Study protocol for The GOAL Trial: comprehensive geriatric assessment for frail older people with chronic kidney disease to increase attainment of patient-identified goals-a cluster randomised controlled trial

BACKGROUND

An increasing number of older people are living with chronic kidney disease (CKD). Many have complex healthcare needs and are at risk of deteriorating health and functional status, which can adversely affect their quality of life. Comprehensive geriatric assessment (CGA) is an effective intervention to improve survival and independence of older people, but its clinical utility and cost-effectiveness in frail older people living with CKD is unknown.

METHODS

The GOAL Trial is a pragmatic, multi-centre, open-label, superiority, cluster randomised controlled trial developed by consumers, clinicians, and researchers. It has a two-arm design, CGA compared with standard care, with 1:1 allocation of a total of 16 clusters. Within each cluster, study participants ≥ 65 years of age (or ≥ 55 years if Aboriginal or Torres Strait Islander (First Nations Australians)) with CKD stage 3-5/5D who are frail, measured by a Frailty Index (FI) of > 0.25, are recruited. Participants in intervention clusters receive a CGA by a geriatrician to identify medical, social, and functional needs, optimise medication prescribing, and arrange multidisciplinary referral if required. Those in standard care clusters receive usual care. The primary outcome is attainment of self-identified goals assessed by standardised Goal Attainment Scaling (GAS) at 3 months. Secondary outcomes include GAS at 6 and 12 months, quality of life (EQ-5D-5L), frailty (Frailty Index - Short Form), transfer to residential aged care facilities, cost-effectiveness, and safety (cause-specific hospitalisations, mortality). A process evaluation will be conducted in parallel with the trial including whether the intervention was delivered as intended, any issue or local barriers to intervention delivery, and perceptions of the intervention by participants. The trial has 90% power to detect a clinically meaningful mean difference in GAS of 10 units.

DISCUSSION

This trial addresses patient-prioritised outcomes. It will be conducted, disseminated and implemented by clinicians and researchers in partnership with consumers. If CGA is found to have clinical and cost-effectiveness for frail older people with CKD, the intervention framework could be embedded into routine clinical practice. The implementation of the trial's findings will be supported by presentations at conferences and forums with clinicians and consumers at specifically convened workshops, to enable rapid adoption into practice and policy for both nephrology and geriatric disciplines. It has potential to materially advance patient-centred care and improve clinical and patient-reported outcomes (including quality of life) for frail older people living with CKD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04538157. Registered on 3 September 2020.

“Achieving Optimal Clinical Outcomes in Autologous Fat Grafting: A Systematic Review of Processing Techniques”

BACKGROUND

Autologous fat grafting (AFG) is a versatile technique in reconstructive and cosmetic surgery. Graft processing is a key source of variability resulting in unreliable clinical outcomes, with no consensus on the optimal methodology. This systematic review identifies the evidence base supporting different processing paradigms.

METHODS

A systematic literature search was conducted using the PubMed, Scopus and The Cochrane Foundation databases. Studies comparing AFG processing methods and reporting long-term patient outcomes were identified.

RESULTS

Twenty-four studies (2413 patients) were identified. Processing techniques evaluated included centrifugation, decantation, washing, filtration, gauze rolling, as well as commercial devices and adipose-derived stem/stromal cell (ASC) enrichment methods. Objective volumetric and subjective patient-reported outcomes were discussed. There was a variable reporting of complications and volume retention rates. Complications were infrequent; palpable cysts (0-20%), surgical-site infections (0-8%) and fat necrosis (0-58.4%) were the most reported. No significant differences in long-term volume retention between techniques were found in AFG in the breast. In head and neck patients, greater volume retention was documented in ASC enrichment (64.8-95%) and commercial devices (41.2%) compared to centrifugation (31.8-76%).

CONCLUSIONS

Graft processing through washing and filtration, including when incorporated into commercial devices, results in superior long-term outcomes compared to centrifugation and decantation methods. ASC enrichment methods and commercial devices seem to have superior long-term volume retention in facial fat grafting.

The oncoprotective fever hypothesis: Have antibiotics, antimalarials and antipyrectics contributed to the global rise in cancer over the past century?

The adaptive and therapeutic nature of fever has been recognized for centuries and both local and systemic thermotherapy are now used to enhance the effectiveness of both chemotherapy and radiation therapy for cancer. We propose that the success of antiseptic, antibiotic, antipyretic and antimalarial strategies and medications over the past century and a half may have had the unintended effect of releasing precancerous growths and neoplastic foci from the inhibitory effects of intermittent fever. This may be a previously unrecognized factor in the overall rise in cancer rates in the late 19th and early 20th centuries.

The role of cardiovascular magnetic resonance imaging with T1 and T2 mapping in sudden cardiac death survivors

Background

Sudden cardiac death (SCD) in the adult population is poorly studied, although determining its etiology is crucial for management and prognosis [1]. Cardiovascular magnetic resonance imaging (CMR) is being increasingly utilized in SCD survivors [1,2]. The role of late gadolinium enhancement (LGE) imaging in patients with recent SCD and no significant coronary artery disease (CAD) is well established, but there is no data on the additive role of T1 and T2 mapping [1–3].

Purpose

This is a retrospective study to assess the role of CMR including T1 and T2 mapping in SCD survivors.

Methods

Between 01/2016 and 12/2019, we retrospectively analyzed patients who underwent CMR on a Siemens Magnetom Avanto 1.5 T scanner within 4 weeks of SCD. CMR protocol included cine imaging, T1 and T2 mapping, and LGE imaging. Native and post-contrast myocardial T1 values were measured within the septum on the mid short axis (SAX) and extracellular volume fraction was calculated using the standard formula. T2 values were measured in six mid segments on the mid SAX map. Additional measurements were performed if long axis T2 maps were available. Clinical data, electrocardiography (ECG), transthoracic echocardiography (TTE), coronary computed tomography angiography (CCTA), and left heart catheterization (LHC) were reviewed from the electronic health record. An ischemic evaluation was performed in 33 (94%) of patients.

Results

A total of 35 patients who underwent CMR for SCD were included for analysis (mean age 46.9±14.1 years; 20 (57%) male). SCD etiology was established based on clinical data, ECG, TTE, CCTA, and LHC in 9 (26%) patients. CMR provided the most probable SCD etiology in an additional 20 (57%) patients with T1 and T2 mapping abnormalities seen in 18 (51%) patients. Diagnoses determined by CMR included myocarditis (35%), hypertrophic cardiomyopathy (CMP) (20%), left ventricular non-compaction CMP (15%), dilated CMP (10%), takotsubo CMP (5%), and myocardial infarction with non-obstructive CAD (15%) (Table, Figure). Elevated native T1 was seen in 15 (43%) (mean T1 1069±60 ms; site specific normal <1080 ms), elevated ECV in 16 (46%) (30±7%; site specific normal <29%), and elevated native T2 in 22 (63%) patients (65±10 ms; site specific normal <60 ms). LGE was present in 31 (89%) patients. The etiology of SCD remained unknown in 6 (17%) patients despite extensive testing including CMR.

Conclusions

CMR has significant diagnostic and prognostic value in assessing SCD etiology compared to non-CMR based evaluation. Myocarditis is a common underdiagnosed cause of SCD in adult patients well seen in a CMR protocol with T1 and T2 mapping. Myocardial inflammation monitoring in SCD survivors with serial CMRs using T1 and T2 mapping could influence clinical decision making by justifying pharmacotherapy modification and timing of ICD implantation. To conclude, CMR with T1 and T2 mapping provides high diagnostic yield in the investigation of SCD etiology.

Funding Acknowledgement

Type of funding sources: None.

Evaluation of Smear Layer Removal and Antimicrobial Efficacy of HybenX Against Enterococcus Faecalis Biofilm

To evaluate the antibacterial efficacy of HybenX, an endodontic irrigant against Enterococcus faecalis biofilm and determine its efficacy in removal of smear layer. Forty root canals were inoculated with E. faecalis for three weeks, divided into 4 groups and irrigated with: Group1: 5 ml 2.5% sodium hypochlorite; Group2: 5 ml 2% chlorhexidine gluconate; Group3: 5 ml HybenX; Group4: 5 ml distilled water (control). Dentin shavings were collected and plated on agar plates, followed by colony forming unit (CFU) determination. For smear layer removal examination, 30 single rooted teeth were instrumented and divided into 3 groups and treated with: GroupI: 5 ml of 17% EDTA; GroupII:5 ml of HybenX; and GroupIII: 5 ml of distilled water. Samples were then subjected to SEM examination. All irrigants showed a significant reduction in CFUs compared to the control group (P⟨ .001), but none compared to each other. Regarding smear layer removal in the apical third, EDTA removed smear layer more effectively than HybenX (P = .014). HybenX demonstrated good antimicrobial efficacy against E. faecalis biofilm and removed the smear layer effectively in coronal and middle third of the root canal system. HybenX can be considered as a promising irrigating agent in root canal treatment of infected teeth.

In Vitro Evaluation of Substantivity, Staining Potential, and Biofilm Reduction of Guava Leaf Extract Mouth Rinse in Combination with its Anti-Inflammatory Effect on Human Gingival Epithelial Keratinocytes

This study aimed to assess the biofilm reduction, staining potential, and cytotoxicity of guava extract mouth rinse compared to chlorhexidine (CHX). Substantivity, staining, and antibiofilm potential were investigated by spectrophotometry, colony-forming units, and luminosity color meter, respectively. The cell viability assay was conducted using a colorimetric assay to determine nontoxic levels of guava (0.15%) and CHX in human gingival epithelial keratinocytes (HGEK-16). Cells were treated with lipopolysaccharides (LPS, 1μg/mL) and guava to assess inflammatory gene expression levels of interleukin-β1, tumor necrosis factor-α, and Prostaglandin E2. A scratch wound healing assay investigated the effects of guava on cell migration. The teeth coated in guava mouth rinse displayed 19.4% higher substantivity compared to CHX (0.2%), and the anti-biofilm reduction was observed with both guava and CHX mouth rinses (P < 0.05). The overall discoloration changes were higher with CHX and distilled water compared to guava. Also, guava significantly enhanced HGEK-16 cell viability (P < 0.05), and IL-β1, TNFα and PGE2 expression presented a 0.6-fold decrease when exposed to guava and LPS (P < 0.05). The present study showed that guava mouth rinse fulfilled the requirement for an effective and useful oral care product with desirable substantivity and anti-biofilm action. In addition, guava reduced the inflammation response in HGEK-16 and may be a potential oral rinse for oral anti-inflammatory therapies.

Systematic review of methodologies used to assess mastectomy flap viability

BACKGROUND

Accurate prediction of mastectomy skin flap viability is vital as necrosis causes significant morbidity, potentially compromising results and delaying oncological management. Traditionally assessed by clinical judgement, a more objective evaluation can be provided using intraoperative imaging modalities. This systematic review aimed to compare all intraoperative techniques for assessment of mastectomy flap viability.

METHODS

A systematic literature review was performed using MEDLINE and Embase databases. Primary outcomes reported included specificity, sensitivity and predictive values of each test, and mean rates of mastectomy flap necrosis and reoperation. Secondary outcomes included cost analysis.

RESULTS

Some 18 studies were included. Designs were prospective cohort study (8), retrospective case series (4), prospective case series (3), retrospective case-control study (1), prospective pilot trial (1) and cost analysis study (1). The studies compared indocyanine green angiography (ICGA) (16 studies) and fluorescein dye angiography (FA) (3 studies) with clinical judgement. Sensitivity and specificity were highest for ICGA (5 studies) ranging from 38 to 100 and 68 to 91 per cent respectively. Both methods overpredicted necrosis. Mean rates of flap necrosis and reoperation decreased with ICGA (7·9 and 5·5 per cent respectively) and FA (3 and 0 per cent) compared with clinical judgement (19·4 and 12·9 per cent). Two studies were designed to define numerical parameters corresponding to perfusion using intraoperative techniques. Two studies performed a cost analysis for ICGA; one claimed a cost benefit and the other advocated its use in high-risk patients only.

CONCLUSION

ICGA and FA are potentially useful tools for mastectomy flap assessment. However, the predictive accuracy is subject to the specific settings and model of equipment used. Current recommendations support their use in high-risk patients.

POEMS syndrome associated with plasmacytoma of the clivus: "Time discovers the truth"

Polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes (POEMS) syndrome is characterized by the presence of a monoclonal plasma cell disorder, peripheral neuropathy, and one or more of the following features: Osteosclerotic myeloma, Castleman's disease (angiofollicular lymph node hyperplasia), increased levels of serum vascular endothelial growth factor (VEGF), organomegaly, endocrinopathy, edema, typical skin changes, and papilledema. [1] Solitary plasmacytomas most frequently occur in the bone but can also be found in soft tissues (extramedullary plasmacytoma). [2] We report a case that showed a rare association of POEMS syndrome with a plasmacytoma of the clivus.

Metal pollution of groundwater in the vicinity of Valiathura Sewage Farm in Kerala, south India

A comprehensive study was conducted to evaluate metal pollution of groundwater in the vicinity of Valiathura Sewage Farm in Thiruvananthapuram district, Kerala using the Heavy Metal Pollution Index (HPI). Forty two groundwater samples were collected during the summer season (April 2010) and the concentration of metals Fe, Cu, Zn, Cd and Pb were analyzed. Results showed that groundwater was contaminated mainly with Fe, Cu and Pb. Correlation analysis revealed that the sources of metals in groundwater in the study area are the same, and it may be due to the leachates from the nearby Sewage Farm, Parvathy Puthanar canal and solid wastes dumped in the residential area. Of the groundwater samples studied, 47.62 % were medium and 2.68 % were classified in HPI high category. HPI was highest (41.79) in DW29, which was adjacent to the polluted Parvathy Puthanar canal and Sewage Farm. The present study points out that the metal pollution causes the degradation of groundwater quality around the Sewage Farm during the study period.

Frequency analysis of medical concepts in clinical trials and their coverage in MeSH and SNOMED-CT

BACKGROUND

Eligibility criteria (EC) of clinical trials play a key role in selecting appropriate study candidates and the validity of the outcome of a clinical trial. However, in most cases EC are provided in unstandardised ways such as free text, which raises significant challenges for machine-readability.

OBJECTIVES

To establish a list of most frequent medical concepts in clinical trials with semantic annotations. This concept list contributes to standardisation of EC and identifies relevant data items in electronic health records (EHRs) for clinical research. The coverage of the list in two major clinical vocabularies, MeSH and SNOMED-CT, will be assessed.

METHODS

Four hundred and twenty-five clinical trials conducted between 2000 and 2011 at a German university hospital were analysed. 6671 EC were manually annotated by a medical coder using Concept Unique Identifiers (CUIs) provided by the Unified Medical Language System. Two physicians performed a semi-automatic CUI code revision. Concept frequency was analysed and clusters of concepts were manually identified.A binomial significance test was applied to quantify coverage differences of the most frequent concepts in MeSH and SNOMED-CT.

RESULTS

Based on manual medical coding of 425 clinical trials, 7588 concepts were identified, of which 5236 were distinct. A top 100 list containing 101 most frequent medical concepts was established. The concepts of this list cover 25 % of all concept occurrences in all analysed clinical trials. This list reveals six missing entries in SNOMED-CT, 12 in MeSH. The median of EC frequency per trial has increased throughout the trial years (2000 -2005: 8 EC/trial, 2011: 14 EC/trial).

CONCLUSIONS

Relatively few concepts cover one quarter of concept occurrences that represent EC in recent studies. Therefore, these concepts can serve as candidate data elements for integration into EHRs to optimise patient recruitment in clinical research.

Subcutaneous panniculitis like T cell lymphoma associated with erythromelalgia

Erythromelalgia is a rare disorder that simulates a small fiber neuropathy and patients often have painful erythematous extremities during episodes. It is of two types: A primary or inherited form that is sometimes associated with a Na channel mutation or a secondary disorder associated with an underlying systemic disorder. We present a 19-year-old boy who presented to us with erythromelalgia and a febrile illness with systemic rash. Detailed work-up revealed another unusual condition: Subcutaneous panniculitis like T cell lymphoma (SPTCL). This is the first report of an association of erythromelalgia with SPTCL.

Renal function and cardiovascular risk profile after conversion from ciclosporin to tacrolimus: prospective study in 80 liver transplant recipients

BACKGROUND

Increased risk of cardiovascular and cerebrovascular disease in liver transplant recipients results in particular from the side effects of calcineurin inhibitor-based immunosuppressive therapy. Several studies have demonstrated a more favourable outcome for patients receiving tacrolimus (TAC) as compared with ciclosporin (CS).

AIM

To investigate the effects of conversion from CS to TAC on cardiovascular risk factors and renal function in liver transplant recipients.

METHODS

In a prospective study, all except two patients had chronic kidney disease stages 2-4 (n = 80), according to estimated glomerular filtration rate using the abbreviated Modification of Diet in Renal Disease equation.

RESULTS

Conversion was accompanied with a mean decrease of total cholesterol from 194.6 +/- 54.0 mg/dL to 175.8 +/- 44.2 mg/dL (P < 0.001), low density lipoprotein cholesterol from 106.7 +/- 39.2 mg/dL to 90.9 +/- 28.6 mg/dL (P < 0.001) and mean arterial blood pressure values from 102.2 +/- 13.2 mm Hg to 95.9 +/- 11.7 mm Hg (P < 0.001). Renal function remained stable. No cases of de novo diabetes mellitus were identified. The Framingham risk score was significantly reduced from 5.2 +/- 4.4 at baseline to 4.4 +/- 5.3 after 12 months (P = 0.006).

CONCLUSIONS

Conversion from CS to TAC has been shown to improve the cardiovascular risk profile and may retard further decline of renal function after liver transplantation.

Malignant phyllodes tumour with intraductal and invasive carcinoma and lymph node metastasis

Phyllodes tumours constitute 2-3 percent of fibroepithelial breast tumours, with a 1-2 percent rate of malignancy. Metastasis is usually haematogeneous, and axillary lymph node dissection is not routinely performed. Carcinoma in a phyllodes tumour is distinctly uncommon, but has been known to occur in benign phyllodes tumours. We describe a 51-year-old woman with a malignant phyllodes tumour with foci of intraductal carcinoma within the tumour and adjacent breast tissue. Though the carcinoma was found to be invasive based on the presence of carcinomatous lymph node metastasis, extensive sampling did not yield an invasive component within the breast, probably because of the marked stromal overgrowth of the phyllodes. A malignant phyllodes tumour with foci of intraductal carcinoma and axillary lymph node metastases was diagnosed rather than carcinosarcoma. Chemotherapy and irradiation were included in the postoperative management. Coexistence of phyllodes tumour and carcinoma is rare, and extensive sampling may be necessary to find the foci of carcinoma within an extensive and obviously malignant stromal overgrowth. There is little consensus on the treatment and prognosis in these cases, and it is recommended that treatment be tailored to individual patients, based on the presence of invasion, lymph node metastasis and/or distant metastasis.

Predictors of variceal bleed among patients with liver cirrhosis in the era of sclerotherapy

INTRODUCTION

Variceal bleed is a common complication of portal hypertension. The bleed pattern has changed considerably with the introduction of variceal band ligation. The bleed pattern in developing countries where sclerotherapy continues to remain a viable option is not known. The aim of the study was to determine the predictors of first and subsequent bleed in individuals with liver cirrhosis.

METHODS

205 subjects with liver cirrhosis and portal hypertension registered in the liver clinic between January and June 2004, were followed-up for 18 months after registration. Bleeders already on pharmacotherapy or endotherapy were excluded. Patient details included age, gender, duration of illness, aetiology, Child-Pugh-Turcotte score and grades of oesophageal varices, details of index and subsequent variceal bleed, and complications during follow-up. Logistic regression multivariate analysis was applied to predict the factors influencing variceal bleed.

RESULTS

There were 95 variceal bleeders and 110 non-bleeders. Age at presentation and gender did not predict a variceal bleed. Grades III and IV oesophageal varices and fundal varices were the significant risk factors for an index bleed (p-value is 0.001). 27 of the 95 bleeders (28.3 percent) had a second bleed after a mean interval of 8 (+/- 7.7) months. Predictors of rebleed were similar to the index bleed. Predictors of index bleed were also similar to those who had bled for the first time after registration. Overall bleed-related mortality was low (2.1 percent).

CONCLUSION

Higher grades of varices, presence of cherry-red spots and fundal varices predicted variceal bleed in patients with liver cirrhosis. Variceal bleed-related mortality was low in the era of sclerotherapy.

Aβ Produced as a Fusion to Maltose Binding Protein Can Be Readily Purified and Stably Associates with Copper and Zinc

The 42 amino acid Alzheimer's Abeta peptide has been produced in E. coli as a soluble fusion to maltose binding protein (MBP). Affinity purification on amylose columns of MBP-Abeta and MBP led to the recovery of proteins at purities that were suited for physicochemical analyses. MBP-Abeta was able to bind approximately 2 mole equivalents of copper or 4 mole equivalents of zinc, while MBP alone bound negligible amounts of zinc or copper. We conclude that Abeta can bind 2 copper or 4 zinc ions in its fusion format. Because MBP-Abeta is a convenient protein to work with, this system is well suited for further studies on the structure of Abeta and its interactions with metals.

Combined femoral and Chiari osteotomies for reconstruction of the painful subluxation or dislocation of the hip in cerebral palsy. A long-term outcome study

In order to treat painful subluxation or dislocation secondary to cerebral palsy, 11 patients (12 hips) underwent combined femoral and Chiari pelvic osteotomies with additional soft-tissue releases at a mean age of 14.1 years (9.1 to 17.8). Relief of pain, improvement in movement of the hip, and in sitting posture, and ease of perineal care were recorded in all, and were maintained at a mean follow-up of 13.1 years (8 to 17.5). The improvement in general mobility was marginal, but those who were able to walk benefited the most. The radiological measurements made before operation were modified afterwards to use the lateral margin of the neoacetabulum produced by the pelvic osteotomy. The radiological migration index improved from a mean of 80.6% (61% to 100%) to 13.7% (0% to 33%) (p < 0.0001). The mean changes in centre edge angle and Sharp's angle were 72 degrees (56 degrees to 87 degrees; p < 0.0001) and 12.3 degrees (9 degrees to 15.6 degrees; p < 0.0001), respectively. Radiological evidence of progressive arthritic change was seen in one hip, in which only a partial reduction had been achieved, and there was early narrowing of the joint space in another. Painless heterotopic ossification was observed in one patient with athetoid quadriplegia. In seven hips the lateral Kawamura approach, elevating the greater trochanter, provided exposure for both osteotomies and allowed the construction of a dome-shaped iliac osteotomy, while protecting the sciatic nerve.

New regio-, stereo-, diastereo- and enantioselective one-pot reactions mediated by organometallic derivatives

In the first part of the lecture, we will discuss the one-pot preparation of chiral homoallylic alcohol and amine derivatives by a copper-catalyzed four-component reaction. In this process, three new carbon-carbon bonds as well as a quaternary and a tertiary chiral center are created with excellent regio- and diastereoselectivities. When the reaction was performed without adding external electrophiles, a β-elimination reaction took place to give polysubstituted allenes in good overall yields. This strategy of zinc-homologation followed by a β-elimination reaction was also synthetically used for the transformation of sp3 sulfoxides into olefins with potential application in asymmetric synthesis. Finally, in the second part of this lecture, the stereoselective preparation of metallated dienes in only two chemical steps from commercially available products will be described. This new strategy is based on a tandem allylic C-H bond activation of a remote ω-double bond followed by an elimination reaction.

VDAC is a conserved element of death pathways in plant and animal systems

Programmed cell death (PCD) is very much a part of plant life, although the underlying mechanisms are not so well understood as in animals. In animal cells, the voltage-dependent anion channel (VDAC), a major mitochondrial outer membrane transporter, plays an important role in apoptosis by participating in the release of intermembrane space proteins. To characterize plant PCD pathways by investigating the function of putative components in a mammalian apoptotic context, we have overexpressed a rice VDAC (osVDAC4) in the Jurkat T-cell line. Overexpression of osVDAC4 induces apoptosis, which can be blocked by Bcl-2 and the VDAC inhibitor DIDS. Modifying endogenous VDAC function by DIDS and hexokinase II (HxKII) in Jurkat cells inhibits mitochondria-mediated apoptotic pathways. Finally, we show that DIDS also abrogates heat-induced PCD in cucumber cotyledons. Our data suggest that VDAC is a conserved mitochondrial element of the death machinery in both plant and animal cells.

Caspase-3 activation is an early event and initiates apoptotic damage in a human leukemia cell line

Many apoptotic pathways culminate in the activation of caspase cascades usually triggered by the apical caspases-8 or -9. We describe a paradigm where apoptosis is initiated by the effector caspase-3. Diethylmaleate (DEM)-induced apoptotic damage in Jurkat cells was blocked by the anti-apoptotic protein Bcl-2, whereas, a peptide inhibitor of caspase-3 but not caspase-9 blocked DEM-induced mitochondrial damage. Isogenic Jurkat cell lines deficient for caspase-8 or the adaptor FADD (Fas associated death domain) were not protected from DEM-induced apoptosis. Caspase-3 activation preceded that of caspase-9 and initial processing of caspase-3 was regulated independent of caspase-9 and Bcl-2. However, inhibitors of caspase-9 or caspase-6 regulated caspase-3 later in the pathway. We explored the mechanism by which caspase-3 processing is regulated in this system. DEM triggered a loss of Erk-1/2 phosphorylation and XIAP (X-linked inhibitor of apoptosis protein) expression. The phorbol ester PMA activated a MEK-dependent pathway to block caspase-3 processing and cell death. Constitutively active MEK-1 (CA-MEK) upregulated XIAP expression and exogenous XIAP inhibited DEM-induced apoptotic damage. Thus, we describe a pathway where caspase-3 functions to initiate apoptotic damage and caspase-9 and caspase-6 amplify the apoptotic cascade. Further, we show that MEK may regulate caspase-3 activation via the regulation of XIAP expression in these cells.

Predictive value of benign percutaneous adrenal biopsies in oncology patients

PURPOSE

Percutaneous CT guided biopsy is accepted as a safe procedure for the diagnosis of indeterminate adrenal masses in oncologic patients. The purpose of this study was to evaluate the accuracy of a 'negative for tumour' adrenal biopsy in the oncologic patient population by assessing subsequent outcome including clinical course, size and imaging characteristics of the adrenal lesions on follow-up imaging studies and pathological findings at re-biopsy or following adrenal mass resection.

MATERIALS AND METHODS

Retrospective analysis of 225 oncological patients (FM, 128;87; age range 33-87 years, mean age 66 years) who had undergone CT guided biopsies of an adrenal mass over a 5-year period was performed. Those patients with a report consistent with 'negative for malignancy' were evaluated by reviewing the medical records for patient demographics, primary malignancy, histology of adrenal tumour, subsequent surgical interventions, repeat adrenal biopsy under image guidance, by open surgery or at autopsy, subsequent abdominal imaging in which the adrenal gland was imaged, and long-term outcome including hospital admissions, or death.

RESULTS

Of the 225 CT-guided adrenal biopsies performed, 41 (18%) were negative for neoplasm. The primary neoplasm in these 41 patients included lung cancer (n=32), breast (n=5), renal cell carcinoma (n=2), bladder (n=1), and prostate (n=1). The size of the adrenal lesions ranged from 2.8-5 cm. Of the 41 biopsies, which were negative for tumour; 10 were identified as adenomas and the rest showed benign adrenal cortical cells or hyperplasia on cytopathology and histopathology. Repeat biopsies were obtained in 13/41 (31%) patients; whereas 2/41 (5%) had their adrenal gland analyzed on post mortem examination. None of these 15 repeat evaluations yielded tumour.

CONCLUSION

In oncological patients, pathological analysis of tissue samples obtained by CT-guided percutaneous biopsy, suggesting benign aetiology, is reliable and predicts a benign course on long-term follow-up. A negative or benign pathology result for a CT guided percutaneous adrenal biopsy can be regarded as a true negative evaluation in oncological patients with no necessity to repeat the biopsy.

Prospective comparison of MRA with catheter angiography in the assessment of patients with aortoiliac occlusion before surgery or endovascular therapy

AIM

The purpose of this study was to evaluate the usefulness of gadolinium enhanced 3D magnetic resonance (MR) angiography (CE MRA) as an alternative to translumbar or brachial angiography in the pre-operative work-up of patients with aortoiliac occlusion.

MATERIALS AND METHODS

Nineteen patients (14 men and five women; age range 45-77 years; mean 62 years), not suitable for perfemoral angiography (aortoiliac occlusion, n = 18; infected femoro-femoral graft with femoral artery pseudoaneurysm, n = 1), underwent pre-operative CE MRA and catheter angiography (translumbar, n = 5; brachial, n = 14). CE MRA was performed using a 3D fast spoiled gradient-recalled pulse sequence during the intravenous injection of 40 ml of gadolinium DTPA and a 32-s breath-hold. All patients subsequently underwent surgical (n = 13) or percutaneous transluminal (n = 6) treatment for their vascular disease. The accuracy of CE MRA was determined compared with the findings at catheter angiography taken as the gold standard.

RESULTS

CE MRA gave accurate information about the occlusion, inflow and distal run-off in the majority of patients. CE MRA revealed occlusions with an accuracy of 94.7% in the aortic segment, 98.7% in the iliac segment, and 100% in the common femoral segment. The arterial segments distal to the common femoral artery were not completely visualized in four patients but CE MRA provided sufficient information to plan either surgical or percutaneous transluminal therapy in all but one patient.

CONCLUSION

CE MRA is highly accurate in showing the presence and extent of aortoiliac occlusions. In our study group, CE MRA gave sufficient information in the pre-operative evaluation of aortoiliac occlusion.

The role of maternal affect mirroring on social expectancies in three-month-old infants

The role of maternal affect mirroring on the development of prosocial behaviors and social expectancies was assessed in forty-one 2- to 3-month-old infants. Prosocial behavior was characterized as infants' positive behavior and increased attention toward their mothers. Social expectancies were defined as infants' expectancy for affective sharing. Mothers and infants were observed twice, approximately 1 week apart. During Visit 1, mothers and infants were videotaped while interacting over television monitors for 3 min. During Visit 2, infants engaged in a live, 3-min interaction with their mothers over television monitors (live condition) and they also viewed a replay of their mothers' interaction from the preceding week (replay condition). The order of conditions was counterbalanced. Maternal affect mirroring was measured according to the level of attention maintenance, warm sensitivity, and social responsiveness displayed. A natural split was observed with 58% of the mothers ranking high and 42% ranking low on these affect mirroring measures (HAM and LAM, respectively). Infants in the HAM group ranked high on prosocial behaviors and social expectancy--they discriminated between live and replay, conditions with smiles, vocalizations, and gazes. Infants in the LAM group ranked low on these variables--they gazed longer during the live condition than during the replay condition, but only when the live condition was presented first; however, they did not smile or vocalize more. These findings indicate that there is a relation between affect mirroring and social expectancies in infants.

The role of calpain in caspase activation during etoposide induced apoptosis in T cells

T cells treated with the drug etoposide undergo apoptotic death characterized by early evidence of nuclear damage followed by loss of mitochondrial integrity and cell lysis. Calpains and caspases are cytoplasmic proteases and there is increasing evidence of cross-talk between these proteases in death pathways. In this study we have investigated the role of calpain, in etoposide-triggered apoptosis in the 2B4 murine T cell hybridoma. Cell permeable inhibitors of calpain, ALLnM, E64 and calpeptin that block Fas ligand-Fas-mediated death in T cells, blocked etoposide-induced nuclear damage, loss of mitochondrial integrity and cell lysis. A broad spectrum peptide inhibitor of caspases, ZVAD-fmk, partially blocked nuclear damage but poorly inhibited mitochondrial damage or cell lysis triggered by etoposide. Etoposide-induced expression of the cleaved, proteolytically active form of caspase 3, and DEVD-ase activity, detected prior to nuclear damage, were blocked in the presence of calpain inhibitors. Collectively, these data describe a role for calpain in regulating etoposide-induced apoptosis via a caspase-dependent pathway in T cells.

Inhibition of p38 Kinase Reveals a TNF-α-Mediated, Caspase-Dependent, Apoptotic Death Pathway in a Human Myelomonocyte Cell Line

TNF-alpha transduces signals of survival or death via its two receptors, R1/p55/p60 and RII/p80/p75. The role of caspases as effectors of cell death is universally accepted, although caspase inhibitors may potentiate TNF cytotoxicity in some instances. In conditions when macromolecular synthesis is blocked, caspases are part of the machinery that executes TNF-triggered apoptotic death in U937, a human myelomonocyte cell line, and in the Jurkat T cell line. However, inhibition of p38 mitogen-activated protein kinase (p38 MAPK) triggered TNF cytotoxicity in U937 cells and murine splenic macrophages, but not the Jurkat cell line. TNF induced expression of the antiapoptotic protein c-IAP2 (cytoplasmic inhibitor of apoptosis protein 2), and was blocked in the presence of a p38 MAPK inhibitor, which also induced caspase-dependent, TNF-mediated apoptosis in U937 cells. Thus, inhibition of p38 MAPK resulted in the activation of caspase 9 and cleavage of the adaptor molecule BH3 interacting domain death agonist, and blocked NF-kappaB-mediated transactivation, without affecting the nuclear translocation of NF-kappaB. Collectively, these data show that activation of p38 MAPK is critical to cell survival by TNF in U937 cells, and demonstrate lineage-specific regulation of TNF-triggered signals of activation or apoptosis.

Sialidase inhibitors related to zanamivir. Further SAR studies of 4-amino-4H-pyran-2-carboxylic acid-6-propylamides

SAR investigations of the 4- and 5-positions of a series of 4-amino-4H-pyran-2-carboxylic acid 6-carboxamides are reported. Potent inhibitors of influenza A sialidase with marked selectivity over the influenza B enzyme were obtained when the basic 4-amino substituent was replaced by hydroxyl or even deleted. Modifications at the 5-position exhibited a tight steric requirement, with trifluoroacetamide being optimal.

Role of sialylation in determining the pharmacokinetics of neutrophil inhibitory factor (NIF) in the Fischer 344 rat

1. Recombinant neutrophil inhibitory factor (NIF) is a glycoprotein. Its amino acid sequence remains constant and has a molecular weight of 28.9 kD. However, approximately 40% of the total molecular weight consists of glycans with variable structure. 2. The pharmacokinetics of 11 different NIF batches with varying extents and patterns of sialylation have been investigated in the Fischer 344 rat following intravenous administration. These data indicate that reducing the extent of NIF sialylation reduces the half-life of the molecule due to an increase in the systemic clearance. Also, an increase in the number of unsialylated or neutral glycans may increase the volume of distribution of NIF, although this effect is marginal. 3. Isolated perfused rat liver (IPRL) investigations have shown that sialylated NIF has a low hepatic extraction (< 1%), while asialo NIF has an extraction that is > 20-fold higher. Co-administration of asialo NIF with asialo fetuin (a protein cleared by hepatic asialoglycoprotein receptor (possibly galactose)-mediated uptake reduced the hepatic extraction of asialo NIF. 4. These data suggest that NIF molecules that have free sugar moieties (possibly galactose) interact with an asialoglycoprotein receptor (possibly galactose-mediated) in the liver (parenchymal cells/hepatocytes). Interaction with this receptor leads to cellular internalization and degradation.

The efficacy, tolerability and safety of diethylcarbamazine-fortified salt in the treatment of the microfilaraemias of brugian filariasis: an open, hospital-based study

Cooking salt fortified with diethylcarbamazine (DEC) has been successfully used to control lymphatic filariasis in several parts of the world. The kinetics and efficacy of DEC-fortified salt in clearing microfilaraemias of Brugia malayi and the salt's tolerability and safety are examined in this study. Twenty individuals with B. malayi microfilaraemias (pre-treatment levels of 108-6358 microfilariae/ml; median = 309/ml) consumed DEC-fortified salt (0.2%, w/w) with their food for 1 year, initially in hospital (for 1 week) and later at home. The mean daily intake of DEC was 21.4 mg (range = 9.0-39.4 mg). Even on the first day of consuming the salt, there was a decrease in the microfilarial levels of 14 patients and a sharp increase in six patients. Microfilarial levels tended to fluctuate thereafter but there was a progressive, general decline. At the end of the study year, eight patients were amicrofilaraemic and microfilarial clearance was > 95% in 58% of the patients. Eight patients did not develop any adverse reactions. Lymph-node tenderness and enlargement were seen in eight patients (40%), and dilated, inflamed lymphatic channels standing out as cords ('string sign') were seen in another five patients. These reactions were transient and did not require any specific treatment. The DEC-fortified salt was well accepted by the study population. The DEC content of fortified salt and the duration of its use for the control of brugian filariasis need to be re-examined. Health education should include messages that mild, self-limiting, adverse reactions are likely to occur even with the use of such salt.

Dihydropyrancarboxamides related to zanamivir: a new series of inhibitors of influenza virus sialidases. 2. Crystallographic and molecular modeling study of complexes of 4-amino-4H-pyran-6-carboxamides and sialidase from influenza virus types A and B

The first paper in this series (see previous article) described structure-activity studies of carboxamide analogues of zanamivir binding to influenza virus sialidase types A and B and showed that inhibitory activity of these compounds was much greater against influenza A enzyme. To understand the large differences in affinities, a number of protein-ligand complexes have been investigated using crystallography and molecular dynamics. The crystallographic studies show that the binding of ligands containing tertiary amide groups is accompanied by the formation of an intramolecular planar salt bridge between two amino acid residues in the active site of the enzyme. It is proposed that the unexpected strong binding of these inhibitors is a result of the burial of hydrophobic surface area and salt-bridge formation in an environment of low dielectric. In sialidase from type A virus, binding of the carboxamide moeity and salt-bridge formation have only a minor effect on the positions of the surrounding residues, whereas in type B enzyme, significant distortion of the protein is observed. The results suggest that the decreased affinity in enzyme from influenza B is directly correlated with the small changes that occur in the amino acid residue interactions accompanying ligand binding. Molecular dynamics calculations have shown that the tendency for salt-bridge formation is greater in influenza A sialidase than influenza B sialidase and that this tendency is a useful descriptor for the prediction of inhibitor potency.

Abdominoscrotal hydrocoeles: little place for conservatism

Abdominoscrotal hydrocoeles (ASH) are infrequently reported in children. The presence of bilateral ASH is even rarer, with fewer than five cases reported to date. ASH are present at birth and tend to be progressive in nature. Spontaneous resolution has not been documented. The pathogenesis is uncertain and their presence in the neonatal period suggests a preformed abnormality of the processus vaginalis. Diagnosis is suspected on clinical examination and confirmed by ultrasonography, which is a reliable diagnostic tool. Undescended testes frequently coexist. Early surgery is the preferred management, and complications are frequent if left unattended. Surgery is simply an extension of a hernia operation, without the need for a laparotomy.

Estimation of ASO titer as an indicator of streptococcal infection precipitating acute adenolymphangitis in brugian lymphatic filariasis

Recurrent episodes of acute adenolymphangitis (ADL) are important clinical manifestations of lymphatic filariasis which contribute significantly to the progression of lymphedema. It is increasingly being recognized that secondary bacterial infections play an important role in the etiology of ADL. We examined the role of streptococcal infection as a precipitating factor of ADL in brugian filariasis, by determining the anti-streptolysin O (ASO) titers and by isolating the causative organism wherever possible. The study population consisted of 30 patients with filariasis related ADL (Group A), 30 patients with chronic filarial edema (Group B) and 60 age and sex matched healthy adults (Group C). ASO titer was estimated by the latex agglutination method at the time of entry into the study, at the 15th day and at 3, 6 and 12 months. ASO titers were persistently elevated in 90% of patients in Group A and a portal of entry for bacterial infection was detected in all of these patients. In Group B only six patients had persistently elevated ASO titers. These patients had grade III lymphedema and three of them had monilial infections in the affected limb. In the control group none had persistently elevated ASO titers. The elevated ASO titers and the detection of a site of entry for bacteria in patients with ADL supports a streptococcal etiology for this condition.

Large scale purification process for recombinant NS1-OspA as a candidate vaccine for Lyme disease

A purification process was developed for the manufacture of NS1-OspA as a candidate vaccine for Lyme disease. NS1-OspA was expressed as a soluble recombinant protein in E. coli from 50 and 200 liter fermentations. A multistep bench scale procedure, including detergent treatment, sonication, Q-Sepharose chromatography, dialysis, and SP-Sepharose chromatography, was used to effectively purify NS1-OspA from E. coli to > 90% purity with a 35% yield. This procedure was subsequently modified and specific steps eliminated to create a manufacturing scale process for the purification of NS1-OspA. Continuous flow centrifugation, mechanical lysis, QA-52 anion exchange chromatography, acid induced precipitation, and cross flow filtration gave a final purity of > 75%, a recovery of > 70%, and measured endotoxin levels of < 5 micrograms/mg of protein. Unique features of this process include using unclarified lysates and a single use (disposable) resin for the batch chromatography step. This simple, cost effective production process provides a recombinant protein with the yield and purity suitable for use as a subunit veterinary vaccine.

Secondary hyperparathyroidism, and not beta 2-microglobulin amyloid, as a cause of spontaneous tendon rupture in patients on chronic hemodialysis

Spontaneous bilateral rupture of the extensor mechanisms of the knees, without significant history of trauma, has been reported rarely, generally in association with chronic metabolic disorders, such as chronic renal failure and secondary hyperparathyroidism. We report spontaneous tendon rupture in two patients on chronic hemodialysis for 4 and 11 years, with documented severe secondary hyperparathyroidism. One patient had spontaneous bilateral rupture of his quadriceps and partial avulsion of the left triceps tendons. The other patient had spontaneous rupture of his right quadriceps tendon. Both patients had markedly elevated serum intact parathyroid hormone and moderately elevated serum beta 2-microglobulin levels. Pathologic examination revealed diffuse immunohistochemical staining for beta 2-microglobulin but negative Congo-red staining of the ruptured tendon specimens. These cases and the previous reports in the literature suggest that secondary hyperparathyroidism may play a role in the pathogenesis of this clinical entity.

Evaluation of a novel hydrophilic derivatized capillary for protein analysis by capillary electrophoresis-electrospray mass spectrometry

A new type of hydrophilic derivatized capillary has been used to enable the on-line capillary electrophoresis separation and electrospray mass spectrometric detection of a mixture of proteins containing bovine cytochrome c, tuna cytochrome c and horse heart myoglobin. Less than 40 fmol of each compound were loaded into the capillary. Baseline resolution of components was achieved, as were accurate assignments of molecular masses. The hydrophilic derivatized capillaries were taken through extensive testing procedures to characterize their performance and capabilities for protein analysis. A mixture of six proteins (cytochrome c, ribonuclease A, alpha-chymotrypsinogen, myoglobin, carbonic anhydrase II and alpha-lactalbumin) in acetic acid-sodium acetate buffer was used to delineate the relationships between migration time and pH, along with migration time and buffer concentration for each protein. The variations in capillary efficiency as a function of pH and as a function of buffer concentration were also characterized for the same six proteins in the acetic acid-sodium acetate system. A pH of 4.8 was found to offer an excellent compromise between separation efficiency (up to 500,000 theoretical plates) and analysis time. Capillary efficiencies were also found to be very good when employing a Tris.HCl electrolyte adjusted to pH 4.8. Lastly, electropherogram reproducibility and capillary durability were examined with the finding that little deterioration of the capillary occurred over the course of 400 injections (200 h run time). This represents a notable improvement over previously documented derivatization procedures designed to reduce protein adsorption to fused-silica capillary walls.

Cetyltrimethylammonium chloride as a surfactant buffer additive for reversed-polarity capillary electrophoresis-electrospray mass spectrometry

The rapid analysis of picomole quantities of various cationic molecules (laser dyes, tripeptides and larger bioactive peptides) has been achieved by on-line capillary electrophoresis-electrospray mass spectrometry (CE-ES-MS). Use of the cationic surfactant, cetyltrimethylammonium chloride (CTAC) in the CE buffer greatly facilitated the analyses. Under reversed-polarity conditions (negative potential at the source vial), CTAC induces electroosmotic flow towards the mass spectrometer, presumably due to the creation of a cationic layer on the inner surface of the fused-silica capillaries. CTAC diminishes analyte-capillary wall interactions, allowing efficient separations and symmetrical peak shapes. It may be used over a wide range of pH values without loss of electroosmotic flow. Added selectivity, provided by the surfactant properties of CTAC, played a critical role in resolving closely related tripeptides as well as larger (five to thirteen amino acid units) peptides. Above the critical micelle concentration of CTAC, interactions with the pseudostationary micellar phase increased selectivity even for ionic analytes.