Characteristics of patients with diabetes hospitalised for COVID-19 infection-a brief case series report

OBJECTIVES

Diabetes has been shown to be a risk factor for corona virus disease-2019 (COVID-19) infection. The characteristics of patients with diabetes vulnerable to this infection are less specified. We aim to present the characteristics of patients with diabetes admitted to hospital with COVID-19.

DESIGN

A retrospective case series.

SETTING

A single clinical centre in the UK.

METHODS

We have retrospectively collected the demographics, medical characteristics and outcome of all patients with diabetes admitted to hospital over two-week period with COVID-19 infection. All cases were diagnosed by a reverse transcription polymerase chain reaction (RT-PCR) of pharyngeal and nasal swabs.

RESULTS

A total of 71 COVID-19 patients were admitted during the study period of whom 16 (22.5%) patients had diabetes and were included in this case series. There was no significant difference between patients with compared to those without diabetes regarding age, gender or clinical presentation. However, comorbidities were more common in patients with diabetes specially hypertension {75% v 36.4%, a difference of 38.6%, 95% confidence interval (CI) 6.5-58.3} and chronic kidney disease (37.5 v 5.5, a difference of 32% (1.6-51.6). Patients with diabetes were significantly more obese than those without diabetes (56.2% v 21.8% a difference of 34.4%, 95% CI 7.7-61.1). About one third (31.3%) of patients with diabetes were frail. Mean {standard deviation (SD)} duration of diabetes was 10 (2.8) years and mean (SD) HbA1c was 60.3 (15.6) mmol/mol. The use of angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and non-steroidal anti-inflammatory drugs (NSAIDs) was common (37.5%, 25% and 18.8% respectively). There was no significant difference in the outcomes between patients with compared to those without diabetes.

CONCLUSION

Patients with diabetes hospitalised for COVID-19 were significantly more obese and had high prevalence of comorbidities than those without diabetes. Other features of patients with diabetes and COVID-19 infection included long duration of diabetes, less tight glycaemic control and common use of ACE inhibitors, ARBs and NSAIDs.

TM3-10 National survey and experimental evaluation of commonly used external ventricular drain (EVD) securement methods in a porcine model; recommendations to improve practise

Objectives

External ventricular drain (EVD) dislodgement is common and can lead to significant morbidity and mortality. UK trial data suggests dislodgement as high as 12%. This study aimed to establish the range of methods used nationally and determine the most secure method in a porcine model.

Design

Survey and experimental study.

Subjects

23 neurosurgical units surveyed. Porcine cadaver experimental model.

Methods

Survey distribution was made through the British Neurosurgical Trainee Research Collaborative. 15 securement methods were tested on the porcine model and peak pull-out force before EVD failure was measured. Failure was defined as catheter displacement 1 cm from the insertion site, catheter fracture or suture fracture.

Results

Nationally, five EVD securement methods were in common use. There were considerable differences in peak pull-out force between methods. The most secure methods were a construct consisting of anchoring suture, further multiple sutures around a coil of catheter followed by either a soft (25.85N, 95% CI 24.95 N-26.75N) or hard plastic flange (29.05N, 95% CI 25.69 N-32.41N). Individually, anchoring sutures, soft flanges, VentriFix and staples were least secure, whilst multiple sutures and hard flanges were most secure.

Conclusions

An anchoring suture followed by a coil of catheter and a flange is the most secure method for securing EVDs, withstanding up to 8.2 times the force of a single anchoring suture. It is easily employed and may decrease the likelihood of EVD dislodgement and associated complications.

Exoplanet detection. A terrestrial planet in a ~1-AU orbit around one member of a ~15-AU binary

Using gravitational microlensing, we detected a cold terrestrial planet orbiting one member of a binary star system. The planet has low mass (twice Earth's) and lies projected at ~0.8 astronomical units (AU) from its host star, about the distance between Earth and the Sun. However, the planet's temperature is much lower, <60 Kelvin, because the host star is only 0.10 to 0.15 solar masses and therefore more than 400 times less luminous than the Sun. The host itself orbits a slightly more massive companion with projected separation of 10 to 15 AU. This detection is consistent with such systems being very common. Straightforward modification of current microlensing search strategies could increase sensitivity to planets in binary systems. With more detections, such binary-star planetary systems could constrain models of planet formation and evolution.

Donation after cardiac death in non-survivable burns

Major burns have previously been considered a contraindication to solid organ donation. We present two cases of successful organ donation and transplantation, after Maastricht category III cardiac death in adult patients with non-survivable burns injury. The implications of the outcome of these cases are that major burns should not be considered a contraindication to organ donation, and that cardiac death provides opportunity for patients with non-survivable burns to contribute to the pool of potential organ donors.

Targeting the hedgehog pathway: the development of cyclopamine and the development of anti-cancer drugs targeting the hedgehog pathway

The Hedgehog signalling pathway plays a critical role in controlling growth, especially during development, but is often over-activated in tumourigenesis. It has recently emerged as an important target for anticancer drugs, with several compounds in clinical trials. This review initially describes the Hedgehog pathway, focussing on the Patched receptor, and the Smoothened GPCR-like protein, as well as discussing the role of Cancer Stem Cells. It subsequently presents the discovery and development of drugs targeting this pathway. The initial focus is on cyclopamine - the first compound discovered that could inhibit the Hedgehog pathway - and selected cyclopamine analogues, including a review of the development of IPI-926. In addition, a number of other compounds are briefly discussed, to give an overview of current therapies in clinical development, and to indicate the possibilities for targeting different parts of the Hedgehog pathway in future. Finally, combination chemotherapy - incorporating a Hedgehog pathway inhibitor as well as another drug - is discussed from the perspective of drug resistance and effects on cancer stem cells.

Risk factors and outcomes of high-dependency patients requiring intensive care unit admission: a nested case-control study

Intermediate-care or high-dependency units can provide a level of care that lies between the intensive care unit (ICU) and general ward, but the patients who are most likely to benefit from such level of care remains uncertain. This nested case-control study assessed the incidence and risk factors of high-dependency patients requiring ICU admission and whether these admissions were associated with a worse outcome when compared to other emergency ICU admissions. Seventy-seven consecutive high-dependency patients requiring ICU admission (cases) were compared with 77 patients who did not require ICU admission (controls) and also 928 emergency ICU admissions from other areas. The incidence of high-dependency patients requiring ICU admission was 6.7% (95% confidence interval 5.3 to 8.2). High-dependency admissions from the ward (odds ratio 4.46, 95% confidence interval 1.55 to 12.78) or emergency department (odds ratio 4.48, 95% confidence interval 1.54 to 13.0) and a need for concurrent non-invasive ventilation, inotrope infusion and acute kidney injury (odds ratio 14.90, 95% confidence interval 3.79 to 58.3) was associated with a higher risk of ICU admission. Hospital mortality of the high-dependency patients requiring ICU admission was not significantly different from other emergency ICU admissions (odds ratio 1.08, 95% confidence interval 0.55 to 2.11). In summary, high-dependency patients requiring ICU admission were uncommon unless they had multi-organ failure and their hospital mortality was not significantly different from other emergency ICU admissions.

Development and evaluation of real-time PCR assays for the detection of the newly identified KI and WU polyomaviruses

Background

Recently, novel human polyomaviruses, KI (KIV) and WU (WUV) were described. Their role in human disease has not yet been determined.

Objectives

The aim of this study was to develop sensitive and specific assays for the detection of KIV and WUV.

Study

Two KIV (KI-A and KI-B) and three WUV (WU-A, WU-B and WU-C) real-time polymerase chain reaction (rtPCR) assays were developed and evaluated. Clinical sensitivities and specificities were determined by testing 200 respiratory specimens and the results compared to those for previously described conventional PCR assays. Limits of detection were determined, and the analytical specificities of the assays were investigated.

Results

No cross-reactivity was observed between the rtPCR methods and unrelated organisms. All five rtPCR assays could reliably detect 10 copies of genomic DNA equivalents per reaction, which was more sensitive than conventional methods. Compared to the conventional PCR assays, the sensitivity of the KI-A, KI-B, WU-A, WU-B and WU-C assays was 100%, 86.7% 95.5%, 100% and 100%, respectively. Specificity was 94.6%, 97.3%, 96.6%, 97.7% and 97.2%, respectively.

Conclusions

The KI-A, WU-B and WU-C assays provide the most sensitive detection of KIV and WUV in clinical specimens and may be used for further research into these viruses.

Development of real-time PCR assays for the detection and differentiation of Australian and European ranaviruses

Serious systemic disease in fish and amphibians is associated with the ranaviruses, epizootic haematopoietic necrosis virus (EHNV) and Bohle iridovirus (BIV) in Australia, and European sheatfish virus (ESV) and European catfish virus (ECV) in Europe. EHNV, ESV and ECV are recognized causative agents of the OIE (Office International des Epizooties) notifiable systemic necrotizing iridovirus syndrome and are currently identified by protein-based assays, none of which are able to rapidly identify the specific agents. The aim of this study was to develop TaqMan real-time PCR assays that differentiated these viruses using nucleotide sequence variation in two ranavirus genes. A conserved probe representing 100% sequence homology was used as a reference for virus-specific probes. The virus-specific probes produced a similar signal level to the conserved probe while those probes binding to non-target viral DNA produced an altered fluorescent curve. The pattern of probe binding was characteristic for each virus. Sensitivity, specificity and dynamic range of the assay were assessed. The test is currently useful as a research and initial screening tool, with the potential to become a sensitive and specific method for detection and differentiation of ranaviruses with further development.

Quality of life and sexual function after high-dose or conventional chemotherapy for high-risk breast cancer

Three hundred and ninety women participated in the quality of life (QL) study of ACCOG1, a high-dose vs conventional adjuvant chemotherapy breast cancer trial, for patients with a high risk of relapse. Patients completed the European Organisation for Research and Treatment of Cancer QLQ-C30, questions on menopausal symptoms and the Sexual Activity Questionnaire. Pretreatment, 6,12, 24, 36, 48 and 60-month assessments were conducted. For the high dose group the median decrease in global QL at 6 months was significantly greater than in the conventional group. At 12 months, however, the median change had returned to 0 for both groups. Social functioning was also significantly lower in the high-dose group at 6 months, again returning to prebaseline levels for both groups after 12 months. The most persistent changes appear to be in the effect of treatment in both arms on sexual outcomes, reflected in problems with discomfort and pleasure. Both high-dose and conventional chemotherapy showed persisting negative effects on sexual health. This has not been previously reported as a long-term complication of high-dose chemotherapy. However, it did not have long-term affects on sexual habit, which appeared to return to pretreatment frequency and similar to that of conventional chemotherapy by about 12 months from treatment.

Virus strains from a flock exhibiting unusually high mortality due to infectious bursal disease

OBJECTIVE

To characterise infectious bursal disease viruses (IBDVs) isolated from commercial broiler flocks exhibiting unusually high mortality due to infectious bursal disease (IBD).

DESIGN

An IBD outbreak occurred in mid 1999 on two broilers farms (A and B) in northern New South Wales amongst chickens 28 to 38 days of age, with a sharp rise in mortality of 2.5%. Initial histopathological diagnosis indicated acute IBD. Since acute IBD caused by classical pathogenic and very virulent (vv) IBDVs is exotic to Australia, samples from both farms A and B were obtained and used for virus characterisation.

METHOD

Tissue homogenates were made from six bursae collected from farm B. One histological sample from farm A was also used. Nucleotide sequencing of the hypervariable region (HVR) within the VP2 gene of IBDVs was determined and the deduced amino acid sequences compared with previously characterised Australian and overseas IBDVs. The phylogenetic relationship between IBDVs from farm B and IBDVs from Australia and overseas was then determined. Pathogenicity of one isolate, N2/99 from farm B, was compared with 3 other local IBDVs, as well as with three pathogenic overseas strains in 3-week-old specific pathogen-free (SPF) chickens.

RESULTS

Initial histopathological characterisation of a sample of bursa from a bird on farm A showed widespread acute lymphoid necrosis, follicular haemorrhage and stromal oedema, indicative of acute IBD. Subsequent analysis using reverse transcriptase polymerase chain reaction (RT-PCR), followed by nucleotide sequencing of the same bursal sample, as well as 6 samples from nearby farm B, showed that the IBDVs involved were similar in sequence to Australian vaccine strains and not to classical pathogenic or vvIBDVs. One isolate, N2/99 from farm B, was only marginally more pathogenic than other local IBDVs. It induced mild clinical signs in 30% of chicks and no mortality. In comparison, vvIBDV CS89 and classical pathogenic 52/70 strains induced severe clinical signs in 100% and 80% of chickens, respectively with mortalities of 27% and 12%, respectively.

CONCLUSIONS

The results illustrated the value of nucleotide sequencing as a method for discrimination of local and exotic types of IBDV.

A prognostic index for operable, node-negative breast cancer

Clinical data and samples from patients diagnosed, more than 10 years previously, with operable node-negative breast cancer (participants in the Scottish Adjuvant Tamoxifen trial), were revisited. Cases with two distinct categories of outcome were selected; more than 10 years disease-free survival ('good outcome') or distant relapse within 6 years of diagnosis ('poor outcome'). An initial set of cases was analysed for a range of putative prognostic markers and a prognostic index, distinguishing the two outcome categories, was calculated. This index was then validated by testing its predictive power on a second, independent set of cases. A combination of histological grade plus immunochemical staining for BCL-2, p27 and Cyclin D1, generated a useful prognostic index for tamoxifen-treated patients but not for those treated by surgery alone. The value of the index was confirmed in a second set of tamoxifen-treated, early stage breast cancers. Overall, it correctly predicted good and poor outcome in 79 and 74% of cases, respectively (odds ratio 11.0). Other markers assessed added little to prediction of outcome. In the case of molecular assays, sensitivity and reliability were compromised by the age of the tissue specimens and the variability of fixation protocols. In selecting patients for adjuvant systemic chemotherapy, the proposed index improves considerably on current international guidelines and matches the performance reported for 'gene-expression signature' analysis.

Serotonergic system and attention deficit hyperactivity disorder (ADHD): a potential susceptibility locus at the 5-HT(1B) receptor gene in 273 nuclear families from a multi-centre sample

Attention deficit hyperactivity disorder (ADHD) is a highly heritable and heterogeneous disorder, which usually becomes apparent during the first few years of childhood. Imbalance in dopamine neurotransmission has been suggested as a factor predisposing to ADHD. However, evidence has suggested an interaction between dopamine and serotonin systems in the pathophysiology of the disorder. Studies using selective agonists of the different 5-HT receptors microinjected into selected brain structures have shown a positive modulating effect on the functional activities of the mesotelencephalic dopaminergic system. This suggests that some of the genetic predisposition to ADHD might be due to DNA variation at serotonin system genes. In this study, we investigated polymorphisms in HTR(1B) and HTR(2A) (which encode the serotonin receptors 5-HT(1B) and 5-HT(2A) respectively) in a European ADHD sample. Using haplotype based haplotype relative risk (HHRR) and transmission disequilibrium test (TDT) analyses, we observed significant preferential transmission of the allele 861G of the HTR(1B) in the total sample (for HHRR; chi(2) = 7.4, P = 0.0065 and TDT; (chi(2) = 6.4, P = 0.014). Analysis of HTR(2A) failed to reveal evidence of association or linkage between the His452Tyr polymorphism and ADHD in the total sample. However, a significantly increased transmission of the allele 452His was observed in the Irish sample alone (chi(2) = 4.9, P = 0.026). These preliminary data suggest an important role for the serotonin system in the development of ADHD. Further studies, preferentially including different ethnic groups are required to substantiate these findings.

Feasibility and compliance of automated measurement of quality of life in oncology practice

PURPOSE

Systematic quality-of-life (QOL) assessment may have value in oncology practice by increasing awareness of a wide range of issues, possibly increasing detection of psychologic morbidity, social problems, and changes in physical status, and improving care and its outcomes. However, logistic problems are substantial. Automated systems solve many of these problems. We field-tested the feasibility and compliance that can be achieved using a computer touchscreen system in two consecutive studies.

PATIENTS AND METHODS

In study 1, a prospective cohort of 272 patients was offered QOL assessment at each clinic appointment for 6 months. In study 2, all patients (N = 1,291) were offered QOL assessment as part of clinic routine during a 12-week period.

RESULTS

In study 1, 82% of patients agreed to take part, but over time, compliance was poor (median, 40%; mean, 43%) and deteriorated with longer follow-up. In study 2, the overall compliance was greatly increased (median, 100%; mean, 70%), and compliance was retained over multiple visits. In study 1, compliance was better in younger patients, males, and socially advantaged patients, but was not affected by the presence of depression or anxiety, or QOL. In the second study, building on experience in the first study, data collection and storage in the computer system was excellent, achieving 98% of collected data stored in one center. In general, patients were comfortable with the computers and the approach. Data collection on the wards was more difficult and less complete than in clinics, especially for patients undergoing acute admissions.

CONCLUSION

Feasibility with higher compliance was demonstrated in study 2, in which the data collection was integrated into routine care, and can be improved with further technical initiatives and education of staff.

Validating automated screening for psychological distress by means of computer touchscreens for use in routine oncology practice

The aim of the study was to confirm the validity of using touchscreen computers for screening for clinically significant levels of distress among cancer patients in routine oncology practice. The Hospital Anxiety and Depression Scale (HADS), EORTC Quality of Life questionnaire (QLQ-C30), Mental Health Inventory-MHI5 and a Concerns Checklist were administered via touchscreen computer to 172 chemotherapy out-patients, twice, 2-4 weeks apart. A standard psychiatric interview (Present State Examination - PSE) was conducted within a week of the second assessment. On interview, 23% of patients were identified as 'cases'. Using the available data (questionnaires, sociodemographic details, self-reported past psychiatric history), the best screening strategy combined scores from MHI-5 and HADS from a single time-point with the following rules: if MHI-5 < 11 = non-case; if MHI-5 > or = 11 then use HADS; then, if HADS > or = 9 = 'case' (sensitivity 85%; specificity 71%; misclassification rate 26%; positive predictive value 47%). The computerized screening system enabled data to be collected, scored, collated and reported in real time to identify patients who warrant further clinical assessment. It offers the potential for improving 'case' detection in routine oncology practice while reducing the burden of questions put to 'non-cases'. Further work is needed to develop optimal choice of screening questions for this purpose.

Association study of a dopamine transporter polymorphism and attention deficit hyperactivity disorder in UK and Turkish samples

Molecular genetic studies in attention deficit hyperactivity disorder (ADHD) have focussed on candidate genes within the dopamine system, which is thought to be the main site of action of stimulant drugs, the primary pharmacological treatment of the disorder. Of particular interest are findings with the dopamine transporter gene (DAT1), since stimulant drugs interact directly with the transporter protein. To date, there have been eight published association studies of ADHD with a 480 base-pair allele of a variable number tandem repeat (VNTR) polymorphism in the 3'-untranslated region of the gene, five that support an association and three against. We have analysed the same VNTR marker in a dataset of UK Caucasian children and an independent dataset of Turkish Caucasian children with DSM-IV ADHD, using the transmission disequilibrium test (TDT). Results from the UK (chi(2) = 8.97, P = 0.001, OR = 1.95), but not the Turkish sample (chi(2) = 0.93, P = 0.34) support association and linkage between genetic variation at the DAT1 locus and ADHD. When considered alongside evidence from other published reports, there is only modest evidence for the association, consistent with a very small main effect for the 480-bp allele (chi(2) = 3.45, P = 0.06, OR = 1.15), however we find significant evidence of heterogeneity between the combined dataset (chi(2) = 22.64, df = 8, P = 0.004).

Attention deficit hyperactivity disorder (ADHD) and the dopamine D4 receptor gene: evidence of association but no linkage in a UK sample

Recent studies report association and linkage between attention deficit hyperactivity disorder (ADHD) and the 7-repeat allele of a 48 base-pair repeat in the dopamine D4 receptor gene (DRD4). We examined the frequency of this allele in a sample of probands with DSM-IV ADHD using a case-control design, as well as the transmission disequilibrium test (TDT) and haplotype-based haplotype relative risk (HHRR) in the subset of probands with DNA available from both parents. One hundred and thirty-two ADHD probands were compared with 189 controls (chi(2) = 6.17, 1 df, P = 0.01, OR = 1.73, 95% CI = 1.11--2.71). A total of 85 complete trios were available for within-family tests of association and linkage. Fifty-two heterozygous parents carrying one copy of the 7-repeat were informative for the TDT (29 transmitted vs 23 non-transmitted, chi(2) = 0.69). Analysis of the entire sample of 132 probands using TRANSMIT provided no additional evidence for excess transmission of the 7-repeat allele (58 transmitted vs 54 non-transmitted). HHRR gave similar results. We conclude that the case-control findings are likely to be falsely positive, resulting from genetic stratification. However we can not rule out alternative explanations of low statistical power and gene-environment correlation.

Patient perspectives on outcomes after treatment with acupuncture

OBJECTIVES

To determine patients' experience of outcomes after acupuncture treatment.

DESIGN

A patient questionnaire followed by semistructured interviews.

SETTING

Acupuncture practices in York, England.

SUBJECTS

Questionnaires were distributed by 4 acupuncturists to all 132 of their patients over a 2-week period, 72 (55%) of whom responded. Of these, 11 patients were interviewed.

INTERVENTIONS

Patients received normal care from their acupuncturists, all of whom were members of the British Acupuncture Council.

OUTCOME MEASURES

Patients reported on physical symptoms, emotional/mental symptoms, lifestyle changes, major life changes and inner life changes affecting outlook and attitudes to health. Patients also reported on the extent they attributed change to acupuncture and what they valued about attending for treatment.

RESULTS

Primary reasons for attending were categorized by patients as physical symptoms (90%), mental and emotional problems (9%) and general health and well-being (1%). For physical symptoms, 75% of patients reported definite change; for emotional and mental symptoms, 67%; lifestyle changes, 40%, major life changes, 27%; and for inner life changes, 54%. Over time, many of the patients (42%) changed their primary reason for attending from their initial physical concerns, half of whom describing their new focus as related to general health and well-being. Some emotional changes were experienced by 83% of patients, irrespective of the initial reason for attending. For all these changes, 58% of patients reported that they "substantially" attributed the changes to acupuncture, and 25% "totally". The interviews provided additional data on the depth of the changes particularly for the longer term patients and on what they valued about treatment.

CONCLUSIONS

Treatment with acupuncture results in a broad range of outcomes from physical and emotional change through to wider benefits involving the patients' lifestyle, outlook, and attitude toward their health. Existing outcome measures are not adequate to assess these wider benefits. The results suggest that patients experienced holistic benefits from acupuncture, an outcome that could be described as holism-in-action.

Development of a European Organization for Research and Treatment of Cancer questionnaire module to assess the quality of life of ovarian cancer patients in clinical trials: a progress report

A questionnaire was developed, according to the European Organization for Research and Treatment of Cancer (EORTC) published guidelines, to supplement the EORTC quality of life questionnaire-core 30 (QLQ-C30) to assess the quality of life (QL) of women with ovarian cancer treated in clinical trials. The provisional 28-item module, OV28, assesses abdominal symptoms; peripheral neuropathy; other chemotherapy side-effects; hormonal symptoms; body image; attitude to disease and treatment; and sexual functioning. The first 24 items of the module (excluding sexual functioning) were included in a UK multicentre trial (SCOTROC). The trial data were used for preliminary scaling analysis. Two problematic items were identified. When these were treated as single items along with the 'other chemotherapy side-effects' the instrument showed excellent scale properties. Mean scale scores discriminated between trial patients pre- and on chemotherapy. This is a promising tool for assessing the QL of women with ovarian cancer. The EORTC international field study (Protocol 15982) to assess more fully the psychometric properties of the OV28 is well underway.

Detecting social problems in cancer patients

Diagnosis of and treatment for cancer may not only create physical and emotional difficulties for patients but may also have an impact on social aspects of patients' lives. Screening for social problems has not become part of routine oncology practice. This may be due to lack of a suitable questionnaire. This paper presents a psychometric analysis of the Problems Checklist with a view to assessing its usefulness as a screening tool for social problems in oncology. Evaluation was undertaken using data from an earlier study of 505 patients who completed the checklist. Frequency of endorsement, missing values, factor analysis and reliability and validity analysis of the summated scales were carried out. Missing data rates ranged from 4 to 18% over the 16 items. Fourteen items were well endorsed. Factor analysis produced a four-factor structure with components labelled daily living, relationships, economics and emotions. Reliability and validity tests endorsed the factor structure with the components on economics and emotions being particularly credible. Difficulties with relationships are harder to measure and results from the analysis suggest that this is an area that warrants further investigation. The checklist is a useful tool for highlighting problems. As a tool for screening for social problems it has some limitations.

First isolation of an aquatic birnavirus from farmed and wild fish species in Australia

During routine sampling and testing, as part of a systematic surveillance program (the Tasmanian Salmonid Health Surveillance Program), an aquatic birnavirus was isolated from 'pin-head' (fish exhibiting deficient acclimatisation on transfer to saltwater) Atlantic salmon Salmo salar, approximately 18 mo old, farmed in net-pens located in Macquarie Harbour on the west coast of Tasmania, Australia. The isolate grows readily in a range of fish cell lines including CHSE-214, RTG-2 and BF-2 and is neutralised by a pan-specific rabbit antiserum raised against infectious pancreatic necrosis virus (IPNV) Ab strain and by a commercial pan-specific IPNV-neutralising monoclonal antibody. Presence of the virus was not associated with gross clinical signs. Histopathological examination revealed a range of lesions particularly in pancreatic tissue. The virus was localised in pancreas sections by immunoperoxidase staining using the polyclonal antiserum and by electron microscopy. Examination by electron microscopy demonstrated that the virus isolated in cell culture (1) belongs to the family Birnaviridae, genus Aquabirnaviridae; (2) was ultrastructurally and antigenically similar to virus identified in the index fish; (3) is related to IPNV. Western blot analysis using the polyclonal rabbit antiserum confirmed the cross-reactions between various aquatic birnavirus isolates. In addition, PCR analysis of isolated viral nucleic acid from the index case indicated that the virus is more closely related to IPNV fr21 and N1 isolates than to other birnavirus isolates available for comparison. Sampling of other fish species within Macquarie Harbour has demonstrated that the virus is present in several other species of fish including farmed rainbow trout Oncorhynchus mykiss, wild flounder Rhombosolea tapirina, cod Pseudophycis sp., spiked dogfish Squalus megalops and ling Genypterus blacodes.

Binary Black Hole Mergers from Planet-like Migrations

If supermassive black holes (BHs) are generically present in galaxy centers, and if galaxies are built up through hierarchical merging, BH binaries are at least temporary features of most galactic bulges. Observations suggest, however, that binary BHs are rare, pointing toward a binary lifetime far shorter than the Hubble time. We show that, almost regardless of the detailed mechanism, all stellar dynamical processes are too slow in reducing the orbital separation once orbital velocities in the binary exceed the virial velocity of the system. We propose that a massive gas disk surrounding a BH binary can effect its merger rapidly, in a scenario analogous to the orbital decay of super-Jovian planets due to a proto-planetary disk. As in the case of planets, gas accretion onto the secondary (here a supermassive BH) is integrally connected with its inward migration. Such accretion would give rise to quasar activity. BH binary mergers could therefore be responsible for many or most quasars.

Experimental reproduction of viral chorioretinitis in kangaroos

OBJECTIVE

To investigate whether preparations containing Wallal and/or Warrego viruses could cause disease when inoculated subcutaneously into captive kangaroos.

DESIGN AND PROCEDURE

Four groups of two kangaroos, seronegative to both Wallal and Warrego virus, were each inoculated with wild Wallal virus, cultured Wallal virus, wild Warrego virus, or wild Warrego virus followed by wild Wallal virus after 3 weeks. A single uninoculated animal served as a control. Animals were monitored weekly under anaesthesia, examined ophthalmoscopically (including fundic photography), and samples collected for haematological and serum biochemical analysis, virus isolation, PCR and serological examination for antibodies against Wallal and Warrego viruses. Animals inoculated with cultured Wallal virus were killed at week 10, and remaining kangaroos were reinoculated with cultured Wallal virus at week 12.

RESULTS

Virus was isolated from the blood of two kangaroos 2 weeks after inoculation with Wallal virus preparations, and from a third kangaroo 2 weeks after reinoculation. By 3 weeks after inoculation, all kangaroos given Wallal virus preparations had seroconverted to Wallal virus and one had seroconverted to Warrego virus. Fundic changes were detected in the three viraemic kangaroos 4 or more weeks after inoculation, and lesions were present in the eye and brain typical of those seen in field cases of chorioretinitis. No other kangaroos had lesions. Wallal virus was identified by PCR and immunohistochemical analysis in the retina of one affected animal and orbivirus-like particles were seen by electron microscopy in the remains of retinal cells.

CONCLUSION

The condition of chorioretinitis was reproduced in three of eight kangaroos by inoculation with preparations containing Wallal virus.

The role of kreisler in segmentation during hindbrain development

The mouse kreisler gene is expressed in rhombomeres (r) 5 and 6 during neural development and kreisler mutants have patterning defects in the hindbrain that are not fully understood. Here we analyzed this phenotype with a combination of genetic, molecular, and cellular marking techniques. Using Hox/lacZ transgenic mice as reporter lines and by analyzing Eph/ephrin expression, we have found that while r5 fails to form in these mice, r6 is present. This shows that kreisler has an early role in the formation of r5. We also observed patterning defects in r3 and r4 that are outside the normal domain of kreisler expression. In both heterozygous and homozygous kreisler embryos some r5 markers are induced in r3, suggesting that there is a partial change in r3 identity that is not dependent upon the loss of r5. To investigate the cellular character of r6 in kreisler embryos we performed heterotopic grafting experiments in the mouse hindbrain to monitor its mixing properties. Control experiments revealed that cells from even- or odd-numbered segments only mixed freely with themselves, but not with cells of opposite character. Transposition of cells from the r6 territory of kreisler mutants reveals that they adopt mature r6 characteristics, as they freely mix only with cells from even-numbered rhombomeres. Analysis of Phox2b expression shows that some aspects of later neurogenesis in r6 are altered, which may be associated with the additional roles of kreisler in regulating segmental identity. Together these results suggest that the formation of r6 has not been affected in kreisler mutants. This analysis has revealed phenotypic and mechanistic differences between kreisler and its zebrafish equivalent valentino. While valentino is believed to subdivide preexisting segmental units, in the mouse kreisler specifies a particular segment. The formation of r6 independent of r5 argues against a role of kreisler in prorhombomeric segmentation of the mouse hindbrain. We conclude that the mouse kreisler gene regulates multiple steps in segmental patterning involving both the formation of segments and their A-P identity.

In pursuit of excellence for patients with cancer: the Scottish Cancer Therapy Network model

The Scottish Cancer Therapy Network (SCTN) was created against a background of rising concerns about perceived variation in the quality of care available to patients with cancer. SCTN has established itself as a major organization with the necessary recognition and infrastructure to provide leadership, support and impetus in the field of clinical guidelines, clinical audit and clinical trials of cancer therapy in Scotland. Since being formed in 1993, SCTN has been instrumental in the development of three evidence-based, clinical guidelines and in the completion of detailed, national, retrospective audits of the treatment of five major tumour sites. The infrastructure has been used successfully to support and encourage trial participation. Challenges for the future are a re-orientation towards prospective audit, widening the constituency and sense of ownership of SCTN as a resource for practising clinicians, and further increasing recruitment into clinical trials.

Automated collection of quality-of-life data: a comparison of paper and computer touch-screen questionnaires

PURPOSE

To evaluate alternative automated methods of collecting data on quality of life (QOL) in cancer patients. After initial evaluation of a range of technologies, we compared computer touch-screen questionnaires with paper questionnaires scanned by optical reading systems in terms of patients' acceptance, data quality, and reliability.

PATIENTS AND METHODS

In a randomized cross-over trial, 149 cancer patients completed the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30, version 2.0 (EORTC QLQ-C30), and the Hospital Anxiety and Depression Scale (HADS) on paper and on a touch screen. In a further test-retest study, 81 patients completed the electronic version of the questionnaires twice, with a time interval of 3 hours between questionnaires.

RESULTS

Fifty-two percent of the patients preferred the touch screen to paper; 24% had no preference. The quality of the data collected with the touch-screen system was good, with no missed responses. At the group level, the differences between scores obtained with the two modes of administration of the instruments were small, suggesting equivalence for most of the QOL scales, with the possible exception of the emotional, fatigue, and nausea/vomiting scales and the appetite item, where patients tended to give more positive responses on the touch screen. At the individual patient level, the agreement was good, with a kappa coefficient from 0.57 to 0.77 and percent global agreement from 61% to 97%. The electronic questionnaire had good test-retest reliability, with correlation coefficients between the two administrations from 0.78 to 0.95, kappa coefficients of agreement from 0.55 to 0.90, and percent global agreement from 56% to 100%.

CONCLUSION

Computer touch-screen QOL questionnaires were well accepted by cancer patients, with good data quality and reliability.

Trends in incidence of and mortality from invasive cancer of the uterine cervix in Scotland (1975-1994)

OBJECTIVE

I. To identify major trends in the incidence of and mortality from invasive cancer of the cervix uteri in Scotland during the twenty year period 1975-1994; II. to consider the extent to which these trends may have been shaped by the introduction of systematic cervical screening.

DESIGN

Analysis of annual age standardised and age specific rates for incidence and mortality, based on data collected by the Scottish Cancer Registry and the General Register Office for Scotland.

SETTING

Scotland.

SUBJECTS

Women registered with the Scottish Cancer Registry as having developed invasive cancer of the cervix during the period of interest.

RESULTS

Annual all ages incidence rates of invasive cervical cancer show little overall change over the period 1975-1989, but exhibit a pronounced decline from 1990 onwards. All-ages mortality rates show clear evidence of decline during the period 1975-1994, the rate for 1994 being some 30% lower than that for 1975. Annual age-specific incidence rates show different patterns by age group, with clear evidence of decreasing trends in the age range 50-64 years but different patterns in younger and older age groups. Most age groups show steep declines in incidence from 1990 onwards. Age specific mortality rates for 1975-1994 exhibit the most pronounced decreasing trends in the age range 50-64 years. The trends identified are broadly similar to those experienced in England and Wales over an approximately comparable period.

CONCLUSIONS

The overall (all ages) incidence of invasive cervical cancer in Scotland changed little during the period 1975-1989, but declined sharply from 1990 onwards. The most pronounced decline in incidence across the period 1975-1994 appears to have taken place in the age range 50-64 years. This decline has been accompanied by a commensurate fall in mortality in the same age range. These reductions in incidence and mortality may be attributable in part to increased coverage of cervical screening programmes during the period of interest. Evidence from other studies suggest that, without the increased coverage of cervical screening achieved during this period incidence rates in Scotland might have been seen to increase.

Variation in the survival of women with breast cancer in Scotland. The Scottish Breast Cancer Focus Group and The Scottish Cancer Therapy Network

We have investigated factors influencing the survival of women with early breast cancer in Scotland. In a retrospective study, clinical, treatment and 'service' factors, e.g. surgical case load, deprivation and geographical area (health board of first treatment) were recorded from hospital records. A total of 2148 women with invasive breast cancer diagnosed in 1987 were identified from the Scottish Cancer Registry, of whom 1619 without metastases at diagnosis underwent surgery as part of their primary treatment. In a multivariate analysis, clinical factors (age, clinical stage, pathological tumour size, node status and oestrogen receptor status) all influenced survival. After allowing for these clinical factors, surgical case load and deprivation did not have statistically significant effects on survival. By contrast, health board did affect survival. This was explained in part by the selection of patients for surgery. There appeared, however, to be a residual effect that may be related to differences in the use of adjuvant systemic treatment among the different health boards. We conclude that, in Scotland, geographical variation in both surgical and non-surgical treatment has a greater effect on variability in survival for women with breast cancer than surgical case load and deprivation.

Initiation of rhombomeric Hoxb4 expression requires induction by somites and a retinoid pathway

Anteroposterior (AP) patterning in the vertebrate hindbrain is dependent upon the establishment of segmental domains of Hox expression. We investigated the mechanism that governs the early expression of Hoxb4 and found that transient signaling from the paraxial mesoderm induces expression in the hindbrain. Induction involves a retinoid pathway requiring retinoic acid receptor (RAR) function within the neural plate. Characterization of a prerhombomeric enhancer from Hoxb4 reveals that a retinoic acid (RA) response element is an essential component of the early neural response to somite (s) signaling and can interpret positional information for setting the anterior boundary of expression. These data suggest a mechanism whereby, during normal hindbrain development, Hoxb4 expression is initiated by extrinsic signals and is subsequently maintained by Hox feedback circuits. This mechanism also accounts for the ectopic response of Hoxb4 in rhombomere (r) transpositions and after exposure to retinoids.

Entry into clinical trials in breast cancer: the importance of specialist teams. Scottish Breast Cancer Focus Group and Scottish Cancer Therapy Network

The aim of this study was to identify the factors influencing entry of women with invasive breast cancer into clinical trials in Scotland. Women diagnosed during 1987 and 1993 were identified from cancer registry data records and their case notes reviewed. Entry into clinical trials was recorded, along with clinical and demographic data for 4688 patients. In 1987, the proportion of women entering clinical trials was 12.3% and, allowing for shorter follow-up, this appeared unchanged in 1993. Patients seen by surgeons with a high case load and those referred to an oncologist were approximately seven times and three times, respectively, more likely to enter a clinical trial (P < 0.0001). The area of Scotland (Health Board) where the woman was first treated also influenced study entry (P < 0.0001), whereas social deprivation had no effect (P = 0.93). Older women, especially those over 80 years of age, were less likely to enter studies (P = 0.05). Extending the management of patients by specialist multidisciplinary teams should increase recruitment into clinical trials and help to identify better treatments for women with breast cancer.

Immunological detection of conformational neoepitopes associated with the serpin activity of plasminogen activator inhibitor type-2

The physiological roles of plasminogen activator inhibitor-2 (PAI-2) are not yet well understood. Kinetic studies suggest a role in the regulation of plasminogen activator-driven proteolysis in many cell types. This study describes a monoclonal antibody (2H5), which uniquely recognizes neoepitope determinants on PAI-2 appearing after thermodynamic relaxation of the molecule. Enzyme-linked immunosorbent assays and native polyacrylamide gel electrophoresis immunoblotting confirmed the specificity of 2H5 for urokinase type plasminogen activator.PAI-2 complexes. Examination of the affinity of 2H5 for complexes formed between PAI-2 and a synthetic 14-mer reactive site loop peptide, PAI-2 treated with tissue plasminogen activator, or thrombin suggests that the 2H5 epitope is determined exclusively by sequences found only on PAI-2 following proteolytic cleavage of the Arg380-Thr381 bond and insertion of the reactive site loop into beta-sheet A. Peptides lacking both the P13 (Glu368) and P14 (Thr367) residues did not induce a conformational change or affect the inhibitory activity of PAI-2, indicating that one or both of these residues are critical for PAI-2 function. To our knowledge, this is the first description of a monoclonal antibody that can distinguish conformational changes in PAI-2 related specifically to its potential biological function(s).

Selectivity, sharing and competitive interactions in the regulation of Hoxb genes

The clustered organisation of Hox complexes is highly conserved in vertebrates and the reasons for this are believed to be linked with the regulatory mechanisms governing their expression. In analysis of the Hoxb4-Hoxb6 region of the HoxB complex we identified enhancers which lie in the intergenic region between Hoxb4 and Hoxb5, and which are capable of mediating the correct boundaries of neural and mesodermal expression for Hoxb5. We examined their regulatory properties in the context of the local genomic region spanning the two genes by transgenic analysis, in which each promoter was independently marked with a different reporter, to monitor simultaneously the relative transcriptional read-outs from each gene. Our analysis revealed that within this intergenic region: (i) a limb and a neural enhancer selectively activate Hoxb4 as opposed to Hoxb5; (ii) a separate neural enhancer is able to activate both genes, but expression is dependent upon competition between the two promoters for the enhancer and is influenced by the local genomic context; (iii) mesodermal enhancer activities can be shared between the genes. We found similar types of regulatory interactions between Hoxb5 and Hoxb6. Together these results provide evidence for three separate general mechanisms: selectivity, competition and sharing, that control the balance of cis-regulatory interactions necessary for generating the proper spatial and temporal patterns of Hox gene expression. We suggest that these mechanisms are part of a regulatory basis for maintenance of Hox organisation.

HOXD4 and regulation of the group 4 paralog genes

From an evolutionary perspective, it is important to understand the degree of conservation of cis-regulatory mechanisms between paralogous Hox genes. In this study, we have used transgenic analysis of the human HOXD4 locus to identify one neural and two mesodermal 3′ enhancers that are capable of mediating the proper anterior limits of expression in the hindbrain and paraxial mesoderm (somites), respectively. In addition to directing expression in the central nervous system (CNS) up to the correct rhombomere 6/7 boundary in the hindbrain, the neural enhancer also mediates a three rhombomere anterior shift from this boundary in response to retinoic acid (RA), mimicking the endogenous Hoxd4 response. We have extended the transgenic analysis to Hoxa4 identifying mesodermal, neural and retinoid responsive components in the 3′ flanking region of that gene, which reflect aspects of endogenous Hoxa4 expression. Comparative analysis of the retinoid responses of Hoxd4, Hoxa4 and Hoxb4 reveals that, while they can be rapidly induced by RA, there is a window of competence for this response, which is different to that of more 3′ Hox genes. Mesodermal regulation involves multiple regions with overlapping or related activity and is complex, but with respect to neural regulation and response to RA, Hoxb4 and Hoxd4 appear to be more closely related to each other than Hoxa4. These results illustrate that much of the general positioning of 5′ and 3′ flanking regulatory regions has been conserved between three of the group 4 paralogs during vertebrate evolution, which most likely reflects the original positioning of regulatory regions in the ancestral Hox complex.

Functions of mammalian Polycomb group and trithorax group related genes

Genes of the Polycomb and trithorax groups (PcG and trxG) are part of a cellular memory system that maintains inactive and active states of homeotic gene expression in Drosophila. Recent genetic evidence indicates that several related loci in mammals are also involved in the regulation of Hox genes. Like their Drosophila counterparts, the vertebrate gene products are components of multiprotein complexes that regulate transcriptional activation, repression and aspects of chromatin structure. Initial indications suggest the existence of a large mammalian PcG and trxG family, with a potential to encode multiple specialised functions in cell fate and cell-cycle control.

Switching the in vivo specificity of a minimal Hox-responsive element

The homeodomain proteins encoded by the Hox complex genes do not bind DNA with high specificity. In vitro, Hox specificity can be increased by binding to DNA cooperatively with the homeodomain protein extradenticle or its vertebrate homologs, the pbx proteins (together, the PBC family). Here we show that a two basepair change in a Hox-PBC binding site switches the Hox-dependent expression pattern generated in vivo, from labial to Deformed. The change in vivo correlates with an altered Hox binding specificity in vitro. Further, we identify similar Deformed-PBC binding sites in the Deformed and Hoxb-4 genes and show that they generate Deformed or Hoxb-4 expression patterns in Drosophila and mouse embryos, respectively. These results suggest a model in which Hox-PBC binding sites play an instructive role in Hox specificity by promoting the formation of different Hox-PBC heterodimers in vivo. Thus, the choice of Hox partner, and therefore Hox target genes, depends on subtle differences between Hox-PBC binding sites.

Positive cross-regulation and enhancer sharing: two mechanisms for specifying overlapping Hox expression patterns

Vertebrate Hox genes display nested and overlapping patterns of expression. During mouse hindbrain development, Hoxb3 and Hoxb4 share an expression domain caudal to the boundary between rhombomeres 6 and 7. Transgenic analysis reveals that an enhancer (CR3) is shared between both genes and specifies this domain of overlap. Both the position of CR3 within the complex and its sequence are conserved from fish to mammals, suggesting it has a common role in regulating the vertebrate HoxB complex. CR3 mediates transcriptional activation by multiple Hox genes, including Hoxb4, Hoxd4, and Hoxb5 but not Hoxb1. It also functions as a selective HOX response element in Drosophila, where activation depends on Deformed, Sex combs reduced, and Antennapedia but not labial. Taken together, these data show that a Deformed/Hoxb4 autoregulatory loop has been conserved between mouse and Drosophila. In addition, these studies reveal the existence of positive cross-regulation and enhancer sharing as two mechanisms for reinforcing the overlapping expression domains of vertebrate Hox genes. In contrast, Drosophila Hox genes do not appear to share enhancers and where they overlap in expression, negative cross-regulatory interactions are observed. Therefore, despite many well documented aspects of Hox structural and functional conservation, there are mechanistic differences in Hox complex regulation between arthropods and vertebrates.