Crohn's Disease-Associated Pathogenic Mutation in the Manganese Transporter ZIP8 Shifts the Ileal and Rectal Mucosal Microbiota Implicating Aberrant Bile Acid Metabolism

BACKGROUND

A pathogenic mutation in the manganese transporter ZIP8 (A391T; rs13107325) increases the risk of Crohn's disease. ZIP8 regulates manganese homeostasis and given the shared need for metals between the host and resident microbes, there has been significant interest in alterations of the microbiome in carriers of ZIP8 A391T. Prior studies have not examined the ileal microbiome despite associations between ileal disease and ZIP8 A391T.

METHODS

Here, we used the Pediatric Risk Stratification Study (RISK)  cohort to perform a secondary analysis of 16S ribosomal RNA gene sequencing data obtained from ileal and rectal mucosa to study associations between ZIP8 A391T carrier status and microbiota composition.

RESULTS

We found sequence variants mapping to Veillonella were decreased in the ileal mucosa of ZIP8 A391T carriers. Prior human studies have demonstrated the sensitivity of Veillonella to bile acid abundance. We therefore hypothesized that bile acid homeostasis is differentially regulated in carriers of ZIP8 A391T. Using a mouse model of ZIP8 A391T, we demonstrate an increase in total bile acids in the liver and stool and decreased fibroblast growth factor 15 (Fgf15) signaling, consistent with our hypothesis. We confirmed dysregulation of FGF19 in the 1000IBD cohort, finding that plasma FGF19 levels are lower in ZIP8 A391T carriers with ileocolonic Crohn's disease.

CONCLUSIONS

In the search for genotype-specific therapeutic paradigms for patients with Crohn's disease, these data suggest targeting the FGF19 pathway in ZIP8 A391T carriers. Aberrant bile acid metabolism may precede development of Crohn's disease and prioritize study of the interactions between manganese homeostasis, bile acid metabolism and signaling, and complicated ileal Crohn's disease.

A - 75 Neuropsychological Consequences of Anoxic Encephalopathy Pursuant to Myocardial Infarction

OBJECTIVE

Myocardial infarctions (MI) often result in irreversible muscle damage to the heart and difficulty returning to daily activities. While the physical consequences of acute cardiac events are well documented in the medical literature (Lesperance et al., 1996), there is less research identifying the cognitive, emotional, and behavioral consequences of MI (Brink et al., 2008) particularly when complicated by anoxia and unresponsiveness.

METHOD

We present a case study of a 54-year-old right-handed male with 12 years of education referred for neuropsychological assessment pursuant to mental status changes following a MI with an estimated 25-30 minutes of unresponsiveness and subsequent diagnosis of anoxic encephalopathy, supported by neuroimaging, which is also positive for a 4 mm pituitary tumor.

RESULTS

Neuropsychological assessment revealed difficulties with cognitive efficiency, sequencing, language production, phonemic fluency, and memory. Performance was also inconsistent with age- and education-weighted norms, and therefore did not reflect a normal aging profile. An objective psychological inventory (PAI) revealed negative self-evaluation, a focus on health matters, acute stress, and substance concerns. Additionally, an endorsement of social isolation, discomfort in social interactions, and a readiness to express anger verbally was indicated. Findings supported diagnosis of cognitive impairment associated with anoxic brain injury from above noted MI.

CONCLUSION

This case provides an example of the neuropsychological consequences of anoxic encephalopathy from MI on cognitive, emotional and behavioral functioning. It also supports the need for awareness of bodily health within the context of overall cognitive health. It emphasizes the benefits of integrating physiological and neurocognitive symptoms when conceptualizing patients with cardiac arrest.

O033 Video tuition of intracavernosal alprostadil injection for management of erectile dysfunction

Introduction

Intracavernosal injections (ICI) are the second line treatment of erectile dysfunction (ED). To reduce the risk of complications, primarily priapism, the first administration has traditionally required face-to-face appointments. With a move to remote working, the safety and feasibility of an instructional video for the first self-administration of ICI was assessed.

Methods

Two centres recruited patients, with participants receiving a pack comprising a written instruction leaflet and a Viridal Duo prescription, followed by an email with our instructional video. Patients were given a specific time to self-administer their ICI (Alprostadil 2.5 micrograms), when our CNS was available for support. The same CNS would follow up two hours later via telephone to assess the experience using a Likert scale semi-structured interview.

Results

Thirty-nine patients were recruited between two centres, with 35 continuing to injection. The median age was 63 years (range 34–78). The most common ED aetiology was post-prostatectomy (18/35). Thirty-four (97%) recruits found the video instructions clear, with it being watched a mean 2 (range 1–8) times. Only 1 patient (3%) required telephone support. At the 2.5mcg dose, the mean erection hardness score was 2 (range 1–4) after an average of 5 minutes. No patients reported significant bruising at the injection site and there was no priapism. Thirty-three patients (94%) were very or extremely likely to recommend this method for starting ICI therapy.

Conclusion

Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity.

Take-home message

Our study shows ICI tuition does not require direct supervision, thereby reducing face-to-face contact and will tackle significant waiting lists by increasing productivity.

What should every dental health professional know about electronic cigarettes?

Electronic cigarettes (E-cigarettes) have become increasingly popular around the world. Currently, dental professionals' knowledge and attitudes are varied with many clinicians unclear regarding the impact of E-cigarette products on the oral and general health of their patients. With developing social and health-related challenges, advice of dental and medical associations and other regulatory bodies on E-cigarette use is changing. Growing evidence demonstrating the risks of E-cigarette usage has prompted a review of legislation in the United Kingdom (UK), United States of America (USA), Australia and Canada to include the sale and availability of E-cigarettes, particularly those containing nicotine. Further consideration within the scientific and public health community is being given to assessing demographic usage patterns particularly uptake by non-smokers and adolescents, efficacy as a cessation tool, the impact of vapour on bystanders and direct injuries via explosions as well as emerging lung injuries. This article aims to provide a summary of the most up to date evidence relating to E-cigarette use, the latest position of dental associations and the oral health implications of E-cigarettes compared to conventional smoking. The article also aims to collate this information in order to provide dental clinicians with guidance on how to advise patients, specifically in answering common questions posed regarding E-cigarette use.

Is there a role for pentoxifylline and tocopherol in the management of advanced osteoradionecrosis of the jaws with pathological fractures? Case reports and review of the literature

Osteoradionecrosis (ORN) is an infrequent but serious complication of radiotherapy, especially in the head and neck region. It is a slowly progressive condition, with management in the early stages focused on symptom control, and surgery usually reserved for advanced ORN. However, established ORN is difficult to treat. The role of hyperbaric oxygen therapy has recently been contested. The use of pentoxifylline in the management of ORN was first described by Delanian in 2004, but its benefits have not been replicated in other studies. In cases of advanced ORN with pathological fractures, many centres still advocate surgical resection and reconstruction. However, in this group of patients who often have multiple medical comorbidities, many of whom have previously undergone significant surgery, a resective plan is not always ideal. This paper presents two successful cases of bony union after the use of pentoxifylline and tocopherol to manage grade III ORN of the mandible. Both patients had pathological fractures and orocutaneous fistulas and were deemed unsuitable for surgery. The possible reasons for the success of pentoxifylline and tocopherol are discussed, and a review of the current literature evidence of similar cases is presented. Pentoxifylline and tocopherol should be considered for the management of advanced ORN where surgical management is not appropriate.

Arctic cut-off high drives the poleward shift of a new Greenland melting record

Large-scale atmospheric circulation controls the mass and energy balance of the Greenland ice sheet through its impact on radiative budget, runoff and accumulation. Here, using reanalysis data and the outputs of a regional climate model, we show that the persistence of an exceptional atmospheric ridge, centred over the Arctic Ocean, was responsible for a poleward shift of runoff, albedo and surface temperature records over the Greenland during the summer of 2015. New records of monthly mean zonal winds at 500 hPa and of the maximum latitude of ridge peaks of the 5,700±50 m isohypse over the Arctic were associated with the formation and persistency of a cutoff high. The unprecedented (1948–2015) and sustained atmospheric conditions promoted enhanced runoff, increased the surface temperatures and decreased the albedo in northern Greenland, while inhibiting melting in the south, where new melting records were set over the past decade.

Atmospheric circulation controls the mass and energy balance of the Greenland ice sheet, yet the exact dynamics remain unknown. Here, the authors show that record conditions over Greenland during the summer of 2015 were associated with the formation and persistency of an Arctic cut-off high.

Non-invasive monitoring of ultrasound-stimulated microbubble radiation enhancement using photoacoustic imaging

Modulation of the tumour microvasculature has been demonstrated to affect the effectiveness of radiation, stimulating the search for anti-angiogenic and vascular-disrupting treatment modalities. Microbubbles stimulated by ultrasound have recently been demonstrated as a radiation enhancer when used with different cancer models including PC3. Here, photoacoustics imaging technique was used to assess this treatment’s effects on haemoglobin levels and oxygen saturation. Correlations between this modality and power doppler assessments of blood flow, and histology measurements of vascular integrity and cell death were also investigated. Xenograft prostate tumours in SCID mice were treated with 0, 2, or 8 Gy radiation combined with microbubbles exposed to 500 kHz ultrasound at a peak negative pressure of 0, 570, and 750 kPa. Tumours were assessed and levels of total haemoglobin, oxygen saturation were measured using photoacoustics before and 24 hours after treatment along with power doppler measured blood flow. Mice were then sacrificed and tumours were assessed for cell death and vascular composition using immunohistochemistry. Treatments using 8 Gy and microbubbles resulted in oxygen saturation decreasing by 28 ± 10% at 570 kPa and 25 ± 29% at 750 kPa, which corresponded to 44 ± 9% and 40 ± 14% respective decreases in blood flow as measured with power doppler. Corresponding histology indicated 31 ± 5% at 570 kPa and 37 ± 5% at 750 kPa in terms of cell death. There were drops in intact vasculature of 15 ± 2% and 20 ± 2%, for treatments at 570 kPa and 750 kPa. In summary, photoacoustic measures of total haemoglobin and oxygen saturation paralleled changes in power doppler indicators of blood flow. Destruction of tumour microvasculature with microbubble-enhanced radiation also led to decreases in blood flow and was associated with increases in cell death and decreases in intact vasculature as detected with CD31 labeling.

Abstract P5-18-21: A Phase II randomized trial of lapatinib with either vinorelbine or capecitabine as first- and second-line therapy for ErbB2-overexpressing metastatic breast cancer (MBC)

Background: Lapatinib (L), a dual kinase inhibitor of epidermal growth factor receptor and ErbB2, is effective in the treatment of ErbB2+ MBC in combination with capecitabine (C) following progression after trastuzumab, anthracyclines, and taxanes. Vinorelbine (V) is an important chemotherapy option in MBC, and multiple Phase II trials have been conducted in combination with trastuzumab. This randomized, open-label, multicenter, Phase II study (LAP112620, VITAL) evaluated the efficacy and safety of L with either V or C in women with ErbB2+ MBC.

Methods: Patients with MBC who had received ≤1 chemotherapy regimen in the metastatic setting were randomized 2:1 to either L 1250 mg orally once daily (QD) continuously plus V 20 mg/m2 intravenously on Days 1 and 8, every third week, or L 1250 mg orally QD continuously plus C 2000 mg/m2/day orally in 2 doses 12 hours apart on Days 1–14 every third week. Patients were stratified by prior receipt of therapy for MBC (Y/N) and site of metastatic disease (visceral/soft tissue or bone-only). The primary endpoint of progression-free survival (PFS) was assessed once all subjects had been followed for a minimum of 6 months or had otherwise progressed, died or withdrawn, if sooner. The primary focus was to evaluate PFS in the L plus V arm with a descriptive intent only. Other endpoints included overall response rate, overall survival, and safety. Patients progressing on one treatment arm were given the option of crossing over to the other arm.

Results: 112 patients were randomized. The results and conclusions sections will be updated once the primary analysis has been completed in September 2012.

ClinicalTrials.gov - NCT01013740

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-18-21.

OT1-02-09: A Phase II Randomized Trial of Lapatinib with Either Vinorelbine or Capecitabine as First- and Second-Line Therapy for HER2−Overexpressing Metastatic Breast Cancer

Background: Lapatinib, a dual kinase inhibitor of epidermal growth factor receptor (EGFR) and the human epidermal growth factor receptor-2 (HER2/ErbB2), is approved for the treatment of HER2−overexpressing (HER2+) metastatic breast cancer (MBC) in combination with capecitabine following progression after trastuzumab, anthracyclines, and taxanes. Vinorelbine is an important chemotherapy option in MBC, and multiple phase II trials in combination with trastuzumab have been conducted.

Methods: This randomized, open-label, multicenter, phase II study (VITAL, LAP112620, NCT01013740) is evaluating the efficacy and safety of lapatinib with either vinorelbine or capecitabine in women with HER2+ MBC. A total of 105 stage IV breast cancer patients with disease progression who have received ≤1 chemotherapy regimen in the metastatic setting with an ECOG performance status of ≤1 are randomized 2:1 to either: lapatinib 1250 mg orally once daily (QD) continuously plus vinorelbine 20 mg/m2 intravenously on days 1 and 8 every third week; or lapatinib 1250 mg orally QD continuously plus capecitabine 2000 mg/m2/d orally in 2 doses 12 hours apart on days 1 to 14 every third week. Following progression in the randomized phase, patients will be given the option to cross over to the other arm. The primary endpoint is progression-free survival and will be analyzed with a descriptive intent since the study is not powered to detect differences between treatment arms. Secondary endpoints include overall response rate, overall survival, duration of response, time to response, and clinical benefit rate.

The study is currently recruiting in 8 countries in Europe (Bulgaria, France, Germany, Greece, Italy, Poland, Serbia, Spain) and 2 in Latin America (Chile, Mexico).

Funding Source: GlaxoSmithKline

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr OT1-02-09.

Morphology of femtosecond laser modification of bulk dielectrics

Using 3D Finite-Difference-Time-Domain simulations, we study the morphology of the laser-created damage inside fused silica. Among the competing effects limiting the intensity in the dielectric, we find the most important is the pulse defocusing by the plasma lens, partially balanced by the Kerr effect. Less important are collisional energy dissipation and laser depletion by multi-photon absorption. We also found that the profile of generated plasma is asymmetrical in the transverse cross-section, with the plasma extended along the direction perpendicular to the laser polarization.

Peak inspiratory flows in children with cystic fibrosis

OBJECTIVE

To show that in children with moderately severe cystic fibrosis lung disease: (i). inspiratory flow may be reduced; and (ii). peak inspiratory flow may be predicted from height, expiratory flow analysis or body mass index.

METHODS

All children attending the Royal Children's Hospital, Melbourne, between May and July, 2001 who had cystic fibrosis, were aged > 5 years, were able to perform spirometry reproducibly and who had a forced expiratory volume in 1 s < 60% predicted were prospectively enrolled. Height, weight, peak inspiratory flow, forced expiratory volume in 1 s and forced vital capacity were recorded. Linear regression analysis was performed.

RESULTS

The age range was 9.4-19.9 years. Sixteen boys and 11 girls were studied. All children had a peak inspiratory flow > 0.5 L/s. There was a significant relationship between peak inspiratory flow and forced vital capacity (R2 = 0.50) especially in boys (R2 = 0.65). In boys, peak inspiratory flow was significantly related to forced expiratory volume in 1 s (R2 = 0.47). There was no relationship between peak inspiratory flow and predicted values of expiratory flow, age, height, weight or body mass index. Logistic regression was used to predict the probability that peak inspiratory flow was < 2.0 L/s for a given forced vital capacity. If the forced vital capacity is > 2.5 L, peak inspiratory flow is likely to be > 2.0 L/s.

CONCLUSIONS

In children with significant cystic fibrosis lung disease, peak inspiratory flow is likely to be > 0.5 L/s, which is required to activate dry powder inhalers. If the forced vital capacity is < 2.5 L, the peak inspiratory flow may be < 2.0 L/s, and a metered dose inhaler and spacer should be considered. Further studies that investigate the relationship between expiratory flow and peak inspiratory flow against an internal resistance are needed.

A case of cerebral haemorrhage-can Ginkgo biloba be implicated?

The case of a 56 year old man who suffered a spontaneous intracerebral haemorrhage after regular self medication with the herbal preparation, Ginkgo biloba leaf extract is described, and the possible association is discussed.

Analytical methods for water disinfection byproducts in foods and beverages

The determination of exposure to drinking water disinfection byproducts (DBPs) requires an understanding of how drinking water comes into contact with human through multiple pathways. In order to facilitate the investigation of human exposure to DBPs via foods and beverages, analytical method development efforts were initiated for haloacetonitriles, haloketones, chloropicrin, and the haloacetic acids (HAAs) in these matrices. The recoveries of the target analytes were investigated from composite foods and beverages. Individual foods and beverages used to investigate the general applicability of the developed methods were selected for testing based on their watercontent and frequency of consumption. The haloacetonitriles, the haloketones, and chloral hydrate were generally well recovered (70-130%), except for bromochloroacetonitrile (64%) and dibromoacetonitrile (55%), from foods spiked after homogenization and following extraction with methyl-t-butyl ether (MTBE); the addition of acetone was found to be necessary to improve recoveries from beverages. The process of homogenization resulted in decreased recoveries for the more volatile analytes despite the presence of dry ice. The HAAs were generally well recovered (70-130%), except for trichloroacetic acid (58%) and tribromoacetic acid (132%), from foods but low recoveries and emulsion formation were experienced with some beverages. With both groups of analytes, certain matrices were more problematic (as measured by volatility losses, emulsion formation) than others with regard to processing and analyte recovery.

Characterization of a gene from Zea mays related to the Arabidopsis flowering-time gene LUMINIDEPENDENS

The molecular biology of flowering has been most extensively studied in the quantitative long-day plant Arabidopsis thaliana. The Arabidopsis LUMINIDEPENDENS (LD) gene encodes a potential transcriptional regulator that acts as a positive effector of flowering, at least in part through suppression of the floral inhibitor gene FLC. As an initial step to explore the conservation of the molecular mechanisms of flowering among plants of various flowering habits, and to further investigate the molecular action(s) of LD, we have identified a gene from maize (Zea mays) that is closely related to Arabidopsis LD. The major product of this gene, which we have designated ZmLD for Zea mays LUMINIDEPENDENS, contains four conserved regions that may constitute functionally important components of the LD proteins. One of these regions closely resembles the canonical homeodomain. The ZmLD gene exists as a single copy in the maize genome, and generates a major ca. 4.0 kb transcript, and a minor ca. 2.6 kb transcript that results from alternative transcriptional termination. The 4.0 kb ZmLD alpha transcript accumulated to highest levels in proliferative tissues, including the shoot apex and developing inflorescences. Expression of ZnLD alpha under control of the Arabidopsis LD promoter in transgenic Arabidopsis caused developmental defects similar to those conferred by loss-of-function mutations in a class of genes involved in maintaining the proliferative nature of the shoot, inflorescence, and floral meristems. These effects were not influenced markedly by the activities of the Arabidopsis LD or FLC genes. We consider the implications for the conservation of LD function between maize and Arabidopsis.

Type XV collagen in human colonic adenocarcinomas has a different distribution than other basement membrane zone proteins

In situ carcinomas must penetrate their own basement membrane to be classified as invasive, and subsequently infiltrate surrounding connective tissue and cross vascular basement membranes to metastasize hematogenously. Accordingly, in many studies, integral basement membrane components, including type IV collagen, laminin, and heparan sulfate proteoglycan, have been localized in a spectrum of tumors to gain insight into their role in neoplasia. A number of recently identified extracellular matrix molecules and isoforms of the aforementioned proteins have been localized to the basement membrane zone, illustrating another level of biochemical heterogeneity in these structures. As the complexity of these matrices becomes more apparent, their roles in maintaining homeostasis and in tumor biology falls into question. Of the new group of collagens localized to the basement membrane zone, type XV was the first to be characterized (Cell Tissue Res, 286:493-505, 1996). This nonfibrillar collagen has a nearly ubiquitous distribution in normal human tissues via a strong association with basement membrane zones, suggesting that it functions to adhere basement membrane to the underlying stroma. To begin investigation of this protein in malignant tumors, we have localized type XV in human colonic adenocarcinomas and compared its distribution with that of type IV collagen and laminin. Collagens XV and IV and laminin were found in all normal and colonic epithelial, muscle, fat, neural, and vascular basement membrane zones, as shown previously. In moderately differentiated, invasive adenocarcinomas, laminin and type IV collagen were sometimes observed as continuous, linear deposits around some of the malignant glands, but more often they were seen in either discontinuous deposits or were completely absent. In contrast, type XV collagen was characterized as virtually absent from the basement membrane zones of malignant glandular elements in moderately differentiated tumors. Nevertheless there were also similarities; all 3 proteins were usually present in the stroma and adjacent vascular basement membrane zones surrounding invasive glands. The loss of type XV collagen from these malignant epithelial basement membrane zones and its increased interstitial expression suggests a role for this protein in the invasive process and the possibility that it may provide a sensitive indicator of tumor invasion.

Comparative injury rates of uninjured, anterior cruciate ligament-deficient, and reconstructed knees in a skiing population

To evaluate the risks of skiing after anterior cruciate ligament injury with or without reconstruction, we performed a 3-year study of 5646 skiers employed by a large ski resort. All skiers underwent knee ligament examinations before entering the study. The participants were divided into three groups based on whether they had never had an anterior cruciate ligament injury (N = 4748), were unilaterally deficient of the ligament (N = 138), or had undergone a unilateral reconstruction of the ligament at least 1 year before (N = 274). The rates of knee injuries requiring evaluation by a physician or time off work were calculated. The results of the reconstructed knees were further evaluated to determine whether ligament repair with semitendinosus/gracilis or patellar tendon autograft had a higher injury rate. Compared with knees with intact anterior cruciate ligaments, ligament-deficient knees had a 6.2-times higher rate of injuries, and knees in which the ligament had been reconstructed had a 3.1-times higher rate. The differences between each of the three groups were significant. Injuries to ligament-intact knees were less severe, with 13% requiring surgery, while 39% of the injuries in the ligament-deficient and 41% of the injuries in the reconstructed-ligament knees required surgery. The rates of injury for the graft types were not significantly different, but skiers with a semitendinosus/gracilis tendon autograft were significantly more likely to rupture their graft than skiers with a patellar tendon autograft.

Segmenting healthcare terminology users: a strategic approach to large scale evolutionary development

Healthcare terminologies have become larger and more complex, aiming to support a diverse range of functions across the whole spectrum of healthcare activity. Prioritization of development, implementation and evaluation can be achieved by regarding the "terminology" as an integrated system of content-based and functional components. Matching these components to target segments within the healthcare community, supports a strategic approach to evolutionary development and provides essential product differentiation to enable terminology providers and systems suppliers to focus on end-user requirements.

Genetic polymorphisms in glutathione S-transferase mu and theta, N-acetyltransferase, and CYP1A1 and risk of gliomas

The role of genetic polymorphisms in modulating susceptibility to carcinogenic exposures has been well explored for tobacco-related neoplasms but not for other neoplasms including gliomas. It is relevant to explore these polymorphisms because certain carcinogenic exposures such as nitrosamines are implicated in the risk of gliomas. We therefore conducted a pilot case-control study to examine the role of polymorphisms in GSTM1, GSTT1, NAT2 (rapid, intermediate, and slow acetylation), and CYP1A1 and risk of glioma. Ninety patients diagnosed with glioma were ascertained as part of an ongoing genetic epidemiological study and were age, gender, and race matched with 90 healthy controls. We used PCR based methodology to determine the prevalence of the above genetic polymorphisms using sequences and PCR conditions directly adapted from studies reported previously. We calculated univariate odds ratios and performed multiple logistic regression to assess interactions between polymorphisms. We found no statistically significant associations between the null genotypes of GSTM1 and GSTT1, and CYP1A1 and risk of gliomas. However, there was an intriguing pattern with NAT2 acetylation status (odds ratios, 1.81, 1.34, and 0.61 for rapid, intermediate, and slow acetylation, respectively; P = 0.10 for trend). It is unlikely that any single polymorphism is sufficiently predictive of risk, and a panel of markers integrated with epidemiological data should be conducted on a large number of study subjects to fully understand the role of genetic polymorphisms and brain tumor risk.

Grade predictions for school-leaving examinations: do they predict anything?

The attributes of 721 medical students admitted to the United Medical and Dental Schools (UMDS) of Guy's and St. Thomas' Hospitals, London, UK between the years 1991 and 1994 were examined to determine the relationship between A-level grade predictions (as completed on each student's UCAS form by their school/college at the time of their application to the school) and subsequent assessments of their academic ability and performance. Predicted A-level grades were found to be significantly, if weakly, correlated with the rating of academic ability made at interview by the UMDS interviewing panel. They were not however, related to the grades obtained by students in the A-level examination itself. Further, while success at pre-clinical examinations was predicted by obtained A-level grades, it showed no relationship with the predicted grades. In contrast, the interview-based rating of the applicant's academic potential was significantly predictive of subsequent A level and, to a lesser extent, pre-clinical examination performance. It is concluded that predicted A-level grades may not offer a valid method of assessing the academic potential of applicants for medical school.

An audit of thyroid surgery in a general surgical unit

A total of 143 patients undergoing thyroid surgery in a general surgical unit over an 8-year period were reviewed. In only two patients did thoracic inlet views or thyroid function tests alter clinical management. Fine-needle aspiration failed to detect one well-differentiated follicular carcinoma (false-negative rate 1.1%). The sensitivity for malignancy of fine-needle aspiration, ultrasound and radioisotope scan were 94%, 53% and 24%, respectively. The corresponding specificity was 59%, 72% and 58% and accuracy 65%, 70% and 49%, respectively. The specificity of fine-needle cytology for detecting neoplastic disease (adenoma or carcinoma) was 86% and accuracy 91%. Combinations of fine-needle cytology, ultrasound and radioisotope scanning increased the sensitivity for malignancy, so that fewer tumours were missed, but at the cost of reduced specificity, positive predictive value and accuracy. Hence, ultrasound was only recommended when fine-needle aspiration was inconclusive. Overall perioperative morbidity was 6.3% (one case of postoperative bleeding, two wound infections, four cases of prolonged hypocalcaemia). There were two proven cases of transient, but no permanent, recurrent laryngeal nerve injuries as a result of surgery. Thyroid surgery may be performed satisfactorily by general surgeons with an interest in thyroid disease. Fine-needle cytology is the most informative preoperative investigation. Although aspiration cytology, ultrasound, and scintigraphy all have appropriate indications and limitations, there is no single test or group of tests that can substitute for careful clinical assessment and follow-up.

Plasma disposal rate and hepatic alanine metabolism in pregnant and nonpregnant rabbits

To better define the glucose-alanine relationship and hepatic alanine metabolism during pregnancy, glucose and alanine turnover rates (TR) and simultaneous hepatic alanine uptake were determined in nine term pregnant (P) and 12 nonpregnant (NP) rabbits who had undergone chronic catheterization of both the systemic and hepatic circulations. [U-14C3]Alanine and [3-3H1]glucose were used as tracers. Whole animal [U-14C3]alanine TR was significantly greater in P than in NP animals (42.7 +/- 1.7 versus 31.9 +/- 1.8 mumol.min-1, respectively, p < 0.001). However, there was no difference when the alanine TR was compared on a weight-specific basis (11.3 +/- 0.6 versus 9.6 +/- 0.6 mumol.min-1.kg-1). The glucose TR was higher in P compared with NP rabbits on both an absolute (122.3 +/- 6.2 versus 79.8 +/- 5.8 mumol.min-1, p < 0.001) and a weight-specific basis (32.9 +/- 1.4 versus 24.0 +/- 1.9 mumol.min-1.kg-1, p < 0.005). Although the fraction of plasma glucose derived from plasma alanine in the whole animal was similar in P and NP animals (16.7% +/- 1.4 versus 13.9 +/- 0.7%, respectively), the absolute amount of plasma glucose derived from plasma alanine was greater in P rabbits (20.8 +/- 1.8 versus 11.2 +/- 1.2 mumol.min-1, p < 0.0005). In addition, the percentage of plasma alanine being converted to plasma glucose was greater in P than in NP animals (48.1 +/- 2.6 versus 34.6 +/- 2.0%, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

An audit of surgery of the parotid gland

The management of patients undergoing 50 surgical procedures to the parotid gland was reviewed. The overall accuracy of fine needle aspiration cytology was 87%, false-positive and false-negative rates for malignant disease both being 4%. The sensitivity, specificity and accuracy of fine needle cytology for malignant parotid tumours was 66%, 95%, and 91%, respectively, that of benign tumours (pleomorphic adenoma or Warthin's tumour) being 88%, 83% and 87%, respectively. Sensitivity, specificity and accuracy for the remaining (principally inflammatory) parotid diseases was 100%, 95% and 96%, respectively. The predictive value of a positive test for malignant tumours, benign tumours and inflammatory conditions was 66%, 94% and 75%, respectively. The negative predictive value for these conditions was 95%, 71% and 100%, respectively. Facial nerve weakness after parotidectomy occurred in three patients (8.8%), being permanent in two cases (both malignant). Although Frey's syndrome was not recorded in any of the notes, careful follow-up revealed two cases (6%). To date there have been no local recurrences after excision of either benign or primary malignant parotid masses. One patient with squamous cell carcinoma metastatic to the parotid gland died, despite block dissection of the neck and radiotherapy. This small series with a limited follow-up suggests that diseases of the parotid gland can be managed by general surgeons with an interest in this field. Although fine needle aspiration and ultrasonic scan may be helpful, the decision to operate should be made on clinical grounds.

After the merger. Quality assurance for combined services

The Patient Support Services Supervisory/Lead Staff have adapted well to using the MQAI format. We had always used a Quality control of Inspection sheet internally to evaluated performance levels, correct problems and generate work orders. Interviewing patients directly on a random basis was first approached with some fear and reticence. However, the positive comments, especially about the friendliness of our staff, made the task more enjoyable. The input of the nurse or area manager has been more difficult to obtain because of busy work schedules. We receive mostly favorable marks about our staff's service, quality and attitude. The most consistent feedback reflects the desire of area managers to have a dedicated support service person for their unit. This is not based on job performance, but personality, a support person who "fits in" with the other unit staff. This is probably a result of a clear shift to a patient centered care of "team" concept. From the MQAI form, we still generate many work orders for the engineering department and seek to correct housekeeping deficiencies. The problem area that seems to stand out is carpet spotting and odor. We have come to the conclusion that due to rising patient acuity levels, carpeting simply does not belong in a patient room. A program to replace carpeted patient rooms, one at a time if necessary, has been initiated. By constant repetition, our staff knows the hospital codes, safety procedures and universal precautions. We are proud to say, the most "appropriate action" based on our Quality Assessment and Improvement Plan has been to congratulate our staff for a job well done.

Hepatic amino acid metabolism during hyperinsulinemia and hyperaminoacidemia in conscious rabbit during late pregnancy

To test whether pregnancy has any effect on amino acid metabolism, we examined in two experimental conditions (1) the effect of hyperinsulinemia on the blood concentration and net hepatic balance of amino acids, and (2) the effect of hyperaminoacidemia on the hepatic handling of amino acids. Experiments were performed in conscious virgin and pregnant rabbits after an 18-hour fast. In the first protocol (hyperinsulinemia), an increment in the plasma insulin level (approximately 45 and 20 microU/mL in the portal vein and artery, respectively) with euglycemia maintained causes a similar decrease (approximately 27% to 34%) in blood amino acid concentrations without any changes in the net hepatic uptake of amino acids in both groups of animals. The hepatic uptake of branched-chain amino acids (BCAA) was practically negligible, whereas there was a consistent uptake of gluconeogenic amino acids in pregnant and nonpregnant rabbits. In the second protocol, hyperaminoacidemia leads to a significantly lower increase in the net hepatic uptake of glycine and serine in pregnant rabbits as compared with nonpregnant rabbits. The same trend was observed for the uptake of individual BCAA, but it did not reach statistical significance. We conclude that in pregnant rabbits (1) insulin does not modify the hepatic uptake of amino acids, and its ability to suppress the release of amino acids from peripheral tissues does not seem to be affected when compared with that in nonpregnant animals, and (2) when hyperaminoacidemia occurs, a greater amount of gluconeogenic amino acids (glycine and serine) would escape the liver, suggesting a higher availability of these circulating amino acids for the fetus.

Hepatic metabolism during fasting-refeeding transition in conscious pregnant rabbits

The aim of the present study was to determine changes induced by pregnancy in the hepatic handling of nutrients during the fasting-refeeding transition. Net hepatic and gut substrate fluxes were determined by the Fick principle in conscious pregnant (day 30) and nonpregnant rabbits in the 2 h after consumption of a mixed meal. Hepatic glucose production was suppressed by approximately 50% in both groups from 15 to 90 min. Pregnant rabbits returned to control levels at 120 min. Pregnant females displayed a larger gut glucose output and a greater arterial hyperglycemia. The hepatic and gut balance of lactate as well as the arterial level was almost unchanged. In pregnant females the hepatic uptake and arterial concentration of free fatty acids (FFA) remained almost unchanged, whereas these measures decreased in nonpregnant females by approximately 55 and approximately 80%, respectively, at 120 min. The decline in hepatic output of beta-hydroxybutyrate was similar in both groups. In pregnant rabbits arterial levels of beta-hydroxybutyrate did not parallel changes in the hepatic release as in nonpregnant females. Pregnant females displayed a greater hyperinsulinemia both in the portal vein and the artery over the first hour. It is concluded that, in pregnant rabbits fed a mixed meal, the ability of the liver to handle glucose is impaired because of insulin resistance. The latter brings about a greater and prolonged arterial hyperglycemia, which is reinforced by peripheral insulin resistance. Furthermore, the higher level of FFA may also contribute to the hyperglycemia. As a result, a greater amount of glucose is diverted to other sites, presumably the uterus.

The influence of aluminum on growth, carbohydrate, and organic acid content of an aluminum-tolerant and an aluminun-sensitive cultivar of wheat

An aluminum-sensitive cultivar (Katepwa) and an aluminum-tolerant experimental line (PT741) of Triticum aestivum were grown in nutrient solutions containing 0–400 μM aluminum at pH 4.5. After 18 days of growth, plant fresh weight was reduced in the Al-sensitive and Al-tolerant germ plasm by as little as 100 and 200 μM Al, respectively, and a number of changes in carbon allocation were observed. Shoot to root ratios increased with Al concentration in the Al-sensitive 'Katepwa' and remained constant in the Al-tolerant PT741.In both 'Katepwa' and PT741, shoot carbon was increasingly deposited into starch and fructan pools with increasing Al concentration. However, fructan deposition was more marked in the Al-sensitive 'Katepwa', possibly reflecting a failure to export carbon to the roots. Differences between Al-tolerant and Al-sensitive germ plasm were also observed in some organic acid levels. Contrary to several previous reports, higher concentrations of organic acids were found in the roots of Al-sensitive 'Katepwa'. In shoots, higher concentrations of organic acid were found in the Al-tolerant PT741. These results suggest that allocation of carbon to specific pools is affected by the concentration of Al. However, synthesis of organic acids and subsequent chelation of intracellular Al does not appear to represent a tolerance strategy in wheat. Observed changes in metabolic levels more likely represent a broad array of toxic lesions, with the magnitude of changes being greater in the Al-sensitive 'Katepwa' than in the Al-tolerant PT741. Key words: stress, aluminum tolerance, aluminum sensitivity, fructans.

The Guy's/Age Concern survey. Prevalence rates of cognitive impairment, depression and anxiety in an urban elderly community

A sample of 890 people aged 65 years and over living at home in the Lewisham and North Southwark Health District was interviewed using a structured schedule containing CARE organic brain syndrome and depression scales, and items dealing with anxiety symptoms. Total prevalence rates were 4.6% for cognitive impairment, 13.5% for depression, 3.7% for generalised anxiety, and 10.0% for phobic disorders. Cognitive impairment increased exponentially with age, and was associated with lower occupational class. There was no significant association between occupational class and depression, generalised anxiety, or phobic disorder in this sample. Cognitive impairment, depression and agoraphobia were associated with significantly higher levels of dependency in the tasks of daily living.

Cloning and analysis of genes involved in coenzyme B12 biosynthesis in Pseudomonas denitrificans

Cobalamin synthesis probably requires 20 to 30 different enzymatic steps. Pseudomonas putida and Agrobacterium tumefaciens mutants deficient in cobalamin synthesis (Cob have been isolated. In P. putida, Cob mutants were identified as being unable to use ethanolamine as a source of nitrogen in the absence of added cobalamin (deamination of ethanolamine requires coenzyme B12 as a cofactor). In A. tumefaciens, Cob mutants were simply screened for their reduced cobalamin synthesis. A genomic library of Pseudomonas denitrificans was constructed on a mobilizable wide-host-range vector. Eleven plasmids from this library were able to complement most of these mutants. By complementation and restriction mapping analysis, four genomic loci of P. denitrificans were found to be responsible for complementation of the Cob mutants. By subcloning fragments from the four genomic loci, we identified at least 14 different genes involved in cobalamin synthesis.