggesting localization in subsets of axons. Western blot studies showed an expected 100-kDa VR1 protein and a P2X3-immunoreactive 66-kDa protein. Conclusion VR1 and P2X3 are present in the human urinary bladder and may contribute to distinct pathophysiological states of bladder overactivity, in accord with their differential expression in sensory neurones. Intravesical vanilloids act via VR1 and are effective in the treatment of detrusor hyper-reflexia. P2X3 may represent a selective therapeutic target for other causes of overactive bladder.

Functionalized carbosilane dendritic species as soluble supports in organic synthesis

A new methodology, which is compatible with the use of reactive organometallic reagents, has been developed for the use of carbosilane dendrimers as soluble supports in organic synthesis. Hydroxy-functionalized dendritic carbosilanes Si[CH2CH2CH2SiMe2(C6H4CH(R)OH)]4 (G0-OH, R = H or (S)-Me) and Si[CH2CH2CH2Si[CH2CH2CH2SiMe2(C6H4CH(R)OH)]3]4 (G1-OH, R = H or (S)-Me) were prepared and subsequently converted into the esters Si[CH2CH2CH2SiMe2(C6H4CH(R)OC(O)CH2Ph)]4 (R = H or (S)-Me) and Si[CH2CH2CH2Si[CH2CH2CH2SiMe2(C6H4CH(R)OC(O)CH2C6H4 R')]3]4 (R = H and R' = H or R = (S)-Me and R' = H or R = H and R' = Br). As an example the latter compound was functionalized under Suzuki conditions. The functionalized carboxylic acid was obtained in high yield after cleavage from the dendritic support. Moreover, the ester functionalized dendrimers were converted to the corresponding zinc enolates followed by a condensation reaction with an imine to a beta-lactam in excellent yield and purity. Furthermore, it was demonstrated that a small combinatorial library of beta-lactams could be prepared starting from a carbosilane dendrimer functionalized with different ester moieties. These results show that carbosilane dendrimers can be applied as soluble substrate carriers for the generation of low molecular weight organic molecules. In combination with nanofiltration techniques, separation and recycling of the dendrimers can be realized.

Enantioselective reduction of prochiral ketones by catecholborane catalysed by chiral group 13 complexes

LiGaH4, in combination with the S,O-chelate 2-hydroxy-2'-mercapto-1,1'-binaphthyl (MTBH2), forms an active catalyst for the asymmetric reduction of prochiral ketones, with catecholborane as the hydride source. Enantioface differentiation is on the basis of the steric requirements of the ketone substituents. Aryl/ n-alkyl ketones are reduced in 90-93% ee and RC(O)Me (e.g. R = iPr, cycloC6H11, tBu) in 60-72% ee. Other borane sources and alternative catalyst structures based on indium do not form enantioselective catalysts.

Rapid detection of BCR/ABL and PML/RARA using fluorescence in situ hybridization in cytospin preparations

Fluorescence in situ hybridization (FISH) is increasingly used as an adjunct to conventional cytogenetic analysis in the diagnosis of haematological malignancies and in monitoring minimal residual disease. FISH, however, is generally performed on slides prepared after short-term sample incubation and therefore, whilst faster than conventional cytogenetics, still requires a minimum of 2 days for a result to be obtained. A simplification of the FISH procedure is reported using uncultured cytospin preparations of bone marrow or peripheral blood for the rapid diagnosis of the BCR-ABL and PML-RARa gene rearrangements. It demonstrates that culturing has no effect on the ratio of normal to abnormal cells in the nondividing population. Data is presented from an analysis of 24 cases in whom unequivocal results were obtained in less than 12 h and in complete concordance with results obtained by conventional cytogenetics and/or interphase FISH.

HTLV-I induced intestinal lymphoma

We document an unusual case of HTLV-I positive adult T-cell leukaemia lymphoma (ATLL) in a 25 year old Chilean patient who presented with primary small intestinal involvement and during evolution developed a leukaemic phase. Duodenal biopsy showed infiltration by pleomorphic lymphoid cells with a CD45RO+ CD20- phenotype. Circulating lymphocytes had a convoluted nucleus and displayed a mature T-cell phenotype: CD2+, CD3+, CD4+, CD8-, CD25+, HLA-Dr+. HTLV-I serology was positive and HTLV-I retroviral sequences were demonstrated by PCR in the tissue. The patient was treated with chlorambucil and is well, disease free five years from diagnosis. Intestinal lymphoma as initial manifestation of ATLL is extremely uncommon, but when a T-cell lymphoma is detected in this localisation, in patients from a HTLV-I endemic area, retroviral studies are recommended in order to exclude an association with this retrovirus.

Localization of ATP-gated P2X2 and P2X3 receptor immunoreactive nerves in rat taste buds

P2X receptors have been suggested to play a role in the transduction of sensory signals such as pain and sound. In the present study, polyclonal antibodies against P2X1 to P2X6 receptors were used to localize P2X receptors in circumvallate and fungiform papillae of rats. Nerve fibres innervating the taste buds stained intensely with P2X3 receptor antibodies. P2X3 receptor-positive nerves were observed in the intra- and subgemmal regions. The nerve fibres were also stained with P2X2 receptor antibodies, but the intensity was much lower. The distribution of P2X2 receptor immunoreactivity overlaps with that of P2X3. These results suggest that ATP might be a neurotransmitter in taste reception cells in the taste buds, where it transducts the taste signals to the afferent taste nerves by activating P2X receptors at the synapses. This is the first experiment indicating such a role for ATP, although supplementary functional studies are required.

Localization of ATP-gated P2X2 receptor immunoreactivity in the rat hypothalamus

Previous pharmacological studies have indicated that ATP receptors may be involved in the regulation of physiological functions in hypothalamus. In the present study, the distribution of P2X2 receptor in the rat hypothalamus was studied with immunohistochemistry. It was shown that P2X2 immunoreactivity-positive neurons and nerve fibres were localized in many hypothalamic nuclei. Intense labelling of both neuronal cell bodies and nerve fibres was observed in the paraventricular nucleus, arcuate nucleus, retrochiasmatic area, periventricular nucleus, and the ventral part of tuber cinereum area. In supraoptic, circular, and ventral tuberomammillary nuclei the neuronal cell bodies were strongly positive, but few nerve fibres were positive. Axons with strong P2X2 immunoreactivity were found in the organum vasculosum of the lamina terminalis and median eminence. Some scattered positive neurons and nerve fibres were found in many hypothalamic nuclei including preoptic nucleus. The results of the present study demonstrated the existence of P2X receptors in hypothalamus, as a basis for detailed studies of the roles of P2X receptors in the regulation of hypothalamic functions.

Aspergillus fumigatus conidia induce a Th1-type cytokine response

The response of human peripheral blood mononuclear cells (MNC) to Aspergillus fumigatus in vitro was evaluated. In studies of the proliferative response of MNC from 18 healthy donors to heat-killed A. fumigatus conidia, 15 displayed a significant response, with a stimulation index (SI) between 4 and 193. In contrast, all donors displayed a positive response to Candida albicans blastoconidia (SI ranged from 10 to 224). Despite the variability in reactivity to A. fumigatus conidia, the response of a particular individual was stable when retested over periods of 1-2 weeks. Supernatant from cocultures of A. fumigatus conidia with MNC contained increased levels of interferon-gamma, granulocyte-macrophage colony-stimulating factor, tumor necrosis factor-alpha, and interleukin (IL)-2, compared with unstimulated cells, but not IL-10 or IL-4. In addition, A. fumigatus induced lymphocyte surface expression of adhesion/activation-associated molecules. These results suggest that lymphocytes may contribute to host defense against Aspergillus by generating a Th1-type response.

Alzheimer disease. Outreach to the African American community

In an attempt to determine the risks for and kinds of dementia most prevalent among the African American population, the Alzheimer's Disease Research Center at the University of Pittsburgh developed a community satellite program specifically targeting the African American and historically medically underserved communities in Allegheny County, PA. The primary mission of the Alzheimer Outreach Center (AOC) was to increase the awareness of Ad among the targeted population. The number on nonwhite patients participating in the studies at ADRC increased from 2 to 16% in the first year of the program. In May 195, the AOC became a permanent ADRC program.

Postnatal growth in infants born between 700 and 1,500 g

Our purpose was to examine postnatal growth in very low birth weight (VLBW) infants (n = 54). A high frequency of intrauterine growth retardation was noted that was corrected by plotting birth weight against crown-heel length and not gestational age. No differences in postnatal growth were noted between infants whose size was appropriate for gestational age (n = 37) and those small for gestational age (n = 17). Overall, growth tended to exceed that previously published. Weight but not length or head gain was less in the smaller (< or = 1,000 g) when compared to the larger (> 1,000 g) VLBW infant. Poorer weight gain could not be related to more "illness" or less nutrient intake in the smaller infants.

The gene for erythropoietin receptor is expressed in multipotential hematopoietic and embryonal stem cells: evidence for differentiation stage-specific regulation

The principal regulator of erythropoiesis is the glycoprotein erythropoietin, which interacts with a specific cell surface receptor (EpoR). A study aimed at analyzing EpoR gene regulation has shown that both pluripotent embryonal stem cells and early multipotent hematopoietic cells express EpoR transcripts. Commitment to nonerythroid lineages (e.g., macrophage or lymphocytic) results in the shutdown of EpoR gene expression, whereas commitment to the erythroid lineage is concurrent with or followed by dramatic increases in EpoR transcription. To determine whether gene activity could be correlated with chromatin alterations, DNase-hypersensitive sites (HSS) were mapped. Two major HSS located in the promoter region and within the first intron of the EpoR gene are present in all embryonal stem and hematopoietic cells tested, the intensities of which correlate well with EpoR expression levels. In addition, a third major HSS also located within the first intron of the EpoR gene is uniquely present in erythroid cells that express high levels of EpoR. Transfection assays show that sequences surrounding this major HSS impart erythroid cell-specific enhancer activity to a heterologous promoter and that this activity is at least in part mediated by GATA-1. These data, together with concordant expression levels of GATA-1 and EpoR in both early multipotent hematopoietic and committed erythroid cells, support a regulatory role of the erythroid cell-specific transcription factor GATA-1 in EpoR transcription in these cells. However, the lack of significant levels of GATA-1 expression in embryonal stem cells implies an alternative regulatory mechanism of EpoR transcription in cells not committed to the hematopoietic lineage.

Management of acute asthma attacks in general practice

A prospective study was carried out in a semirural group practice between June 1988 and December 1989 to investigate acute asthmatic attacks treated with nebulized salbutamol. Questionnaires were completed by the attending doctor and by the patient (or his or her parent). Sixty nine episodes, occurring in 52 patients, were recorded during the 18 month study period. The majority of the attacks were managed exclusively in the community, with hospital admission occurring on only three occasions, one patient being admitted twice. A large proportion of the patients had a severe attack of asthma as judged by their previous history. Oral steroids were prescribed in 62.3% of attacks, oral theophyllines in 31.9% and antibiotics in 37.7%; the salbutamol nebulizer was used on more than one occasion during 41.2% of attacks. Significant morbidity was experienced by the patients during the studied attack, with 85% suffering sleep disturbance and two thirds being unable to attend work or school. Only 52.5% of patients were on prophylactic treatment and 37.5% of the patients had discontinued some aspect of their asthma therapy in the three months prior to the attack. Patients' and doctors' views about the cause of the attacks differed widely: patients most commonly cited infection (26/41) and allergy (8/41) with only two patients citing poor compliance or inadequate treatment. Although doctors also attributed the cause of many attacks to infection (33/64), they cited poor compliance or inadequate treatment in 28 of 64 responses.(ABSTRACT TRUNCATED AT 250 WORDS)