Ensuring both quality and quantity of EMS

In this latest article from the RCVS about the forthcoming changes to its policy on extramural studies (EMS), senior vice president and chair of the RCVS education committee Kate Richards describes how a new balance is being sought between the number of EMS weeks veterinary students are required to undertake and the quality of the placements.

Glomangiomatosis of the lower leg

This paper demonstrates a case of multiple glomangiomas, or glomangiomatosis, including clinical presentation, imaging appearances, and subsequent management. Differentiating features from typical glomus tumors are described. To the best of our knowledge, this is the first reported case of a glomangioma involving the distal tibiofibular syndesmosis.

From practice, pharma and politics to president

Making 'connections that count' is the theme of Kate Richards' presidential year, as she takes the reins at the top of the RCVS. Here, Josh Loeb chats to her about her background, her varied career and her plans for the future.

Retention and Transmission of Grapevine Leafroll-Associated Virus 3 by Pseudococcus calceolariae

Grapevine leafroll-associated virus 3 (GLRaV-3), an economically significant pathogen of grapevines, is transmitted by Pseudococcus calceolariae, a mealybug commonly found in New Zealand vineyards. To help inform alternative GLRaV-3 control strategies, this study evaluated the three-way interaction between the mealybug, its plant host and the virus. The retention and transmission of GLRaV-3 by P. calceolariae after access to non-Vitis host plants (and a non-GLRaV-3 host) White clover (Trifolium repens L. cv. “Grasslands Huia white clover”), Crimson clover (T. incarnatum), and Nicotiana benthamiana (an alternative GLRaV-3 host) was investigated. For all experiments, P. calceolariae first instars with a 4 or 6 days acquisition access period on GLRaV-3-positive grapevine leaves were used. GLRaV-3 was detected in mealybugs up to 16 days on non-Vitis plant hosts but not after 20 days. GLRaV-3 was retained by second instars (n = 8/45) and exuviae (molted skin, n = 6/6) following a 4 days acquisition period on infected grapevines leaves and an 11 days feeding on non-Vitis plant hosts. Furthermore, GLRaV-3 was transmitted to grapevine (40−60%) by P. calceolariae second instars after access to white clover for up to 11 days; 90% transmission to grapevine was achieved when no alternative host feeding was provided. The 16 days retention period is the longest observed in mealybug vectoring of GLRaV-3. The results suggest that an alternative strategy of using ground-cover plants as a disrupter of virus transmission may be effective if mealybugs settle and continue to feed on them for 20 or more days.

Understanding spatial and temporal variability of N leaching reduction by winter cover crops under climate change

Winter cover crops are sown in between main spring crops (e.g. cash and forage crops) to provide a range of benefits, including the reduction of nitrogen (N) leaching losses to groundwater. However, the extent by which winter cover crops will remain effective under future climate change is unclear. We assess variability and uncertainty of climate change effects on the reduction of N leaching by winter oat cover crops. Field data were collected to quantify ranges of cover crop above-ground biomass (7 to 10 t DM/ha) and N uptake (70 to 180 kg N/ha) under contrasting initial soil conditions. The data were also used to evaluate the APSIM-NextGen model (R² from 62 to 96% and RMSEr from 7 to 50%), which was then applied to simulate cover crop and fallow conditions across four key agricultural locations in New Zealand, under baseline and future climate scenarios. Cover crops reduced N leaching risks for all location/scenario combinations but with large variability in space and time (e.g. 21 to 47% of fallow) depending on the climate change scenario. For instance, end-of-century estimates for northern (warmer) locations mostly showed non-significant effects of climate change on cover crop effectiveness and N leaching. In contrast for southern (colder) locations, there was a systematic increase in N leaching risks with climate change intensity despite a concomitant, but less than proportional, increase in cover crop effectiveness (up to ~5% of baseline) due to higher winter yields and N uptake. This implies that climate change may not only modify the geography of N leaching hotspots, but also the extent by which cover crops can locally reduce pollution risks, in some cases requiring complementary adaptive measures. The patchy- and threshold-nature of leaching events indicates that fine spatio-temporal resolutions are better suited to evaluate cover crop effectiveness under climate change.

Landspreading with co-digested cattle slurry, with or without pasteurisation, as a mitigation strategy against pathogen, nutrient and metal contamination associated with untreated slurry

North Atlantic European grassland systems have a low nutrient use efficiency and high rainfall. This grassland is typically amended with unprocessed slurry, which counteracts soil organic matter depletion and provides essential plant micronutrients but can be mobilised during rainfall events thereby contributing to pathogen, nutrient and metal incidental losses. Co-digesting slurry with waste from food processing mitigates agriculture-associated environmental impacts but may alter microbial, nutrient and metal profiles and their transmission to watercourses, and/or soil persistence, grass yield and uptake. The impact of EU and alternative pasteurisation regimes on transmission potential of these various pollutants is not clearly understood, particularly in pasture-based agricultural systems. This study utilized simulated rainfall (Amsterdam drip-type) at a high intensity indicative of a worst-case scenario of ~11 mm hr^-1 applied to plots 1, 2, 15 and 30 days after grassland application of slurry, unpasteurised digestate, pasteurised digestate (two conditions) and untreated controls. Runoff and soil samples were collected and analysed for a suite of potential pollutants including bacteria, nutrients and metals following rainfall simulation. Grass samples were collected for three months following application to assess yield as well as nutrient and metal uptake. For each environmental parameter tested: microbial, nutrient and metal runoff losses; accumulation in soil and uptake in grass, digestate from anaerobic co-digestion of slurry with food processing waste resulted in lower pollution potential than traditional landspreading of slurry without treatment. Reduced microbial runoff from digestate was the most prominent advantage of digestate application. Pasteurisation of the digestate further augmented those environmental benefits, without impacting grass output. Anaerobic co-digestion of slurry is therefore a multi-beneficial circular approach to reducing impacts of livestock production on the environment.

0438 Automatic Nighttime Agitation and Sleep Disruption Detection Using a Wearable Ankle Device and Machine Learning

Introduction

Nighttime agitation behavior such as wandering and restlessness during awake and sleep in people with Alzheimer’s disease (AD) is expensive to manage and adversely affects sleep. Nighttime agitation is mostly noted by subjective caregiver reports. An automated process for this assessment would improve clinical management. Here we report on the RestEaZeTM system that uses an ankle band and machine learning to automatically classify sleep status and nighttime agitation behaviors in older adults with AD.

Methods

We collected data on 7 adults (mean: 81 years, SD: 10.6) with AD. They wore the RestEaZeTM ankle band with a 3-axis accelerometer, a 3-axis gyroscope, and three textile capacitive sensors. A trained Research Assistant (RA) continuously observed for wandering, restlessness, wake, and sleep between 5pm and 7am using the Cohen Mansfield Agitation Inventory (CMAI). We merged, and band-pass filtered the data and divided it into 10-second non-overlapping windows. CMAI labels and time-series features (scaled using StandardScaler) extracted from the RestEaZeTM data were used to train a Random Forest binary classifier. The significant features were extracted based on the impact on the p-value for the classifier. We used the Synthetic Minority Oversampling Technique (SMOTE) to balance the dataset and performed 5-fold cross-validation with a 67-33 train-test split.

Results

We report the sensitivity, specificity, accuracy, and Area-under-the Curve (AUC) for the ROC curve for the classifiers: (1) Sleep/Awake: sensitivity=0.95, specificity=0.87, accuracy=0.92, AUC=0.97; (2) Wandering/Non-Wandering: sensitivity=0.85, specificity=0.99, accuracy=0.98, AUC=0.99; and (3) Restless/Non-Restless: sensitivity=0.84, specificity=0.84, accuracy=0.84, AUC=0.92. The significant features were related to the intensity of movements.

Conclusion

Our preliminary results show the feasibility of using RestEaZeTM for quantitatively measuring nighttime agitation. These can provide clinically useful objective measures of agitation that can be automatically transmitted to clinical or research records with minimal staff time requirements.

Support

The authors acknowledge the funding support from the National Institute on Aging under award R01AG051588 and Arbor Pharmaceuticals for support for Horizant and the matching placebo.

30 The Role of A Virtual Clinic in Reducing Waiting Times for Out-Patient Follow-Up

Topic

Hospital admissions for older people are increasing with subsequent pressure on out-patient (OP) clinics. By early 2018, 350 patients were waiting up to 6 months for follow-up, with limited capacity in existing clinics. There were concerns regarding potential harm to patients from delayed review of significant results.

Intervention

A working group considered options for managing the OP waiting list. We decided to pilot a fortnightly virtual clinic (VC) where cases were reviewed without the patient present. All patients awaiting results were listed for the VC rather than routine OP. Each VC had 50 patients listed. Patient’s GP received a clear action plan. Clinic rules were modified as issues were identified. Links with other specialities evolved reducing the number of missing results. Data was analysed for 50% of consultations between January 2018 and March 2019.

Improvement

311 VC appointments were reviewed: 207 in 2018 and 104 up to March 2019. Maximum 25 cases could be completed per clinic, additional sessions cleared initial backlog within 3 months. Completion time/case ranged from 2-15 minutes depending on complexity. Main reason for VC was test results: 82% in 2018, increasing to 93% in 2019. 61% in 2018, 80% in 2019 were discharged directly from VC. 20% required a 2nd VC for outstanding results. OP review post-VC fell from 16% in 2018 to just 2% in 2019. General OP requirements fell from 24hrs to 10 hours/ week as a result of VCs, releasing consultants for other clinical areas.

Discussion

VCs are an effective means of reviewing outstanding results from recent admissions and OP consultations. Routine listing of patients with outstanding investigations provides a safety net. Most results are normal and do not require follow-up. Repeat CXRs at 6 weeks continue to be requested for severely frail people who are unlikely to benefit.

Genetic control of α-farnesene production in apple fruit and its role in fungal pathogenesis

Terpenes are important compounds in plant trophic interactions. A meta-analysis of GC-MS data from a diverse range of apple (Malus × domestica) genotypes revealed that apple fruit produces a range of terpene volatiles, with the predominant terpene being the acyclic branched sesquiterpene (E,E)-α-farnesene. Four quantitative trait loci (QTLs) for α-farnesene production in ripe fruit were identified in a segregating 'Royal Gala' (RG) × 'Granny Smith' (GS) population with one major QTL on linkage group 10 co-locating with the MdAFS1 (α-farnesene synthase-1) gene. Three of the four QTLs were derived from the GS parent, which was consistent with GC-MS analysis of headspace and solvent-extracted terpenes showing that cold-treated GS apples produced higher levels of (E,E)-α-farnesene than RG. Transgenic RG fruit downregulated for MdAFS1 expression produced significantly lower levels of (E,E)-α-farnesene. To evaluate the role of (E,E)-α-farnesene in fungal pathogenesis, MdAFS1 RNA interference transgenic fruit and RG controls were inoculated with three important apple post-harvest pathogens [Colletotrichum acutatum, Penicillium expansum and Neofabraea alba (synonym Phlyctema vagabunda)]. From results obtained over four seasons, we demonstrate that reduced (E,E)-α-farnesene is associated with decreased disease initiation rates of all three pathogens. In each case, the infection rate was significantly reduced 7 days post-inoculation, although the size of successful lesions was comparable with infections on control fruit. These results indicate that (E,E)-α-farnesene production is likely to be an important factor involved in fungal pathogenesis in apple fruit.

Phalangeal fracture leading to digital amputation, sustained during manipulation for Dupuytren's disease as part of clostridial collagenase treatment

Collagenase injection was approved in Europe for use in the treatment of Dupuytren's disease in 2011. Reported adverse effects include skin tears, swelling, pain and complex regional pain syndrome. Here, we present a case of a rare complication of phalangeal fracture following treatment with collagenase clostridium and the resultant digital amputation. An 81-year-old man was treated for a 25-year history of progressively disabling Dupuytren's disease of his left middle and ring fingers. Nine days post-manipulation he presented with persistent pain and swelling and was diagnosed with a displaced fracture of the proximal phalanx of his ring finger. Following discussion of surgical options and potential outcome, he elected to undergo amputation of the digit. He has experienced good treatment results in his middle finger and has no significant functional impairment as a result of this complication. Those offering collagenase injection in the management of Dupuytren's disease should be aware of this potential complication and it should be included in the consent process.

George Rafferty

A well-respected, understanding veterinary surgeon who was as comfortable with his clients as with the many species of animals he treated. He was Deputy Lord Lieutenant for Inverness-shire and was awarded an MBE for his services to agriculture.

Increasing Access to Cost Effective Home-Based Rehabilitation for Rural Veteran Stroke Survivors

INTRODUCTION

An estimated 750,000 Americans experience a stroke annually. Most stroke survivors require rehabilitation. Limited access to rehabilitation facilities has a pronounced burden on functional outcomes and quality of life. Robotic devices deliver reproducible therapy without the need for real-time human oversight. This study examined the efficacy of using home-based, telerobotic-assisted devices (Hand and Foot Mentor: HM and FM) to improve functional ability and reduce depression symptoms, while improving access and cost savings associated with rehabilitation.

METHODS

Twenty stroke survivors performed three months of home-based rehabilitation using a robotic device, while a therapist remotely monitored progress. Baseline and end of treatment function and depression symptoms were assessed. Satisfaction with the device and access to therapy were determined using qualitative surveys. Cost analysis was performed to compare home-based, robotic-assisted therapy to clinic-based physical therapy.

RESULTS

Compared to baseline, significant improvement in upper extremity function (30.06%, p= 0.046), clinically significant benefits in gait speed (29.03%), moderate improvement in depressive symptoms (28.44%) and modest improvement in distance walked (30.2%) were observed. Participants indicated satisfaction with the device. Home-based robot therapy expanded access to post-stroke rehabilitation for 35% of the people no longer receiving formal services and increased daily access for the remaining 65%, with a cost savings of $2,352 (64.97%) compared to clinic-based therapy.

CONCLUSION

Stroke survivors made significant clinically meaningful improvements in the use of their impaired extremities using a robotic device in the home. Home-based, robotic therapy reduced costs, while expanding access to a rehabilitation modality for people who would not otherwise have received care.

Pre-operative thrombotic complications of neoadjuvant chemotherapy for breast cancer: Implications for immediate breast reconstruction

Thrombotic complications arising during the treatment of breast cancer can impact the breast reconstruction pathway. We set out to review the details of cases of thromboembolism occurring during neoadjuvant chemotherapy and peri-operatively to study the impact of the event and its management on subsequent breast reconstruction.

METHODS

We retrospectively reviewed the medical records of seven patients who had experienced a thrombotic event during their treatment of breast cancer between 2008 and 2012, who then proceeded to breast reconstruction. We recorded size and grade of tumour, neoadjuvant chemotherapeutic regimen, details of port insertion, planned reconstruction, thrombotic event and its management and the surgery performed and outcome.

RESULTS

All patients received chemotherapy via central venous access and went on to present with local symptomatic thrombosis. They were managed with anticoagulant regimens at the time of mastectomy and reconstruction, which were unique for each patient. The results revealed delays to surgery and modifications to planned reconstruction.

DISCUSSION

The majority of patients developing thrombotic complications go on to achieve successful reconstruction. There is significant variation in the anticoagulation management in this patient group. Identification of optimal anticoagulant regimes and the possibilities for prophylaxis may prove key in informing surgeons when planning the reconstructive process.

CONCLUSION

An awareness of the effects of thrombotic events in this patient group is important in terms of developing an understanding of its impact on the performance of reconstruction, on the management of anticoagulation peri-operatively and on monitoring for post-operative complications.

Progression to insulin for patients with diabetes mellitus on dual oral antidiabetic therapy using the US Department of Defense Database

AIM

To compare 'progression to insulin' for three cohorts on oral antidiabetic medication combinations: metformin/sulphonylurea (Met/SU), metformin/thiazolidinedione (Met/TZD) and sulphonylurea/thiazolidinedione (SU/TZD).

METHODS

Retrospective cohort analysis design was used. The subjects were US nationwide members of military and their families. A total of 5608 patients who were on antidiabetic monotherapy for at least 1 year before adding a second agent to their medication regimen between October 2001 and September 2008 participated in this study. Mean age ranged from 64 to 71 years among the cohorts. Cox regression compared the progression to insulin, adjusting for demographics, months of follow-up and co-morbidities [measured with Chronic Disease Score (CDS)].

RESULTS

By the end of the 2- to 6-year follow-up period, 14.3% of the Met/TZD cohort, 23.6% of the Met/SU cohort and 28.2% of the SU/TZD cohort had insulin added to their regimen. Those in the Met/SU cohort had a 1.8 times higher probability of progression to insulin than those in the Met/TZD cohort [odds ratio (OR) = 1.80, 95% confidence interval (CI) = 1.51-2.14), and those in the SU/TZD cohort had a 2.5 times higher probability of progression to insulin than those in the Met/TZD cohort (OR = 2.51, 95% CI = 2.04-3.08).

CONCLUSION

When sensitizers were paired (Met/TZD), a lower percentage of patients progressed to insulin during the study period, as opposed to patients who used a combination of a secretagogue with a sensitizer (SU/TZD or Met/SU).

Do cancer centers need to assess quality and outcomes? Introducing a customized ACS-NSQIP for oncology (Onc-NSQIP)

475

Background: To identify quality improvement opportunities, hospitals can use ACS NSQIP to compare their risk-adjusted performance to other hospitals. However, Cancer Centers have few opportunities to compare their outcomes to similar hospitals for oncologic operations. Our objective was to develop an oncology-specific version of ACS NSQIP (Onc-NSQIP) and determine whether it could be useful for Cancer Centers.

Methods: From ACS-NSQIP (2006-2009), patients undergoing major colorectal (n=34,858; 221 hospitals) and pancreatic (n=7,667; 65 hospitals) as well as esophageal, gastric, and soft tissue operations for malignancy were identified. Risk-adjusted postoperative outcomes were assessed with regression models adjusting for demographics, comorbidities, and operative procedure. Relative rankings of NCI-designated Comprehensive Cancer Centers in ACS NSQIP among the other ACS NSQIP hospitals were compared.

Results: Cancer Center outcomes varied widely for colorectal and pancreas. For overall colorectal morbidity, Cancer Centers were ranked in the top third (n=4), middle third (n=7), and bottom third (n=10). For colorectal 30-day mortality, Cancer Centers were ranked in the top (n=14), middle (n=3), and bottom third (n=4). For overall pancreatic morbidity, Cancer Centers were ranked in the top (n=5), middle (n=7), and bottom third (n=7). For pancreatic 30-day mortality, Cancer Centers were ranked in the top (n=5), middle (n=6), and bottom third (n=8). Similar results were observed for colorectal and pancreas for DVT/PE, SSI, reoperation, and length of stay. Onc-NSQIP models were comparable to standard ACS NSQIP models. At least some Cancer Centers were statistical outliers for most outcomes (P<0.05). Results were similar for other malignancies.

Conclusions: Cancer Center outcomes varied as much as other ACS NSQIP hospitals, demonstrating need for quality assessment. Without standardized risk-adjusted outcomes comparisons, Cancer Centers cannot accurately assess their outcomes to identify quality improvement targets. ACS NSQIP's new platform allows customization so hospitals can compare surgical oncology-specific risk-adjusted processes and outcomes.

No significant financial relationships to disclose.

Compendium of gene expression profiles comprising a baseline model of the human liver drug metabolism transcriptome

Oligonucleotide microarrays were used to study the variability of pharmacokinetics and drug metabolism (PKDM)-related gene expression in 75 normal human livers. The objective was to define and use absorption, distribution, metabolism and excretion (ADME) gene expression variability to discern co-regulated genes and potential surrogate biomarkers of inducible gene expression. RNA was prepared from donor tissue and hybridized on Agilent microarrays against an RNA mass balanced pool from all donors. Clustering of PKDM gene sets revealed donors with distinct patterns of gene expression that grouped genes known to be regulated by the nuclear receptor, pregnane X-receptor (PXR). Fold range metrics and frequency distributions from the heterogeneous human population were used to define the variability of individual PKDM genes in the 75 human livers and were placed in context by comparing expression data with basal ADME gene expression variability in an inbred and diet/environment controlled population of 27 Rhesus livers. The most variable genes in the hepatic transcriptome were mainly related to drug metabolism, intermediary metabolism, inflammation and cell cycle control. Unique patterns of expression across 75 individuals of inducible ADME gene expression allowed their expression to be correlated with the expression of many other genes. Correlated genes for AhR, CAR and PXR responsive genes (CYP1A2, CYP2B6 and CYP3A4) were identified that may be co-regulated and, therefore, provide clues to the identity of surrogate gene or protein markers for CYP induction. In conclusion, microarrays were used to define the variable expression of hepatic ADME genes in a diverse human population, the expression variability of ADME genes was compared with the expression variability in an inbred population of Rhesus monkeys, and genes were defined that may be co-regulated with important inducible CYP genes.

A phase II study of dexamethasone, ifosfamide, cisplatin and etoposide (DICE) as salvage chemotherapy for patients with relapsed and refractory lymphoma

The 4-day combination of dexamethasone, ifosfamide, cisplatin, and etoposide (DICE) is a salvage regimen for lymphoma. We report a prospective phase II multi-center trial of a modified DICE regimen in relapsed or refractory Hodgkin (HL) or non-Hodgkin lymphoma (NHL) and chronic lymphocytic leukemia (CLL), constituting a single day of intravenous administration followed by 3 days of oral administration, aimed at reducing inpatient days without losing efficacy. Forty patients (median age 56, range 25 - 79) were included: 28 (70%) NHL, 9 (23%) HL and 3 (8%) CLL. Fifty-three per cent had received 2 prior treatment regimens. International Prognostic Index (IPI) was 2 in 75% of NHL patients. Patients aged 55 and those with previous autologous stem cell transplantation (ASCT) started on a lower-dose regimen, with dose escalation possible in 2 patients. Overall response rate was 41%. Thirty-eight per cent of patients had stable disease. With a median of 3.1 years of follow-up, estimated progression-free survival (PFS) and overall survival (OS) rates at 3 years were 15% and 43% respectively. OS was longer in the < 55 compared to the 55 age cohort (P = 0.0091), longer for HL than NHL (P = 0.59 and 0.039 respectively) and longer for Low/Low-Int IPI than High/High-Int IPI (P = 0.0074 and 0.0009 respectively). Median duration of inpatient stay was 3 days. There were no treatment-related deaths. In conclusion, this modification of DICE is an effective and well tolerated salvage regimen, even in this poor prognosis group of patients. Further clinical studies of DICE in first relapse and in older patients, possibly with the addition of rituximab, are warranted.

Results of a nationwide prospective audit of stoma complications within 3 weeks of surgery

OBJECTIVE

Actuarial analysis of stoma complications (problematic stomas) is lacking. The objectives of this audit were: to identify the incidence of stoma complications within the UK; to highlight any dissimilarity of incidence from centre to centre; to ascertain if the height of the stoma (distance of stoma lumen from the skin) at the time of fashioning is a predisposing factor to problems; and finally to initiate much needed research.

METHOD

Commencing 1st January 2005, stoma care services nationwide (256) were invited to audit prospectively their next 50 enteric stomas or for a period of 1 year which ever came first. The definition of a problematic stoma being one, which needed one or more accessories to keep the patient clean and dry for a minimum period of 24 h. The incident is to have happened within 3 weeks of surgery. Factors taken into account were: type of stoma, height of stoma within 48 h of surgery; emergency or elective procedure, problem identified, BMI, gender and underlying diagnosis of the patient. The identities of the participating centres are confidential.

RESULTS

Of the 256 hospital-based stoma care services within the UK, 93 (36%) participated. A total of 3970 stomas were recorded, of which 1329 (34%) were identified as problematic. Sixty-two centres reported 45-50 stomas with a range of complications 6-96%. The loop ileostomy was found to be the stoma which causes most problems. A stoma of <10 mm is a predisposing factor to complications and problems are more likely to occur following an emergency procedure. More men than women have stomas formed, but have significantly fewer problems and there is no significant difference between underlying diagnoses.

CONCLUSION

The stoma height, stoma type and gender of the patient are significant risk factors identified in this audit. The BMI of patient did not affect the outcome. Patients undergoing an emergency procedure are more likely to have a problematic stoma. The significant variation of complications from centre to centre indicates surgical technique as being the key factor in stoma formation and subsequent quality of life for the patient.

Subcellular localization of the Triple Gene Block movement proteins of Beet necrotic yellow vein virus by electron microscopy

The Triple Gene Block proteins TGBp1, TGBp2, and TGBp3 of Beet necrotic yellow vein virus (BNYVV) are required for efficient cell-to-cell spread of the infection. The TGB proteins can drive cell-to-cell movement of BNYVV in trans when expressed from a co-inoculated BNYVV RNA 3-based 'replicon'. TGBp2 and TGBp3 expressed from the replicon were nonfunctional in this assay if they were fused to the green fluorescent protein (GFP), but addition of a hemagglutinin (HA) tag to their C-termini did not incapacitate movement. Immunogold labeling of ultrathin sections treated with HA-specific antibodies localized TGBp2-HA and TGBp3-HA to what are probably structurally modified plasmodesmata (Pd) in infected cells. A similar subcellular localization was observed for TGBp1. Large gold-decorated membrane-rich bodies containing what appear to be short fragments of endoplasmic reticulum were observed near the cell periphery. The modified gold-decorated Pd and the membrane-rich bodies were not observed when the TGB proteins were produced individually in infections using the Tobacco mosaic virus P30 protein to drive cell-to-cell movement, indicating that these modifications are specific for TGB-mediated movement.

Nonregulated expression of TGBp3 of hordei-like viruses but not of potex-like viruses inhibits beet necrotic yellow vein virus cell-to-cell movement

Plant viruses containing a Triple Gene Block (TGB) movement protein gene cassette fall into two classes. We have shown previously that the third TGB protein (TGBp3) of beet necrotic yellow vein virus (BNYVV; Class 1) and peanut clump virus (Class 1) inhibit BNYVV intercellular movement when expressed from a co-inoculated BNYVV RNA 3-based replicon. Here we show that autonomous expression of TGBp3's of four other Class 1 viruses of various genera also inhibits BNYVV movement. No such effect was observed for four Class 2 virus TGBp3's, suggesting that the roles of Class 1 and 2 TGBp3's in movement differ significantly.

Rapid screening for depression--validation of the Brief Case-Find for Depression (BCD) in medical oncology and palliative care patients

Depression in oncology patients is under-recognised and associated with poor outcomes. Screening can increase case recognition. The Brief Case-Find for Depression (BCD) is a four-question, interviewer-administered instrument that has been previously validated in a general medical setting. The primary aim of this study was to validate the BCD in a medical oncology/palliative care setting, primarily by comparing its association with physical illness measures and with the Primary Care Evaluation of Mental Disorders (PRIME-MD), the Beck Depression Inventory (BDI) and the Hospital Anxiety and Depression Scale (HADS). Eligible adult oncology patients gave informed consent and completed the above measures and a pain scale. Agreement between the BCD and other instruments was assessed. Construct validity was determined by comparing depressed/nondepressed patients with respect to performance status, symptoms, pain score and functional impairment. A total of 100 patients had a median age of 58 (range 21–90) and ECOG performance status (PS) 2 (0–4). In all, 60% had metastatic disease. The therapeutic goal was curative/adjuvant in 39% and palliative in 61%. Prevalence of depression according to the various measures was: BCD 34%, PRIME-MD 12%, BDI 19% and HADS 14%. In total, 45% of patients responded positively to a single-item screening question. The BCD showed fair agreement with the PRIME-MD (kappa=0.21), moderate agreement with the BDI (kappa=0.43) and fair agreement with the HADS (kappa=0.27). Against the PRIME-MD diagnosis of depression, the BCD had greater sensitivity, but lesser specificity and overall agreement, compared with the BDI and depression scale of the HADS. Patients with probable depression (according to BCD) had inferior PS (P=0.0064), increased pain (P=0.045) and greater impairment of functioning (PRIME-MD: P=0.0003). There was no association with gender, age, disease status or therapeutic goal. Depression is common in oncology patients. The BCD is a quick, easy-to-administer screen for depression, which has reasonable psychometric properties in this population.

Minimally invasive radioguided parathyroidectomy (MIRP)

The technique of parathyroidectomy has traditionally involved a bilateral exploration of the neck with the intent of visualizing 4 parathyroid glands and resecting pathologically enlarged glands. Parathyroid scanning using technetium-99m sestamibi has evolved and can now localize 80% to 90% of parathyroid adenomas. The technique of minimally invasive radioguided parathyroidectomy (MIRP) is a surgical option for most patients with primary hyperparathyroidism and a positive preoperative parathyroid scan. The technique makes use of a hand-held gamma probe that is used intraoperatively to guide the dissection in a highly directed manner with the procedure often performed under local anesthesia. The technique results in excellent cure rates while allowing most patients to leave the hospital within a few hours after the completion of the procedure. Current data also suggest the procedure can decrease hospital charges by approximately 50%. This technique may significantly change the management of primary hyperparathyroidism.

Defining "early dementia" and monitoring intervention: what measures are useful in family caregiving?

Measures of cognition are often used to define and measure the progress of dementia and outcomes of intervention. This paper examines whether measures of psychosocial disability used with those of cognition are more useful than measures of cognition alone, particularly in early dementia. A measure of cognition and two instruments of caregiver burden, used as routine clinical outcome measures of three types of Old Age Psychiatry dementia services, were examined. All cases with dementia in a memory clinic (MC; n = 149), a community mental health service for older people (CMHT; n = 120) and a specialist dementia day hospital (DH; n = 118), in one NHS district were followed up at 12 months. Measures of cognition (MMSE), behaviour, caregiver coping (Problem Checklist; PC) and caregiver mood (Hospital Anxiety and Depression Scale; HAD) were taken at baseline (MC, n = 48; CMHT, n = 113; DH, n = 55) and at follow-up (MC, n = 35; CMHT, n = 34; DH, n = 23). At baseline, all three groups had an average MMSE score of "mild impairment" but measures of behaviour and caregiver burden showed subtle between-group differences. At the 12-month follow-up, cognition remained stable in all groups, but the frequency of day-to-day problems increased and caregiver mood deteriorated in families receiving DH support. The use of psychosocial measures of disability in conjunction with those of cognition, are important in the definition and longitudinal measurement of intervention and support in early dementia.

Acute normovolaemic haemodilution in colorectal surgery

AIMS

Blood transfusions are often given to surgical patients. This study was designed to assess whether acute normovolaemic haemodilution (ANH) reduces exposure to allogeneic blood, affects clinical outcome and hospital stay, and is feasible in colorectal surgery.

METHODS

All ASA 1 and 11 patients undergoing colectomies performed between 1997 and 1999 were identified retrospectively from our colorectal cancer database to ascertain our current peri and postoperative transfusion practice. Twenty-six selected patients subsequently underwent ANH during colectomy surgery. The number of patients and units transfused were identified.

RESULTS

One hundred and twenty-three of 317 (39%) patients identified from our colorectal cancer database were transfused a total of 328 units (median 2, range 1-7). Of the 26 patients undergoing ANH, 4 (15%) were transfused a total of 13 units (median 3, range 2-5). The reduction in number of patients transfused was statistically significant (P=0.017). ANH increased anaesthetic time by a median of 19 min. There were no complications associated with ANH and the median hospital stay was 9 days (range 6-13).

CONCLUSIONS

In this pilot study of selected patients, ANH is a feasible and effective method of reducing allogeneic blood exposure in major colorectal surgery. A prospective randomised controlled trial is now urgently required.

Beet necrotic yellow vein virus particles localize to mitochondria during infection

Fluorescent beet necrotic yellow vein virus (BNYVV) particles were produced by replacing part of the readthrough domain of the minor coat protein P75 with the green fluorescent protein (GFP). The recombinant virus was functional in plants and P75-GFP was incorporated at one end of the rod-shaped virions. Laser scanning confocal microscopy and transmission electron microscopy showed that virus-like particles, almost certainly authentic BNYVV virions, localized to the cytoplasmic surface of mitochondria at early times postinfection but relocated at later times to semiordered clusters in the cytoplasm. This is the first report of specific targeting of plant virus particles to the mitochondria in vivo.

Fungal infection of the diabetic foot: two distinct syndromes

AIMS

Fungal infection of diabetic foot ulcers has not been described. We analysed the features of 17 patients with diabetic foot ulcers probably infected with fungi.

METHODS

Seventeen patients were identified with clinically infected foot ulcers, (i) which had failed to heal despite prolonged antibiotic therapy and intensive podiatric care, (ii) from which Candida spp. was isolated or hyphae +/- yeasts were visualized in material from ulcers or surrounding skin.

RESULTS

Multiple ulcers arising simultaneously were present in 10 patients (59%), preceded by blistering in seven cases. Single ulcers with markedly ulcerated margins were present in seven (41%) patients and were preceded by blisters in two. All 17 cases had neuropathy and 15 (88%) had severe peripheral vascular disease. All ulcers responded to antifungal therapy.

CONCLUSIONS

Candida spp. is associated with two distinctive patterns of protracted ulceration in diabetic feet which improve following systemic antifungal therapy. Diabet. Med. 18, 567-572 (2001)

Is training in psychology associated with increased responsiveness to suicidality?

Training is associated with improved responses to suicidal individuals, but it is not clear whether any training helps or whether the training needs to be in psychology. The authors compared beginning and advanced psychology graduate students and practicing psychologists to nursing graduate students. A total of 139 participants in these 4 groups read a vignette about Pat, who had either contemplated suicide or never contemplated suicide, then completed questions about how they would respond to a distressed telephone call from Pat, how suicidal they thought Pat was, and how good a no-suicide contract would be for Pat. Advanced students and psychologists were more helpful in their responses than beginning graduate students, who were more helpful than nursing graduate students. However, all participants noticed whether Pat had contemplated suicide, and all were faintly positive about no-suicide contracts.