Pacemaker-lead-associated thrombosis in dogs: a multicenter retrospective study

INTRODUCTION

Pacemaker implantation is the treatment of choice for clinically relevant bradyarrhythmias. Pacemaker-lead-associated thrombosis (PLAT) occurs in 23.0-45.0% of people with permanent transvenous pacemakers. Serious thromboembolic complications are reported in 0.6-3.5%. The incidence of PLAT in dogs is unknown.

ANIMALS, MATERIALS AND METHODS

multicenter retrospective study of seven centers with 606 client-owned dogs undergoing permanent pacemaker implantation between 2012 and 2019. 260 dogs with a transvenous pacemaker with echocardiographic follow-up, 268 dogs with a transvenous pacemaker without echocardiographic follow-up and 78 dogs with an epicardial pacemaker.

RESULTS

10.4% (27/260) of dogs with transvenous pacemakers and echocardiographic follow-up had PLAT identified. The median time to diagnosis was 175 days (6-1853 days). Pacemaker-lead-associated thrombosis was an incidental finding in 15/27 (55.6%) dogs. Of dogs with a urine protein:creatinine ratio measured at pacemaker implantation, dogs with PLAT were more likely to have proteinuria at pacemaker implantation vs. dogs without PLAT (6/6 (100.0%) vs. 21/52 (40.4%), P=0.007). Urine protein:creatinine ratio was measured in 12/27 (44.4%) dogs at PLAT diagnosis, with proteinuria identified in 10/12 (83.3%) dogs. Anti-thrombotic drugs were used following the identification of PLAT in 22/27 (81.5%) dogs. The thrombus resolved in 9/15 (60.0%) dogs in which follow-up echocardiography was performed. Dogs with PLAT had shorter survival times from implantation compared to those without PLAT (677 days [9-1988 days] vs. 1105 days [1-2661 days], P=0.003).

CONCLUSIONS

Pacemaker-lead-associated thrombosis is identified in 10.4% (27/260) of dogs following transvenous pacing, is associated with proteinuria, can cause significant morbidity, and is associated with reduced survival times.

Online prediction tools for melanoma survival: A comparison

BACKGROUND

Breslow thickness, patient age and ulceration are the three most valuable clinical and pathological predictors of melanoma survival. A readily available reliable online tool that accurately considers these and other predictors could be valuable for clinicians managing melanoma patients.

OBJECTIVE

To compare online melanoma survival prediction tools that request user input on clinical and pathological features.

METHODS

Search engines were used to identify available predictive nomograms. For each, clinical and pathological predictors were compared.

RESULTS

Three tools were identified. The American Joint Committee on Cancer tool inappropriately rated thin tumours as higher risk than intermediate tumours. The University of Louisville tool was found to have six shortcomings: a requirement for sentinel node biopsy, unavailable input of thin melanoma or patients over 70 years of age and less reliable hazard ratio calculations for age, ulceration and tumour thickness. The LifeMath.net tool was found to appropriately consider tumour thickness, ulceration, age, sex, site and tumour subtype in predicting survival.

LIMITATIONS

The authors did not have access to the base data used to compile various prediction tools.

CONCLUSION

The LifeMath.net prediction tool is the most reliable for clinicians in counselling patients with newly diagnosed primary cutaneous melanoma regarding their survival prospects.

The effects of the DASH dietary pattern on clinical outcomes and quality of life in adults with uncontrolled asthma: Design and methods of the ALOHA Trial

BACKGROUND

Poor diet quality is an important risk factor for increased asthma prevalence and poor asthma control. To address the question of whether adults with asthma can benefit from following a healthy diet, this trial will test the efficacy and mechanisms of action of a behavioral intervention promoting the Dietary Approaches to Stop Hypertension (DASH) dietary pattern with sodium reduction among patients with uncontrolled asthma.

METHODS

In this 2-arm randomized clinical trial, 320 racially/ethnically and socioeconomically diverse adults with uncontrolled asthma on standard controller therapy will be randomized to either a control or an intervention group and assessed at baseline, 3, 6 and 12 months. Control and intervention participants will receive education on lung health, asthma, and other general health topics; additionally, the intervention group will receive DASH behavioral counseling over 12 months. The primary hypothesis is that the DASH behavioral intervention, compared with the education-only control, will lead to significantly more participants with minimum clinically important improvement (responders) in asthma-specific quality of life at 12 months. Secondary hypotheses will test the intervention effects on other asthma (e.g., asthma control, lung function) and non-asthma outcomes (e.g., quality of life). Additionally, therapeutic (e.g., short chain fatty acids, cytokines) and nutritional biomarkers (e.g., dietary inflammatory index, carotenoids) will be assessed to understand the mechanisms of the intervention effect.

CONCLUSION

This trial can substantially advance asthma care by providing rigorous evidence on the benefits of a behavioral dietary intervention and mechanistic insights into the role of diet quality in asthma.

CLINICALTRIALS

gov #: NCT05251402.

Myelodysplastic Syndrome with Monosomy 7 in a Patient with Ataxia-Pancytopenia Syndrome

Introduction/Objective

Ataxia-pancytopenia syndrome is caused by mutations in SAMD9L, a tumor suppressor gene on chromosome 7 with roles in normal hematopoiesis and cerebellar development. Syndrome manifestations consist of a combination of progressive ataxia, multilineage cytopenias, and increased risk of myeloid neoplasms associated with monosomy 7. Histopathologic and radiologic descriptions of this recently described disorder are scarce and treatment strategies are not standardized. Additionally, features that predict spontaneous hematologic remission of myeloid neoplasms are incompletely understood. Therefore, detailed discussions of this disorder and its possible outcomes are warranted.

Methods/Case Report

A six-year-old boy was brought to his doctor when his parents noticed head tilting while reading and impaired coordination. Brain MRI revealed extensive T2/FLAIR hyperintensities of white matter, cerebellar hypoplasia, and a thinned corpus callosum. Further evaluation excluded autoimmune etiologies, infectious diseases, and inherited leukodystrophies. Whole exome sequencing demonstrated a previously uncharacterized heterozygous mutation in SAMD9L, c.2062T>A; p.Tyr688Asn. Subsequent testing revealed pancytopenia. A bone marrow biopsy showed small megakaryocytes with abnormal nuclear lobation and erythroid progenitors with nuclear blebbing and binucleation. Blasts were borderline increased (4%). Fluorescence in-situ hybridization and karyotype showed monosomy 7. A myeloid next-generation sequencing panel identified an ETV6 mutation (p.Gln143Ter, VAF=5.4%). A diagnosis of myelodysplastic syndrome with monosomy 7 in the setting of ataxia-pancytopenia syndrome was rendered. The patient underwent allogeneic stem cell transplant and is doing well at last follow-up.

Results (if a Case Study enter NA)

N/A

Conclusion

Ataxia pancytopenia syndrome is a recently described and incompletely understood disorder. Some myeloid neoplasms in ataxia-pancytopenia syndrome can undergo somatic revertant mosaicism via uniparental disomy, resulting in spontaneous hematologic remission. Factors that predict spontaneous remission are unclear; however, secondary mutations have been associated with poorer outcomes. This case emphasizes the value of comprehensive genetic testing modalities in challenging cases. Screening for SAMD9L mutations in cases of pediatric myelodysplastic syndrome could be considered.

Infiltrative laryngeal disease in dogs

OBJECTIVES

To describe the clinical features and outcome of neoplastic and inflammatory infiltrative laryngeal disease in dogs.

MATERIALS AND METHODS

Medical records at a single referral centre were retrospectively reviewed for dogs diagnosed with infiltrative laryngeal disease by CT or laryngoscopy.

RESULTS

Fifteen dogs were included, with a median age of 6 years (range 1-14 years). Thirteen dogs were diagnosed with inflammatory disease including granulation tissue (n = 4) and neutrophilic (n = 2), septic neutrophilic (n = 2), eosinophilic (n = 1) lymphocytic/plasmacytic (n = 1) and mixed/unclassified (n = 3) inflammation. One dog was diagnosed with large cell lymphoma and one dog was diagnosed with mast cell tumour. Twelve dogs survived to discharge. Follow-up was available for 10 dogs diagnosed with inflammatory disease. Four had fully recovered (7, 10, 23 and 32 months) and one dog developed acute leukaemia and was euthanased at 2 months. Five dogs had recurrence of clinical signs at 1, 1, 5, 17 and 26 months. The dog with lymphoma was euthanased at 8 months and the dog with mast cell tumour died at 5 months.

CLINICAL SIGNIFICANCE

In this cohort, infiltrative inflammatory lesions of the larynx were more common than neoplastic infiltration. For dogs that survived to discharge, outcome was fair although relapse was common.

Fatal Canine Intoxications Linked to the Presence of Saxitoxins in Stranded Marine Organisms Following Winter Storm Activity

At the start of 2018, multiple incidents of dog illnesses were reported following consumption of marine species washed up onto the beaches of eastern England after winter storms. Over a two-week period, nine confirmed illnesses including two canine deaths were recorded. Symptoms in the affected dogs included sickness, loss of motor control, and muscle paralysis. Samples of flatfish, starfish, and crab from the beaches in the affected areas were analysed for a suite of naturally occurring marine neurotoxins of dinoflagellate origin. Toxins causing paralytic shellfish poisoning (PSP) were detected and quantified using two independent chemical testing methods in samples of all three marine types, with concentrations over 14,000 µg saxitoxin (STX) eq/kg found in one starfish sample. Further evidence for PSP intoxication of the dogs was obtained with the positive identification of PSP toxins in a vomited crab sample from one deceased dog and in gastrointestinal samples collected post mortem from a second affected dog. Together, this is the first report providing evidence of starfish being implicated in a PSP intoxication case and the first report of PSP in canines.

Genetic Variation in Total Carotene, Iron, and Zinc Contents of Maize and Cassava Genotypes

Deficiencies of vitamin A, iron, and zinc are widespread in sub-Saharan Africa, where the diets are mainly plant-based and the intakes of animal products are low. The overall objective of this investigation was to determine the extent of genetic variation of these micronutrients in 16 yellow-seeded improved maize varieties, 109 maize inbred lines (60 from mid-altitude and 49 from lowland/savannah agroecologies), and 162 cassava clones resistant to the cassava mosaic disease. The yellow-seeded improved maize varieties were analysed for physical and chemical characteristics and total carotene content; the maize inbred lines and cassava clones were analysed for iron and zinc content. The results showed statistically significant and large genotypic differences in total carotene content among the 16 yellow-seeded improved, open-pollinated maize varieties. The total carotene content ranged from 143 to 278 μg/g. Significant genotypic variation was also observed for iron and zinc concentrations in maize inbred lines and cassava storage roots. Iron concentration ranged from 15 to 159 ppm for mid-altitude and from 14 to 134 ppm for lowland maize inbred lines; zinc concentration ranged from 12 to 96 ppm for mid-altitude inbreds and from 24 to 96 ppm for lowland inbred lines. For cassava storage roots, the range was 4 to 95 ppm for iron and 4 to 18 ppm for zinc. A strong and positive relationship was observed between iron and zinc concentrations for both mid-altitude and lowland maize inbred lines, but this relationship was weak for the cassava clones. The potential exists for improving carotene, iron, and zinc contents in maize and cassava genotypes through plant-breeding.

The use of a negative pressure wound management system in perineal wound closure after extralevator abdominoperineal excision (ELAPE) for low rectal cancer

BACKGROUND

Perineal wound healing is a significant challenge after extralevator abdominoperineal excision (ELAPE) due to a high rate of wound breakdown. Negative pressure therapy has proven benefits in open wounds, and recently a negative pressure system has been developed for use on closed wounds at high risk of breakdown, such as apronectomy and hysterectomy. The aim of the present study was to determine whether negative pressure therapy applied to closed perineal wounds after ELAPE improved wound healing and compare outcomes to the published literature and outcomes from a historical cohort of patients who had undergone 'standard' abdominoperineal resection (APR) and primary closure of the perineal wounds.

METHODS

Prospective data on consecutive patients having ELAPE in the period from November 2012 to April 2015 were collected. The pelvic floor defect was reconstructed with biologic mesh. The adipose tissue layer was closed with vicryl sutures, a suction drain was left in the deep layer, the subcuticular layer and skin were closed, and the negative pressure system was applied. Any wound breakdown within the first 30 days postoperatively was recorded.

RESULTS

Of the 32 consecutive ELAPE patients whose perineal wounds were closed within 30 days with the use of the negative pressure system, there was 1 patient with major perineal wound breakdown and 2 patients with a 1 cm superficial wound defect, which needed no further treatment. In the remaining 29 (90 %) patients, the perineal wounds healed fully without complications. Twenty-five patients underwent standard APR in 2010-2011 with primary closure of their perineal wounds. Ten out of 25(40 %) of patients who had undergone standard APR and primary closure of perineal wounds had major wound complications (p = 0.01).

CONCLUSIONS

Our results suggest that after ELAPE the application of a negative pressure system to the perineal wound closed with biologic mesh may reduce perineal wound complications and may reduce the need for major perineal reconstruction.

Single-incision laparoscopic surgery for rectal cancer: early results and medium-term oncological outcome

AIM

Conventional laparoscopic surgery for rectal cancer management is now widely accepted as an alternative to open surgery, bestowing specific advantages without causing detriment to oncological outcome. Evolving from this, single-incision laparoscopic surgery (SILS) has been successfully utilized for the removal of colonic tumours, but the literature lacks data analysing the suitability of SILS for rectal cancer resection, particularly on oncological outcome. We report the medium-term oncological outcome from a prospective observational study of SILS for rectal cancer, including high and low anterior resections.

METHOD

A prospective electronic database was collated of all patients undergoing SILS rectal cancer resection in our institution, between 2009 and 2014. In addition to patient, tumour and operative data, histopathological and medium-term oncological end-points were recorded. Kaplan-Meier curves were used to analyse survival.

RESULTS

Sixty-one patients underwent SILS for rectal cancer by high anterior resection (n = 34), low anterior resection with total mesorectal excision (TME) (n = 24) and low anterior resection with TME and hand-sewn colo-anal anastomosis (n = 3). The median operation time was 105 (37-280) min and 92% of cases were completed by SILS. The mean interval to resuming oral feeding was 11 h and the median length of stay was 2 (1-8) days. The median number of lymph nodes found by the histopathologist in the resected specimen was 18 (6-44) and all operations completely removed the tumour (R0 resection). At a median follow-up of 46 (16-64) months, eight (13%) patients developed metastatic disease, of whom three had local recurrence. Overall, three patients have died, of whom all had metastatic disease.

CONCLUSION

Anterior resection with TME for rectal cancer can be safely performed using the SILS technique, with acceptable histopathological results and good oncological outcome.

Missense SNP of the MC1R gene is associated with plumage variation in the Gyrfalcon (Falco rusticolus)

A single nucleotide polymorphism (MC1R: c.376A>G) in the MC1R gene was found to be highly correlated with pigment phenotype in the Gyrfalcon. Homozygous genotypes c.376GG and c.376AA were found to dominate the extreme white and dark plumage types respectively, and heterozygotes occurred mainly in intermediate phenotypes. However, some heterozygotes were associated with extreme phenotypes, indicating that melanism/albinism might also involve other loci.

Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete?

AIM

Perineal approaches are considered to be the 'gold standard' in treating elderly patients with external rectal prolapse (ERP) because morbidity and mortality with perineal approaches are lower compared with transabdominal approaches. Higher recurrence rates and poorer function are tolerated as a compromise. The aim of the present study was to assess the safety of laparoscopic ventral rectopexy (LVR) in elderly patients, compared with perineal approaches.

METHOD

The prospectively collected databases from two tertiary referral pelvic floor units were interrogated to identify outcome in patients of 80 years of age and older with full-thickness ERP treated by LVR. The primary end-points were age, American Society of Anesthesiology (ASA) grade, mortality, and major and minor morbidity. Secondary end-points were length of stay (LOS) and recurrence.

RESULTS

Between January 2002 and December 2008, 80 [median age 84 (80-97) years] patients underwent rectopexy. The mean ± standard deviation ASA grade was 2.44 (± 0.57) (two patients were ASA grade I, 42 patients were ASA grade II, 35 patients were ASA grade III and one patient was ASA grade IV). The median LOS was 3 (range 1-37) days. There was no mortality, and 10 (13%) patients had complications (one major and nine minor). At a median follow-up of 23 (2-82) months, two (3%) patients had developed a recurrent full-thickness prolapse.

CONCLUSION

LVR is a safe procedure for using to treat full-thickness ERP in elderly patients. Mortality, morbidity and hospital stay are comparable with published rates for perineal procedures, with a 10-fold lower recurrence.

Laparoscopic ventral rectopexy for external rectal prolapse is safe and effective in the elderly. Does this make perineal procedures obsolete?

AIM

Perineal approaches are considered to be the 'gold standard' in treating elderly patients with external rectal prolapse (ERP) because morbidity and mortality with perineal approaches are lower compared with transabdominal approaches. Higher recurrence rates and poorer function are tolerated as a compromise. The aim of the present study was to assess the safety of laparoscopic ventral rectopexy (LVR) in elderly patients, compared with perineal approaches.

METHOD

The prospectively collected databases from two tertiary referral pelvic floor units were interrogated to identify outcome in patients of 80 years of age and older with full-thickness ERP treated by LVR. The primary end-points were age, American Society of Anesthesiology (ASA) grade, mortality, and major and minor morbidity. Secondary end-points were length of stay (LOS) and recurrence.

RESULTS

Between January 2002 and December 2008, 80 [median age 84 (80-97) years] patients underwent rectopexy. The mean ± standard deviation ASA grade was 2.44 (± 0.57) (two patients were ASA grade I, 42 patients were ASA grade II, 35 patients were ASA grade III and one patient was ASA grade IV). The median LOS was 3 (range 1-37) days. There was no mortality, and 10 (13%) patients had complications (one major and nine minor). At a median follow-up of 23 (2-82) months, two (3%) patients had developed a recurrent full-thickness prolapse.

CONCLUSION

LVR is a safe procedure for using to treat full-thickness ERP in elderly patients. Mortality, morbidity and hospital stay are comparable with published rates for perineal procedures, with a 10-fold lower recurrence.

Older women's experiences of depression: a hermeneutic phenomenological study

This hermeneutic phenomenological study, informed by Max van Manen and Martin Heidegger, describes what it is like for four older women to live with depression. Each participant was interviewed up to three times. Interviews were semi-structured, audiotaped and transcribed verbatim. Data were analysed using van Manen's methodological themes and Heidegger's philosophical concepts of Being-in-the-world and Being-with-others. The themes that emerged were: self-loathing; being overwhelmed by the feelings; hiding from the world; the struggle of everyday life; Being-alone; misinterpreting self and other people; the stigma of mental illness - society and self; and seeking understanding from other people. The findings revealed that depression had a major effect on the women's beliefs about themselves, resulting in a self-loathing and a feeling of failure. The participants described how their self-loathing caused them to believe that other people thought badly of them, which led to their withdrawal. Their inability to connect contributed to them feeling alone and isolated. These women were more able to talk to other people when they were met with understanding. This has implications for the therapeutic nurse-patient relationship, which is fundamental to mental health nursing, because the relationship should be based upon an understanding of the patient's world.

Detection of impaired glucose tolerance and undiagnosed type 2 diabetes in UK South Asians: an effective screening strategy

AIM

We tested a stepwise, community-based screening strategy for glucose intolerance in South Asians using a health questionnaire in conjunction with body mass index (BMI). Anthropometric measurements (waist and hip circumference, sagittal diameter and percentage body fat) were then conducted in a hospital setting followed by an oral glucose tolerance test (OGTT) to identify subjects at the highest risk and analyse the factors predicting that risk.

METHODS

A health questionnaire was administered to 435 subjects in a community setting and BMI was measured. Subjects were graded by a risk score based on the health questionnaire as high, medium and low. Subjects with high and medium risk scores and a representative sample of those with low scores had anthropometric measurements in hospital followed by an OGTT. In total, 205 (47%) of the subjects had an OGTT performed.

RESULTS

In total, 48.7% of the subjects tested with an OGTT had evidence of glucose dysregulation: 20% had diabetes and 28.7% had impaired glucose tolerance (IGT). Logistic regression model explained 49.1% of the total variability. The significant predictors of diabetes and IGT were Blood Glucose Monitoring Strips (BMI), random blood glucose (BM), sibling with diabetes and presence of diagnosed hypertension or ischaemic disease. Most of these predictors along with other heredity diabetes factors create a composite score, with high predictability, as the receiver operating curve analysis shows.

CONCLUSION

We describe a simple, stepwise strategy in a community setting, based on a health questionnaire and anthropometric measurements, to explain about 50% of cases with IGT and diabetes and diagnose about 50% of cases from the population screened. We have also identified factors that predict the risk.

Physical assessment: implications for nurse educators and nursing practice

AIM

In New Zealand, the physical assessment of a patient has traditionally been the domain of the medical profession. As a country implementing advanced practice roles, with an expectation that both nurse practitioners and registered nurses will use physical assessment skills, the relevancy of physical assessment for each scope of practice has currency. The aim of this literature review was to discover what could be learnt from the experiences of Western countries that already incorporate physical assessment skills into nurses' health assessment.

FINDINGS

Nurses in the USA, and more recently Canada and Australia, readily incorporate physical assessment skills into their nursing practice as a component of health assessment. The international literature identified that any change to the nurse's role in health assessment, to include physical assessment skills, requires strategies that involve the regulatory, educational and practice components of nursing.

CONCLUSION

Nurses and other health professionals must perceive that this role expansion will improve health outcomes for the diverse populations accessing health care. Teaching physical assessment skills within a holistic health model will enable nurses to contribute a more comprehensive health assessment to the planning and monitoring of people's health care.

Cost-effectiveness of screening with contrast enhanced magnetic resonance imaging vs X-ray mammography of women at a high familial risk of breast cancer

Contrast enhanced magnetic resonance imaging (CE MRI) is the most sensitive tool for screening women who are at high familial risk of breast cancer. Our aim in this study was to assess the cost-effectiveness of X-ray mammography (XRM), CE MRI or both strategies combined. In total, 649 women were enrolled in the MARIBS study and screened with both CE MRI and mammography resulting in 1881 screens and 1–7 individual annual screening events. Women aged 35–49 years at high risk of breast cancer, either because they have a strong family history of breast cancer or are tested carriers of a BRCA1, BRCA2 or TP53 mutation or are at a 50% risk of having inherited such a mutation, were recruited from 22 centres and offered annual MRI and XRM for between 2 and 7 years. Information on the number and type of further investigations was collected and specifically calculated unit costs were used to calculate the incremental cost per cancer detected. The numbers of cancer detected was 13 for mammography, 27 for CE MRI and 33 for mammography and CE MRI combined. In the subgroup of BRCA1 (BRCA2) mutation carriers or of women having a first degree relative with a mutation in BRCA1 (BRCA2) corresponding numbers were 3 (6), 12 (7) and 12 (11), respectively. For all women, the incremental cost per cancer detected with CE MRI and mammography combined was £28 284 compared to mammography. When only BRCA1 or the BRCA2 groups were considered, this cost would be reduced to £11 731 (CE MRI vs mammography) and £15 302 (CE MRI and mammography vs mammography). Results were most sensitive to the unit cost estimate for a CE MRI screening test. Contrast-enhanced MRI might be a cost-effective screening modality for women at high risk, particularly for the BRCA1 and BRCA2 subgroups. Further work is needed to assess the impact of screening on mortality and health-related quality of life.

Distal adenomatous polyps are rare in patients with inflammatory bowel disease

OBJECTIVE

There is an increased risk of colorectal cancer in patients with inflammatory bowel disease (IBD). The aim of this study was to compare the prevalence of left sided adenomas in patients with IBD aged 55-64 years with a local age matched control population.

METHOD

A review of clinical notes. The prevalence of adenomas in patients with IBD attending for either sigmoidoscopy or colonoscopy was compared with local age matched controls that participated in the national screening trial for colorectal cancer with flexible sigmoidoscopy.

RESULTS

Of 106 patients (61 male, 45 female, mean age of 59 years), 80 suffered from ulcerative colitis, 20 from Crohn's disease, and six from indeterminate colitis. All patients had undergone at least one flexible sigmoidoscopy and 75 had a colonoscopy. Distal adenomas were found in three patients with ulcerative colitis compared with 67 of 749 controls (2.8% v 8.9%, chi(2) = 4.6, p = 0.03).

CONCLUSIONS

The results suggest that distal adenomatous polyps are rare in patients aged 55-64 years with IBD compared with a control population. This supports the hypothesis that lesions other than polyps are important for the development of colorectal cancer in patients with IBD.

Serial analysis of gene expression (SAGE) of host-plant resistance to the cassava mosaic disease (CMD)

Cassava mosaic disease (CMD) is a viral disease of the important tropical staple crop cassava (Manihot esculenta) and preferred management involves use of host-plant resistance. The best available resistance is controlled by a single dominant gene. Serial analysis of gene expression (SAGE) was used to analyze the gene expression pattern in a bulk of 40 each of CMD resistant and susceptible genotypes drawn from a gene mapping progeny. Messenger RNA used for the SAGE analysis came from plants that were exposed to heavy disease pressure over a period of 2 years in the field. A total of 12,786 tags were studied, divided into 5733 and 7053 tags from the resistant and susceptible genotypes, respectively. Tag annotation was by PCR amplification using the tag sequence as sense primer and 4000 cassava ESTs generated from the bulk of CMD resistant genotypes. Annotation of more than 30 differentially expressed tags revealed several genes expressed during systemic acquired resistance (SAR) in plants and other genes involved in cell-to-cell and cytoplasm-to-nucleus virus trafficking. Differential expression of the most abundantly expressed tag, corresponding to a beta-tubulin gene, was confirmed by Northern Analysis. RFLP analysis of the tags in the parents and bulks of the CMD mapping progeny revealed only one tag, a WRKY transcription factor, associated with the region bearing the dominant CMD gene.

Evaluation of a multiprofessional community stroke team: a randomized controlled trial

OBJECTIVES

There is inconclusive evidence of the effectiveness of stroke rehabilitation by a community stroke team. The aim was to evaluate a specialist multiprofessional team in a community setting.

DESIGN

Randomized controlled trial.

SETTING

Community.

PARTICIPANTS

Stroke patients and their informal carers who were referred to receive rehabilitation from a community stroke team.

OUTCOME MEASURES

Barthel Index, Extended Activities of Daily Living Scale (EADL), General Health Questionnaire (GHQ-12) by patient and carer, Carer Strain Index (CSI), Euroquol, knowledge of stroke and satisfaction with services six months after recruitment.

RESULTS

There were no significant differences between patients who received rehabilitation from community stroke team (n = 189) and those who received routine care (n = 232) in their independence in activities of daily living, mood, quality of life or knowledge of stroke. The patients in the community stroke team group were significantly more satisfied with the emotional support they had received (p < 0.01). There were no significant differences between the groups in satisfaction with practical help or overall satisfaction. Carers of patients in the community stroke team were under significantly less strain than carers in the routine care group (p < 0.04). Carers of patients in the community stroke team group were significantly more satisfied with their knowledge of stroke (p < 0.01) and were more satisfied overall (p < 0.01).

CONCLUSIONS

The patients treated by the community stroke team were more satisfied with the emotional support they received and had equivalent outcomes in terms of independence in activities of daily living and mood. Their carers were under less strain and were more satisfied with their knowledge of stroke recovery, the emotional support they received and overall satisfaction with services. The results support the provision of rehabilitation by a community-based specialist multiprofessional team.

Entonox analgesia for prostatic biopsy

We performed a prospective randomised double-blind study to evaluate the efficacy of Entonox (nitrous oxide) as an analgesic for trans-rectal ultrasound (TRUS) and prostate biopsy. A total of 50 patients breathed either Entonox or air during sextant prostatic biopsies all of which were performed by the same surgeon. The degree of pain experienced was recorded on a 100 mm visual analogue pain scale. A total of 17 further patients were excluded from the study because they wished to drive home after TRUS. Most patients breathing air experienced moderate pain (median pain score 34), whereas those breathing Entonox experienced minimal pain (median pain score 11). Two patients who used Entonox and one breathing air experienced severe pain. We conclude that patients undergoing prostate biopsy without analgesia experience moderate pain and this can be reduced significantly by using Entonox.

Ocular palsy following Le Fort 1 osteotomy: a case report

A 33-year-old female patient developed an ipsilateral sixth nerve palsy and partial third nerve palsy following a Le Fort 1 osteotomy. Complete resolution occurred at 10 weeks. The likely mechanism of injury secondary to pterygo-maxillary dysjunction is highlighted, with description of the relevant anatomy. Previous cases of ocular motility complications following Le Fort 1 osteotomy are discussed. We recommend that significant care be taken in osteotome placement in the pterygo-maxillary fissure, particularly in those prone to unpredicted fractures such as older patients, or where the anatomy is congenitally abnormal or altered by previous surgery.

Penetration of herbicides to groundwater in an unconfined chalk aquifer following normal soil applications

The persistence and penetration of the herbicides isoproturon and chlorotoluron in an unconfined chalk aquifer has been monitored over a 4-year period through soil sampling, shallow coring and groundwater monitoring. Chlorotoluron was applied on plots as a marker compound, having never been used previously on that, or surrounding fields. The fieldsite had a 5 degree slope with soil depths of 0.5 to 1.5 m and a water table between 20 and 5 m from the soil surface. Where the water table was deepest (9-20 m below surface (mbs)) little or no positive herbicide detections were made. However, where the water table was at only 4-5 mbs, a regular pesticide signal of around 0.1 microg/l for isoproturon and chlorotoluron could be distinguished. Over the winter recharge period automatic borehole samplers revealed a series of short-lived peaks of isoproturon and chlorotoluron reaching up to 0.8 microg/l. This is consistent with a preferential flow mechanism operating at this particular part of the field. Such peaks were occurring over 2 years after the last application of these compounds. Shallow coring failed to uncover any significant pesticide pulse moving through the deep unsaturated zone matrix at the fieldsite.

Genetic testing and insurance: opportunities and challenges for society

The increased availability of genetic tests poses new challenges to society. Here, we address the wider implications of genetic testing, with an emphasis on the markets for insurance. It also considers issues such as confidentiality, patient autonomy and fear of discrimination and the doctor-patient relationship.

Small scale water recycling systems--risk assessment and modelling

This paper aims to use quantitative risk analysis, risk modelling and simulation modelling tools to assess the performance of a proprietary single house grey water recycling system. A preliminary Hazard and Operability study (HAZOP) identified the main hazards, both health related and economic, associated with installing the recycling system in a domestic environment. The health related consequences of system failure were associated with the presence of increased concentrations of micro-organisms at the point of use, due to failure of the disinfection system and/or the pump. The risk model was used to assess the increase in the probability of infection for a particular genus of micro-organism, Salmonella spp, during disinfection failure. The increase in the number of cases of infection above a base rate rose from 0.001% during normal operation, to 4% for a recycling system with no disinfection. The simulation model was used to examine the possible effects of pump failure. The model indicated that the anaerobic COD release rate in the system storage tank increases over time and dissolved oxygen decreases during this failure mode. These conditions are likely to result in odour problems.