Temperature changes of CoolSticks during simulated use

INTRODUCTION

Cold sensation is often used to check neuraxial anaesthesia and analgesia. One opportunity to reduce the carbon footprint of anaesthesia is to replace vapo-coolant sprays such as ethyl chloride with a reusable device called the CoolStick, which is cooled in a refrigerator between uses. We designed a study to investigate how long the CoolStick remains at its working temperature, which we defined as <15 °C.

METHOD

Experiments were undertaken using a thermocouple and digital temperature sensor attached to the CoolStick. We conducted two experiments to assess temperature changes following removal from the refrigerator for 10 min; the first investigated passive re-warming in the ambient theatre environment and the second investigated re-warming in simulated use. In our third experiment, we investigated the time taken to cool the device in the refrigerator, following use. Each experiment was repeated three times.

RESULTS

In the passive re-warming experiment, the mean CoolStick temperature was 7.3 °C at the start, and 14.3 °C after 10 min. In the simulated use experiment, the mean CoolStick temperature was 7.3 °C at the start, and 18.9 °C at 10 min. In the cooling experiment, the mean CoolStick temperature was 15 °C at the start and 7.6 °C at 40 min.

CONCLUSION

Our study indicates that it is feasible to use the CoolStick for providing cold sensation in clinical practice. Further study would be required to directly compare the effectiveness of the device to existing methods such as coolant sprays or ice in the clinical setting.

'Give us the real tools to do our jobs': views of UK stakeholders on the role of a public health objective for alcohol licensing

OBJECTIVES

This study ascertains the views of UK stakeholders on the actual, and possible, impact of a public health licensing objective in their day-to-day work.

STUDY DESIGN AND METHODS

Twenty-eight interviews were conducted with members of public health teams who were actively engaged in alcohol licensing in their local area between 2017 and 2019. Six teams were based in Scotland (where there is a public health licensing objective) and 14 in England (where there is no similar objective).

RESULTS

Scottish participants reported that while challenges remained in applying the public health licensing objective, progress had been made and the objective was beneficial to their work. Participants in England felt that an objective would increase the legitimacy, value and impact of their contributions. In both Scotland and England, constructive relationships between PHTs, licensing authorities and other key stakeholders were developing suggesting that PHTs could have a sustainable and positive role in licensing.

CONCLUSIONS

In many Scottish areas, the alcohol licensing system is evolving to take constructive account of its public health objective. In England, PHTs that have invested resources in engaging in this area have demonstrated an ability to work effectively within licensing systems. Strong support for the adoption of a public health licensing objective among these PHTs adds weights to calls for the UK Government to reconsider its previous decision not to introduce such an objective.

AB0682 RHEUMATOLOGY TEACHING IN TIMES OF COVID-19

Background:

The COVID-19 pandemic has affected the delivery of face-to-face teaching especially bedside teaching for medical students in the hospitals. Rheumatology outpatient clinics have mostly become virtual or telephone consultation clinics which prevent medical students from seeing patients in person. Students are deprived of the opportunities to take rheumatology history, examining patients and seeing signs of rheumatologic diseases. New adaptations have to be made to ensure equitability and that students still receive the relevant teaching in line with their learning curriculum and to help them prepare for their examinations.

Objectives:

Our aims are:

1)To adapt bedside teaching in the wards to simulated teaching in the classroom using trained simulated ‘patients’; and

2)To create simulation teaching of patient journeys in Objective Structured Clinical Examination (OSCE) format known as Clinically Observed Medical Education Tutorials (COMET) (Nair et al., 2001).

Methods:

1)For simulated teaching in the classroom, we have trained our teaching colleagues as simulated or standardized patients (SPs). We write up fictitious patient histories which simulate common presentations at rheumatology clinics. We train the SPs to give as accurate a history as possible and to simulate pains in different joints (e.g. pain at the metacarpophalangeal joints and proximal interphalangeal joints in rheumatoid arthritis) on clinical examinations. For clinical presentations that are not easily simulated, we use photographs of the relevant signs. This method is used not only as formative assessments but also as end-of-placement summative assessments.

2)COMET comprises 3 OSCE-style stations with a tutor each where the students perform different tasks based on a patient’s clinical problem (e.g. acute hot swollen joint). The first station is initial A-to-E assessment of the patient (using a simulator), followed by investigations and interpretations of lab results and imaging (station 2) and lastly, management (including prescribing medications) and communication skills (e.g. explain arthrocentesis to the patient).

Results:

The overall feedback from students is very positive. We use Likert scale to assess confidence level before and after the teaching session, and pre-session and post-session multiple choice questions to assess learning and knowledge gained.

Conclusion:

While simulated teaching cannot replace encounters with real patients, students do enjoy these sessions as they get to ‘experience’ a large variety of rheumatologic cases and practice their clinical skills which at times are limited with real patients due to reluctance and pain of the patients.

References:

[1]Nair, R., Morrissey, J., Carasco, D., Desilva, S. & Patel, V. (2001) COMET: Clinically Observed Medical Education Tutorial - a novel educational method in clinical skills. International Journal of Clinical Skills

[2]Van der Vleuten, C.P.M. & Swanson, D.B. (1990) Assessment of clinical skills with standardized patients: state of the art. Teach Learn Med, 2: 58-76.

Disclosure of Interests:

None declared

815 The Impact and Implications for The Workload for Vascular Surgery as A Result of the COVID-19 Lockdown

Introduction

The emergence of the coronavirus pandemic and subsequent UK lockdown resulted in a significant reduction in elective vascular surgery to increase critical care capacity. We aimed to ascertain the impact of lockdown on the workload of a busy vascular surgical unit.

Method

Data on all major vascular procedures performed between March 2020 and June 2020 were collected prospectively. Comparison to the same time period over the last 6 years was performed using a prospectively maintained database.

Results

92 major cases were performed, a reduction of 30% compared with cases performed during similar periods (803 cases total, mean 133), with an increased proportion of unplanned & emergency cases(35.9% & 31.5% vs 31.4% & 20.5%).

There was a significant reduction in aortic procedures (19 vs mean 36). Despite the reduction in cases there was a similar number of amputations performed (9 vs mean 10).

Conclusions

The lockdown period resulted in a 30% reduction in cases performed with far fewer aortic procedure performed and a similar number of amputations. These pending cases will need consideration, especially with critical care capacity to ensure they are completed within a timely period. Considerations for capacity are also pertinent given the approach of winter and the possibility of a second wave.

Training in colorectal surgery in Europe and 20 years of the European Board of Surgical Qualification coloproctology examination

AIM

Training in colorectal surgery across Europe is not yet standardized. The European Board of Surgical Qualification (EBSQ) coloproctology examination has been held annually since 1998. The aims of this study were to illustrate the current situation of coloproctology specialization in Europe and to analyse the EBSQ examinations held over the last 20 years.

METHOD

A survey, focused on current training and education in colorectal surgery in Europe, was conducted among all national representatives of the European Society of Coloproctology (ESCP) in 2018. Candidate demographics (1998-2018) and the results of the EBSQ examination (2007-2018) were analysed.

RESULTS

In Europe, there are currently 26 national colorectal societies, 27 national annual colorectal meetings, 16 national specialized training programmes and 13 national colorectal fellowships. Six countries have board certification in colorectal surgery and five a dedicated examination. During the last 20 years, 475 candidates from 29 countries, of whom 88 (19%) were women, passed the EBSQ examination. The pass rate was higher in younger applicants (< 42 years, P = 0.01). The success rate was higher for candidates with academic experience (more than five publications or presentations) and with an academic title (thesis) (P = 0.01).

CONCLUSION

Colorectal surgical training is still not standardized in Europe, although efforts have been made to recognize colorectal surgery as an independent speciality. The number of holders of the EBSQ Diploma has increased over the years, demonstrating the acceptance of the examination among European surgeons. Young candidates with an academic profile are the most successful.

Dual therapy with renally adjusted lamivudine and dolutegravir: a switch strategy to manage comorbidity and toxicity in older, suppressed patients?

OBJECTIVES

The aim of the study was to evaluate the efficacy of dual therapy with lamivudine (3TC), with dose adjustment for renal function, and dolutegravir (DTG) in a subgroup of patients fully suppressed on treatment who were switched because of concerns about comorbidity and toxicity on their current triple drug regimen.

METHODS

A retrospective evaluation of clinical and pathological parameters from an electronic patient record from a single centre was carried out.

RESULTS

There were no virological failures in 52 patients with a median age of 60.5 years. The median duration of follow-on dual therapy was 2.29 years (28 months; range 1.10-3.34 years). In 25 of 52 (48%) cases, the dose of 3TC was adjusted taking into account reduced renal function, and none of these patients experienced virological failure. Four additional patients discontinued early, because of side effects of the switch, with no failure.

CONCLUSIONS

This retrospective review suggests that 3TC and DTG may be effective in controlling viral load in older patients with comorbidities. This regimen appears to be a useful option in the context of comorbidities (including renal impairment) and polypharmacy in older patients. However, this review has been conducted in one centre and in a small population of patients. Therefore, further multicentre trials involving larger populations of patients are needed.

Session 3: Many ways to organ preserve the rectum but which is correct?

From the patient's perspective, cancer cure with full preservation of function is a crucial goal. There are many advances that have emerged which may make this possible in a greater proportion of patients without compromising oncological outcomes. Professor Tekkis reviews the options and evidence to date for 'organ preservation' and the expert panel discuss the implications for current and future patient care.

Session 3: Beyond TME and radiotherapy MRI evaluation of rectal cancer treatment response

Magnetic resonance imaging plays an increasingly important role in evaluating the effect of cancer treatment. Imaging alone cannot predict pathological complete response and imaging interpretation should be combined with clinical information and endoscopy findings to predict complete response. Professor Blomqvist reviews current and future imaging techniques and whether the quantitative can add significant or important prognostic information over the current qualitative techniques.

Session 3: Intra-operative radiotherapy - creating new surgical boundaries

In patients with advanced and recurrent colorectal cancer, surgical resection with clear margins is the greatest challenge and is limited by known anatomical constraints. Preoperative or intra-operative assessment of the limits of surgical dissection may help to explore the possibility of improving resectability through either targeted external beam radiotherapy or intra-operative radiotherapy. Professor Chang reviews the evidence base and potential advantages and disadvantages of this approach, whilst the expert panel agree a consensus on the evidence for assessment and therapy of such patients.

Session 3: Beyond the boundaries of Total Mesorectal Excision - where surgeons fear to tread

Approximately 10-15% of patients present with an advanced rectal cancer that extends beyond the conventional total mesorectal excision (TME) planes. In such cases extending the surgery to ensure resection with clear margins (R0 resection) is essential in order to achieve long-term cure. Professor Holm describes the techniques of beyond-TME exenterative surgery, the methods of patient selection and outcomes.

Perception of Slope and Distance in Photographs and in the Real World

We report a series of experiments in which spatial judgments of the real world were compared with equivalent judgments of photographs of the real-world scenes. In experiment 1, subjects judged the angle from the horizontal of natural slopes. Judgments of slope correlated with true slope (r=0.88) but judgments were in general overestimates. Equivalent judgments of slope in photographs again correlated with true slope (r=0.91) but judgments tended to be overestimates for small angles (6°) and underestimates for larger angles (up to 25°). In experiment 2 slope judgments were made under laboratory conditions rather than in the natural world. The slopes, which were viewed monocularly, varied from 5° – 45°, and were either plain, or textured, or included perspective information (a rectangle drawn on the surface) or had both texture and perspective. Judgments were overestimates, but the correlation with true slope was high (r=0.97). Slopes with either texture or perspective were judged more accurately than plain slopes, but combining texture and perspective information conferred no further benefit. Judgment of the angle of the same slopes in photographs produced similar results, but the degree of overestimation (closer to the vertical) was greater than for the real slopes. In experiment 3, subjects either judged the distance of landmarks ranging from 200 m to 5000 m from the observation point, or judged distance to the landmarks in photographs. In both cases subjects' judgments were well described by a power function with exponents close to one. Although there are large individual differences, subjects' judgments of slope and distance are accurate to a scale factor, and photographs yield similar judgments to real scenes.

Restorative proctocolectomy in patients with ulcerative colitis: a cross-sectional Danish population study on function and quality of life

AIM

The study evaluated function and quality of life (QoL) in all patients having restorative proctocolectomy (RPC) in Denmark for ulcerative colitis (UC) from 1980 to 2010. Inclusion of all patients in one country has never previously been achieved.

METHOD

All patients who had had a RPC in Denmark, from the first case in 1980 to the last case in 2010, were studied. A cross-sectional questionnaire survey was performed, and function and QoL were assessed using a standardized questionnaire - the Short-Form 36 (SF36) - and the inflammatory bowel disease questionnaire (IBDQ).

RESULTS

The median duration of follow up was 11 (range, 1-30) years. Apart from deaths, pouch failures and research protection, data on function and QoL were obtained from 1047 (85%) of 1229 patients who had a functioning pouch at the time of the investigation. More female patients than male patients experienced urgency (56% vs 44%, P = 0.0021). The median number of bowel movements per 24 h was 7 (range, 1-23) in female patients and 6 (range, 1-20) in male patients (P < 0.001). Pad usage was more frequent among female patients than among male patients (62% vs 38%, P < 0.001). A higher incidence of major incontinence (P = 0.009) and use of pads (P = 0.01) was found among patients who had been operated on 21-30 years previously compared with those operated on 11-20 years previously. The prevalence of urgency was higher in patients who received surgery 0-10 years previously compared with 11-20 years previously (P = 0.009). The total IBDQ score was higher in male patients than in female patients (P < 0.001). Male patients scored higher in five of eight SF36 domains (P < 0.001).

CONCLUSION

Female patients had more urgency, a higher frequency of defaecation and higher pad usage. This was associated with a reduced QoL. Nevertheless, RPC resulted in good function and a high degree of satisfaction in most patients.

Junior doctors' satisfaction with the ward pharmacy service in the Hammersmith and Queen Charlotte's special health authority

A questionnaire was drawn up to ascertain junior doctors' satisfaction with the ward pharmacy service in the Hammersmith and Queen Charlotte's special health authority, London. The questionnaire was designed for face to face interviews lasting not more than 10 minutes. The interviews were taped and the interviewer was not known to the doctors. The survey took place in January, 1992. Forty three out of 135 senior house officers, registrars and senior registrars employed by the special health authority were randomly selected for interview and 26 (60 per cent) of these were seen. Eighty five per cent of doctors thought the service was better than average and most doctors were satisfied with aspects of the service such as prescription monitoring, advice received from and friendliness of ward pharmacists. Only one doctor rated the service as worse than that in other hospitals in which he had worked. Fifteen doctors suggested increased liaison or contact between ward pharmacists and doctors would make the service better. A number of issues have been raised concerning the service which have been addressed and we intend to repeat the survey in the future.

COX-2 inhibition in combination with preoperative chemoradiation for CA esophagus

e15607

Background: Squamous cell carcinoma of the thoracic esophagus (ESCC) is often diagnosed in advanced stage. Pre-operative chemoradiation is employed to downstage the disease before operation. Pathological complete response (pCR) was observed in around 20–40% of patients and was associated with improved survival. Cyclooxygenase 2 (COX-2) is overexpressed in ESCC and may contribute to chemo- and radio-resistance. This pilot study evaluates if COX-2 inhibition in combination with pre-operative chemoradiation will improve the response rate in ESCC. Methods: Patients with histologically confirmed ESCC undergo endoscopic ultrasound, ultrasound of neck and PET/ thoracic, abdominal CT for staging. Patients with disease which is considered potentially resectable are eligible. The primary and involved lymph nodes are irradiated to 40Gy in 20 fractions over 4 weeks with 2 cycles of concurrent cisplatin (100mg/sqm, D1, D22) and 5 fluorouracil (500mg/sqm, D1–5, D22–26). Celecoxib, a specific COX-2 inhibitor, 400mg bid, is started for 2 weeks before chemoradiation, continued throughout chemoradiation and for 4 more weeks after completion of chemoradiation. Patients are re-evaluated and esophagectomy is performed 6–8 weeks after completion of chemoradiation. Results: From 2004 to 2008, 32 patients were recruited. Pre-operative staging was stage II in 4, stage III in 25 and stage IVA in 3 patients. Celecoxib was well tolerated. 3 patients did not have full course of celecoxib: 1 complained of epigastric pain, 1 died early of disease, 1 had renal impairment after chemotherapy. 29 patients had esophagectomy performed after chemoradiation. Median follow-up after completion of chemoradiation was 11 months (range: 3 to 43 months). 23 patients (79.3%) had downstaging of the primary compared with pre-operative staging. The pCR rate in primary tumor was 51.7% (15/29 patients) and pCR rate in lymph nodes was 65.4% (17/26 patients). 3 years overall survival of patients who had esophagectomy was 79.3%. Conclusions: COX-2 inhibition in combination with pre-operative chemoradiation is well tolerated. Preliminary results of the pCR rates and survival are encouraging. Incorporation of COX-2 inhibition into multi-modality treatment of ESCC should be further investigated in a randomized trial.

No significant financial relationships to disclose.

Continuous figure-of-eight suturing in upper and lower gastrointestinal anastomosis

INTRODUCTION

The optimal technique for gastrointestinal anastomosis is controversial. The three most popular techniques are two layers, one layer and the stapling method. However, there is no universal agreement on the best technique. The aim of this study was to evaluate the safety, feasibility, and efficacy of continuous figure-of-eight suturing in gastrointestinal anastomosis.

METHODS

This was a retrospective study of 170 patients who underwent gastrointestinal anastomosis using continuous figure-of-eight suturing for the first layer and continuous seromuscular suturing for the second layer from August 1993 to January 2006. All operations were performed by a single consultant surgeon. We assessed each anastomosis by checking the integrity, vascularity and patency, and also ensuring tension-free status. Postoperatively, patients were managed by routine care of intravenous fluids and nasogastric tube until they had active bowel sounds and started absorbing. Imaging was arranged for patients who developed clinical signs and symptoms of leak.

RESULTS

170 patients underwent gastrointestinal anastomosis by continuous figure-of-eight suturing for different pathologies over a two-and-a-half-year period. There were 92 (54.1 percent) men and 78 (45.9 percent) women. The mean age of the patients was 56 (range 20-88) years. The median follow-up was 74 months. There were 124 (72.9 percent) small bowel anastomosis and 46 (27.1 percent) large bowel anastomosis. An important complication after gastrointestinal anastomosis was leakage, which was reported in three (1.8 percent) patients. One of them had gastric cancer, one had Crohn's disease and one had intestinal ischaemia. No mortality was reported in relation to anastomotic failure. Two (1.2 percent) patients developed stenosis and 15 (8.8 percent) patients died because of progression of their disease or other pathologies during the follow-up.

CONCLUSION

Continuous figure-of-eight suturing is a simple, easy to learn, safe and satisfactory upper and lower gastrointestinal anastomosis technique.

Sedimentary and water column processes in the Oyster Grounds: a potentially hypoxic region of the North Sea

The purpose of this research was to investigate the potential causes of low oxygen levels in the bottom water of the Oyster Grounds region of the shallow southern North Sea, an area which provides suitable conditions for low oxygen levels to develop. At the end of the summer stratified period, relevant biogeochemical processes were investigated using a combination of sedimentary and water column rate measurements. Phytoplankton nitrate and ammonium uptake was measured throughout the water column using (15)N labelled isotopes and showed ammonium uptake dominated in the upper and bottom mixed layer with a maximum 294.4 micromol N m(-3)h(-1). In the deep chlorophyll maximum at the thermocline, primary production was dominated by nitrate uptake, with an average of 35.0 micromol N m(-3)h(-1), relative to ammonium uptake, with an average of 24.6 micromol N m(-3)h(-1). This high relative nitrate uptake will in part result in exportable new production to the isolated bottom mixed layer and sediments, as opposed to regenerated ammonium driven uptake. This biomass export was indicated by significant benthic oxygen consumption rates in the stratified region (782-1275 micromol O(2)m(-2)h(-1)micromol N m(-3)h(-1)) long after the end of the spring bloom. The sediments were also an active net source of nitrate, ammonium, phosphate and silicate into the bottom mixed layer of 4.4, 8.4, 2.3 and 68.8 micromol m(-2)h(-1), respectively. The export of new production within the thermocline to the bottom mixed layer and the consequent sediment oxygen consumption in the isolated bottom mixed layer in the Oyster Grounds are expected to have contributed to the low bottom water oxygen concentrations of 2.07 mg l(-1) (64.7 micromol l(-1)) measured. The long stratified period associated with this low oxygen is predicted to occur more regularly in the future and continued monitoring of this ecologically important region is therefore essential if the causes of these potentially damaging low oxygen levels are to be fully understood.

Minimally invasive and selective hydrodynamic gene therapy of liver segments in the pig and human

This paper highlights our experience of the transfer of hydrodynamic gene therapy (HGT) from the large animal, the pig, into clinical practice. The modification of balloon catheters and the development of a minimally invasive technique to allow selective isolation of liver segments for HGT in the large animal and human are described. Finally, our preliminary results from a phase I clinical study of HGT for thrombopoietin (TPO) in cirrhotic patients with thrombocytopenia are discussed. Based on these provisional data, minimally invasive selective HGT of liver segments appears to be technically safe, but further work is required to optimize the efficiency of gene transfer in order to achieve clinical benefit.

Increase of annexin 1 immunoreactivity in spinal cord of newborn opossum (Monodelphis domestica) at the time when regeneration after injury stops being possible

Annexins constitute a family of proteins that associate reversibly with cell membranes in a calcium dependent manner. We have studied the distribution of annexin 1, which is known to mediate anti-inflammatory actions of glucocorticoids, and which is upregulated after spinal cord injury, in newborn and adult South American opossum (Monodelphis domestica) spinal cord. We show the increase in the annexin 1 immunoreactivity in spinal cords of neonatal opossums over the critical period when regeneration after injury ceases to be possible. We further show the restricted and specific sites at which it is detected in adult opossum cerebellum and hippocampus. Since the procedures used in immunochemistry of annexin in CNS have in the past yielded conflicting results, different procedures were tested and shown to be reliable. As a control, annexin 1 distribution was surveyed in kidney.

Consensus conference on the stapled transanal rectal resection (STARR) for disordered defaecation

An international working party was convened in Rome, Italy on 16-17 June, 2005, with the purpose of developing a consensus on the application of the circular stapling instrument to the treatment of certain rectal conditions, the so-called Stapled Transanal Rectal Resection (STARR). Since the procedure has been submitted to only limited objective analysis it was felt prudent to hold a meeting of interested individuals for the purpose of evaluating the current status and to make conclusions and recommendations concerning the applicability of this new approach.

Up-regulation of macrophage migration inhibitory factor in infants with acute neonatal necrotizing enterocolitis

AIMS

To investigate the role of macrophage migration inhibitory factor (MIF) and its downstream cytokine cascade in necrotizing enterocolitis (NEC).

METHODS AND RESULTS

The expression of MIF mRNA and protein in NEC guts was assayed by in situ hybridization and immunohistochemistry, respectively. Concentrations of MIF, interleukin (IL)-6 and IL-8 in the serum and in the supernatant of macrophage cultures were examined by ELISA. Increased expression of MIF mRNA and protein was observed in the NEC guts, mainly in the infiltrating macrophages in the mucosa and submucosal layers. Up-regulation of MIF was associated with the accumulation of macrophages and T cells. In addition, serum levels of MIF, IL-6 and IL-8 in NEC patients during the acute stage of the disease were significantly increased. The expression of MIF decreased both locally and systemically after the disease was resolved. MIF was also found to increase the secretion of IL-6 and IL-8 by macrophages isolated from healthy individuals in vitro in NEC.

CONCLUSIONS

MIF acts by stimulating macrophage production of IL-6 and IL-8. This further aggravates the inflammatory process by increasing the infiltration of neutrophils and activating inflammatory cells. The results of this study suggest that MIF plays an important role in the pathogenesis of NEC and may serve as a target for therapeutic intervention in NEC.

Strategies for identifying genes that play a role in spinal cord regeneration

A search for genes that promote or block CNS regeneration requires numerous approaches; for example, tests can be made on individual candidate molecules. Here, however, we describe methods for comprehensive identification of genes up- and down-regulated in neurons that can and cannot regenerate after injury. One problem concerns identification of low-abundance genes out of the 30,000 or so genes expressed by neurons. Another difficulty is knowing whether a single gene or multiple genes are necessary. When microchips and subtractive differential display are used to identify genes turned on or off, the numbers are still too great to test which molecules are actually important for regeneration. Candidates are genes coding for trophic, inhibitory, receptor and extracellular matrix molecules, as well as unknown genes. A preparation useful for narrowing the search is the neonatal opossum. The spinal cord and optic nerve can regenerate after injury at 9 days but cannot at 12 days after birth. This narrow window allows genes responsible for the turning off of regeneration to be identified. As a next step, sites at which they are expressed (forebrain, midbrain, spinal cord, neurons or glia, intracellular or extracellular) must be determined. An essential step is to characterize proteins, their levels of expression, and their importance for regeneration. Comprehensive searches for molecular mechanisms represent a lengthy series of experiments that could help in devising strategies for repairing injured spinal cord.

Coronavirus as a possible cause of severe acute respiratory syndrome

BACKGROUND

An outbreak of severe acute respiratory syndrome (SARS) has been reported in Hong Kong. We investigated the viral cause and clinical presentation among 50 patients.

METHODS

We analysed case notes and microbiological findings for 50 patients with SARS, representing more than five separate epidemiologically linked transmission clusters. We defined the clinical presentation and risk factors associated with severe disease and investigated the causal agents by chest radiography and laboratory testing of nasopharyngeal aspirates and sera samples. We compared the laboratory findings with those submitted for microbiological investigation of other diseases from patients whose identity was masked.

FINDINGS

Patients' age ranged from 23 to 74 years. Fever, chills, myalgia, and cough were the most frequent complaints. When compared with chest radiographic changes, respiratory symptoms and auscultatory findings were disproportionally mild. Patients who were household contacts of other infected people and had older age, lymphopenia, and liver dysfunction were associated with severe disease. A virus belonging to the family Coronaviridae was isolated from two patients. By use of serological and reverse-transcriptase PCR specific for this virus, 45 of 50 patients with SARS, but no controls, had evidence of infection with this virus.

INTERPRETATION

A coronavirus was isolated from patients with SARS that might be the primary agent associated with this disease. Serological and molecular tests specific for the virus permitted a definitive laboratory diagnosis to be made and allowed further investigation to define whether other cofactors play a part in disease progression.

Cardiovascular disease as a long-term complication of treatment for testicular cancer

PURPOSE

To assess the risk of cardiovascular morbidity and cardiac risk factors in long-term survivors of testicular cancer according to treatment received.

PATIENTS AND METHODS

All resident male patients registered in the United Kingdom between 1982 and 1992 attending for follow-up were eligible for recruitment. Patients completed a current health questionnaire and underwent clinical review, along with hematologic, biochemical, and hormonal profiles. For patients not under routine review, follow-up information was sought from their general practitioner and mortality data were sought from the Office of National Statistics. Descriptive analysis was performed on all variables and comparisons were made among patients treated by orchidectomy and follow-up only, chemotherapy alone (C), radiotherapy alone (RT), and radiotherapy and chemotherapy (C/RT).

RESULTS

Data on cardiovascular events were available on 992 patients. After a median follow-up of 10.2 years, 68 events had been reported, including 18 deaths. After adjusting for age, increased risk for cardiac events was seen after C (relative risk [RR] = 2.59; 95% confidence interval [CI], 1.15 to 5.84; P =.022), RT (RR = 2.40; 95% CI, 1.04 to 5.45; P =.036), and C/RT (RR = 2.78; 95% CI, 1.09 to 7.07; P =.032). There were no significant differences in cardiac risk factors. On multivariate analysis, age, treatment group, free thyroxine, protein, and magnesium levels were associated with cardiovascular disease.

CONCLUSION

In long-term survivors of testicular cancer, we observed a two-fold or greater risk of developing cardiovascular disease. This was not due to increases in cardiac risk factors, which suggests a direct or indirect treatment effect. These data support the continued research into the minimization of treatment in good-prognosis testicular cancer.

Predicting the risk of bleomycin lung toxicity in patients with germ-cell tumours

BACKGROUND

Bleomycin pulmonary toxicity (BPT) has been known since the early clinical trials of bleomycin in the 1960s. Postulated risk factors include cumulative bleomycin dose, reduced glomerular filtration rate (GFR), raised creatinine, older age and supplemental oxygen exposure.

PATIENTS AND METHODS

From our prospectively collected testicular cancer research database, we reviewed 835 patients treated at the Royal Marsden NHS Trust (Sutton, UK) with bleomycin-containing regimens for germ-cell tumours between January 1982 and December 1999, to identify those with BPT.

RESULTS

Fifty-seven (6.8%) patients had BPT, ranging from X-ray/CT (computed tomography) changes to dyspnoea. There were eight deaths (1% of patients treated) directly attributed to BPT. The median time from the start of bleomycin administration to documented lung toxicity was 4.2 months (range 1.2-8.2). On multivariate analysis, the factors independently predicting for increased risk of BPT were GFR <80 ml/min [hazard ratio (HR) 3.3], age >40 years (HR 2.3), stage IV disease at presentation (HR 2.6) and cumulative dose of bleomycin >300,000 IU (HR 3.5).

CONCLUSIONS

Patients with poor renal function are at high risk of BPT, especially if they are aged >40 years, have stage IV disease at presentation or receive >300,000 IU of bleomycin. In such cases alternative drug regimens or dose restriction should be considered.

Characterization of adenosine receptors mediating the vasodilator effects of adenosine receptor agonists in the microvasculature of the hamster cheek pouch in vivo

1 The aim of this study was to characterize the adenosine receptor mediating vasodilation in the microvasculature of the hamster cheek pouch in vivo. A range of adenosine agonists was used including N6-cyclopentyladenosine (CPA) (A1 agonist), 5'-N-ethylcarboxamidoadenosine (NECA) (non-selective), 2-chloroadenosine (2CADO) (non-selective), 2-p-(2-carboxyethyl)-phenethylamino-5'-N-ethylcarboxamidoadenosine (CGS 21680) (A2A agonist), N6-(3-iodobenzyl)-adenosine-5'-N-methyluronamide (IBMECA) (A3 agonist) and adenosine, as well as the adenosine antagonists 8-sulphophenyltheophylline (8-SPT) (A1/A2 antagonist), 1,3-dipropyl-8-cyclopentylxanthine (DPCPX) (A1 antagonist) and 4-(2-[7-amino-2-(2-furyl)[1,2,4]-triazolo[2,3-a][1,3,5]triazin-5-ylamino]ethyl)phenol (ZM 241385) (A2A antagonist). 2 All the adenosine analogues used induced vasodilation at concentrations between 10 nm and 1 microm, and the potency order was NECA > CGS 21680 > 2CADO > CPA=IBMECA >> adenosine, indicating an action at A2A receptors. 8-SPT (50 microm) antagonized vasodilator responses to NECA with an apparent pKB of 5.4, consistent with an action at A1 or A2 receptors and confirming that A3 receptors are not involved in this response. 3 DPCPX (10 nm) had no effect on vasodilation evoked by NECA, suggesting that this response was not mediated via A1 receptors, while ZM 241385 (10 nm) antagonized dilator responses to NECA with an apparent pKB of 8.9 consistent with an action via A2A receptors. 4 Overall these results suggest that adenosine A2A receptors mediate vasodilation in the hamster cheek pouch in vivo.

Management of extensive cervical nodal metastasis in nasopharyngeal carcinoma after radiotherapy: a clinicopathological study

OBJECTIVES

To evaluate the efficacy of afterloading brachytherapy following radical neck dissection (RND) in the management of extensive cervical lymph node disease in nasopharyngeal carcinoma after radiotherapy; and to examine prospectively prognostic factors and the pathologic behavior of neck disease.

PATIENTS

Twenty-seven patients with nasopharyngeal carcinoma who had extensive cervical lymph node metastasis following external radiotherapy were treated with RND. Thirteen of them also underwent afterloading brachytherapy with iridium wire (Ir 192). The RND specimens of the 27 patients were also examined with step serial whole-specimen sectioning.

RESULTS

All patients survived and their wounds healed primarily. Pathologic examination revealed 183 tumor-bearing lymph nodes that contained tumors in the neck: level I, 4% (8/183); level II, 53% (96/183); level III, 34% (62/183); level IV, 5% (9/183); and level V, 4% (8/183). Extracapsular tumor extension was seen in 84% of patients. Multivariate analysis identified the number of tumor-bearing lymph nodes detected in the specimens to be the only significant factor that affected control of disease. Although the neck disease in the group of patients who had afterloading brachytherapy was more extensive, the 3-year actuarial tumor control for the groups with and without brachytherapy were 60% and 61%, respectively.

CONCLUSIONS

Recurrent cervical lymph nodes after radiotherapy in nasopharyngeal carcinoma are extensive and RND is mandatory for a successful salvage. When the nodal metastasis infiltrate or adhere to surrounding tissue, afterloading brachytherapy with iridium wire can provide satisfactory local tumor control.

Comparative analysis of the expression of the Epstein-Barr virus (EBV) anti-apoptotic gene BHRF1 in nasopharyngeal carcinoma and EBV-related lymphoid diseases

Epstein-Barr virus (EBV) has been identified in a wide range of neoplastic and non-neoplastic disorders. The EBV open reading frame BHRF1 encodes a protein with partial sequence and functional homology to the anti-apoptotic onco-protein Bcl-2 and may therefore have a role in the proliferation of EBV positive cells. We have developed a rat monoclonal antibody against pBHRF1, which can detect BHRF1 in paraffin sections. While a number of mutant versions of BHRF1 were recognised, the monoclonal did not detect the BHRF1 homologue encoded by Herpesvirus papio or two mutants with deletions in the BH2 region. This novel rat monoclonal antibody (6A9) was used to examine tissue sections from 39 cases of non-keratinising undifferentiated nasopharyngeal carcinoma (NPC), 6 cases of metastatic NPC, 7 cases of EBV-positive NPC with squamous differentiation from Chinese patients, 15 cases of EBV-positive post-transplant lymphoproliferative disorder (PTLD), 6 EBV-containing lymphoblastoid cell lines, and 2 cases of oral hairy leukoplakia (OHL). In 11 cases of undifferentiated NPC, RT-PCR data were available for comparison with the immunohistochemistry. Both cases of OHL and two cases of LCL were positive for BHRF1 but none of the PTLD showed positive staining. All cases of undifferentiated NPC were positive for Bcl-2 but only one BHRF1 positive cell was identified in 1 of 39 cases of primary undifferentiated NPC. The 6A9 antibody produced less background staining and no nuclear positivity compared with the commercially available mouse monoclonal 5B11. It is concluded that BHRF1 can not be detected by immunohistochemistry in NPC and therefore it appears not to play a significant anti-apoptotic role in the progression of this EBV-associated tumour. The 6A9 monoclonal appears to be superior to 5B11 for the detection of pBHRF1 in tissue sections.