P-031 AN UNUSUAL CASE OF AN INCARCERATED 5MM PORT SITE HERNIA FOLLOWING LAPAROSCOPIC FUNDOPLICATION

Aim

Port site hernias are a rare, but recognised risk of laparoscopic surgery. Literature supports fascial closure at port sites of 10mm or greater. However, there are few reported cases of herniation through 5mm port sites.

Methods

This case report focuses on a 67-year-old female who underwent an uncomplicated primary laparoscopic Toupet's fundoplication. 11 days post procedure she presented with an incarcerated port site hernia. CT scan demonstrated high grade small bowel obstruction with a transition point at the site of the 5mm right sided port. A laparotomy was performed, the hernia reduced, small bowel was viable, and the port site hernia was closed internally using vicryl sutures.

Results

The incidence of 5mm trocar-site hernias is rare. A recent literature review found only 10 such cases related to general surgery (cholecystectomy:6; appendicectomy: 2; right hemicolectomy: 1; paraesophageal hernia:1). Risk factors for port-site hernias include: high BMI, midline position, size, number and type of trocar tip. The limited current literature identifies excessive trocar manipulation as the major risk factor for developing 5mm port-site hernias, yet routine fascial closure is not supported.

Conclusion

Herniation at 5mm port sites is rare but attention should be paid when patients present with symptoms suggesting its occurrence.

The promise of layer-specific neuroimaging for testing predictive coding theories of psychosis

Predictive coding potentially provides an explanatory model for understanding the neurocognitive mechanisms of psychosis. It proposes that cognitive processes, such as perception and inference, are implemented by a hierarchical system, with the influence of each level being a function of the estimated precision of beliefs at that level. However, predictive coding models of psychosis are insufficiently constrained-any phenomenon can be explained in multiple ways by postulating different changes to precision at different levels of processing. One reason for the lack of constraint in these models is that the core processes are thought to be implemented by the function of specific cortical layers, and the technology to measure layer specific neural activity in humans has until recently been lacking. As a result, our ability to constrain the models with empirical data has been limited. In this review we provide a brief overview of predictive processing models of psychosis and then describe the potential for newly developed, layer specific neuroimaging techniques to test and thus constrain these models. We conclude by discussing the most promising avenues for this research as well as the technical and conceptual challenges which may limit its application.

Effect of broiler genetics, age, and gender on performance and blood chemistry

A total of 640 broilers were used to determine the effects of strain, sex, and age on hematology and blood chemistry using rapid detection devices. Day old chicks from two genetic lines of common fast-growing and high-yield broiler strains were sexed and allocated to 40 pens (16 birds per pen) containing either male or female and Ross or Cobb strains (n = 10). Venous blood was analyzed weekly using 2 broilers from each pen (n = 20) using the i-STAT® Alinity Handheld Clinical Analyzer, Zoetis Vetscan VS2, and iCheck™ Carotene devices at 14, 21, 28, 35, and 42 d, as well as growth performance. Post-mortem health tracking metrics were also recorded on 42 d. Broilers were deemed healthy based on posting data results and performed in accordance with industry standards with males presenting greater BW and reduced FCR than female broilers. Ross broilers displayed greater BW to 14 d with similar FCR compared with Cobb birds. Day of age had a highly significant impact on blood calcium, phosphorus, potassium, sodium, chloride, carotene, aspartate aminotransferase, creatine kinase, bile acids, uric acid, total protein, albumin, globulin, total carbon dioxide, hematocrit, and malondialdehyde. Male broilers had reduced blood sodium, chloride, carotene, uric acid, albumin, and increased total protein, glucose, and total carbon dioxide. Ross broilers had greater blood potassium, and sodium, as well as reduced uric acid, total protein, globulin, and malondialdehyde, compared with Cobb birds. These results demonstrated the effectiveness of point-of-care devices in measuring blood chemistry and hematology in modern broilers. These data can be utilized to determine normal healthy blood ranges in these types of broilers when accounting for strain, sex, and age.

Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing

Background

The use of preoperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative outcomes is increasingly prevalent. CPET-derived information enables personalised perioperative care and enhances shared decision-making. Sex-related differences in physical fitness are reported in non-perioperative literature. However, little attention has been paid to sex-related differences in the context of perioperative CPET.

Aim

We explored differences in the physical fitness variables reported in a recently published multi-centre study investigating CPET before colorectal surgery. We also report the inclusion rate of females in published perioperative CPET cohorts that are shaping guidelines and clinical practice.

Methods

We performed a post hoc analysis of the trial data of 703 patients who underwent CPET prior to major elective colorectal surgery. We also summarised the female inclusion rate in peer-reviewed published reports of perioperative CPET.

Results

Fitness assessed using commonly used perioperative CPET variables—oxygen consumption at anaerobic threshold (AT) and peak exercise—was significantly higher in males than in females both before and after correction for body weight. In studies contributing to the development of perioperative CPET, 68.5% of the participants were male.

Conclusion

To our knowledge, this is the first study to describe differences between males and females in CPET variables used in a perioperative setting. Furthermore, there is a substantial difference between the inclusion rates of males and females in this field. These findings require validation in larger cohorts and may have significant implications for both sexes in the application of CPET in the perioperative setting.

Synapsin I in Intraocular Hippocampal Transplants during Maturation and Aging: Effects of Brainstem Cografts

The role of target innervation for maintenance of synaptic proteins in the hippocampal formation during aging was investigated. Fetal CA1 tissue and brainstem tissue containing the nucleus locus coeruleus was dissected from albino rats and grafted sequentially into the anterior chamber of the eye of adult rat recipients. Synapsin protein distribution and levels were evaluated by immunohistochemistry and quantitative immunolabeling in single hippocampal grafts or brainstem-hippocampal double grafts at 6,12, or 24 mo postgrafting. The synapsin levels in 6-mo-old single hippocampal transplants were significantly lower than those in situ, and remained at these lower levels at 12 and 24 mo. On the contrary, synapsin levels were close to normal in the hippocampal portion of double grafts in the 6- and the 12-mo-group. However, in the 24-mo-old double transplants the levels had declined significantly, approaching levels seen in single hippocampal grafts. The immunoblot results were supported by morphological observations with synapsin antibodies and immunohistochemistry. The present data demonstrate that hippocampal tissue maintained near normal synapsin levels when grafted together with brainstem tissue, as compared to the lower levels seen in single hippocampal grafts. This normalization of synapsin levels was, however, not seen in the aged hippocampal-brainstem double grafts.

Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery

BACKGROUND

In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery.

METHODS

Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity.

RESULTS

Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o₂ at θ^_L ) and at peak exercise (V˙o_2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o₂ at θ^_L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o_2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙_E /V˙co₂ at θ^_L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m² : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres.

CONCLUSION

These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.

Attentional bias modification (ABM) training induces spontaneous brain activity changes in young women with subthreshold depression: a randomized controlled trial

BACKGROUND

Attention bias modification (ABM) training has been suggested to effectively reduce depressive symptoms, and may be useful in the prevention of the illness in individuals with subthreshold symptoms, yet little is known about the spontaneous brain activity changes associated with ABM training.

METHOD

Resting-state functional MRI was used to explore the effects of ABM training on subthreshold depression (SubD) and corresponding spontaneous brain activity changes. Participants were 41 young women with SubD and 26 matched non-depressed controls. Participants with SubD were randomized to receive either ABM or placebo training during 28 sessions across 4 weeks. Non-depressed controls were assessed before training only. Attentional bias, depressive severity, and spontaneous brain activity before and after training were assessed in both training groups.

RESULTS

Findings revealed that compared to active control training, ABM training significantly decreased depression symptoms, and increased attention for positive stimuli. Resting-state data found that ABM training significantly reduced amplitude of low-frequency fluctuations (ALFF) of the right anterior insula (AI) and right middle frontal gyrus which showed greater ALFF than non-depressed controls before training; Functional connectivity strength between right AI and the right frontoinsular and right supramarginal gyrus were significantly decreased after training within the ABM group; moreover, the improvement of depression symptoms following ABM significantly correlated with the connectivity strength reductions between right AI and right frontoinsular and right supramarginal gyrus.

CONCLUSION

These results suggest that ABM has the potential to reshape the abnormal patterns of spontaneous brain activity in relevant neural circuits associated with depression.

Validation of preoperative cardiopulmonary exercise testing-derived variables to predict in-hospital morbidity after major colorectal surgery

BACKGROUND

In single-centre studies, postoperative complications are associated with reduced fitness. This study explored the relationship between cardiorespiratory fitness variables derived by cardiopulmonary exercise testing (CPET) and in-hospital morbidity after major elective colorectal surgery.

METHODS

Patients underwent preoperative CPET with recording of in-hospital morbidity. Receiver operating characteristic (ROC) curves and logistic regression were used to assess the relationship between CPET variables and postoperative morbidity.

RESULTS

Seven hundred and three patients from six centres in the UK were available for analysis (428 men, 275 women). ROC curve analysis of oxygen uptake at estimated lactate threshold (V˙o₂ at θ^_L ) and at peak exercise (V˙o_2peak ) gave an area under the ROC curve (AUROC) of 0·79 (95 per cent c.i. 0·76 to 0·83; P < 0·001; cut-off 11·1 ml per kg per min) and 0·77 (0·72 to 0·82; P < 0·001; cut-off 18·2 ml per kg per min) respectively, indicating that they can identify patients at risk of postoperative morbidity. In a multivariable logistic regression model, selected CPET variables and body mass index (BMI) were associated significantly with increased odds of in-hospital morbidity (V˙o₂ at θ^_L 11·1 ml per kg per min or less: odds ratio (OR) 7·56, 95 per cent c.i. 4·44 to 12·86, P < 0·001; V˙o_2peak 18·2 ml per kg per min or less: OR 2·15, 1·01 to 4·57, P = 0·047; ventilatory equivalents for carbon dioxide at estimated lactate threshold (V˙_E /V˙co₂ at θ^_L ) more than 30·9: OR 1·38, 1·00 to 1·89, P = 0·047); BMI exceeding 27 kg/m² : OR 1·05, 1·03 to 1·08, P < 0·001). A laparoscopic procedure was associated with a decreased odds of complications (OR 0·30, 0·02 to 0·44; P = 0·033). This model was able to discriminate between patients with, and without in-hospital morbidity (AUROC 0·83, 95 per cent c.i. 0·79 to 0·87). No adverse clinical events occurred during CPET across the six centres.

CONCLUSION

These data provide further evidence that variables derived from preoperative CPET can be used to assess risk before elective colorectal surgery.

Acute fluoxetine modulates emotional processing in young adult volunteers

BACKGROUND

Fluoxetine is generally regarded as the first-line pharmacological treatment for young people, as it is believed to show a more favourable benefit:risk ratio than other antidepressants. However, the mechanisms through which fluoxetine influences symptoms in youth have been little investigated. This study examined whether acute administration of fluoxetine in a sample of young healthy adults altered the processing of affective information, including positive, sad and anger cues.

METHOD

A total of 35 male and female volunteers aged between 18 and 21 years old were randomized to receive a single 20 mg dose of fluoxetine or placebo. At 6 h after administration, participants completed a facial expression recognition task, an emotion-potentiated startle task, an attentional dot-probe task and the Rapid Serial Visual Presentation. Subjective ratings of mood, anxiety and side effects were also taken pre- and post-fluoxetine/placebo administration.

RESULTS

Relative to placebo-treated participants, participants receiving fluoxetine were less accurate at identifying anger and sadness and did not show the emotion-potentiated startle effect. There were no overall significant effects of fluoxetine on subjective ratings of mood.

CONCLUSIONS

Fluoxetine can modulate emotional processing after a single dose in young adults. This pattern of effects suggests a potential cognitive mechanism for the greater benefit:risk ratio of fluoxetine in adolescent patients.

Decision making in young people at familial risk of depression

BACKGROUND

Major depression is associated with abnormalities in reward processing at neural and behavioural levels. Neural abnormalities in reward have been described in young people at familial risk of depression but behavioural changes in reward-based decision making have been less studied in this group.

METHOD

We studied 63 young people (mean age 18.9 years) with a parent with a diagnosis of major depression but who had never been depressed themselves, that is with a positive family history of depression (the FH+ group). Participants performed the Cambridge Gambling Task (CGT), which provides several measures of decision making including deliberation time, quality of decision making, risk taking, risk adjustment and delay aversion. A control group of 49 age- and gender-matched young people with no history of mood disorder in a first-degree relative undertook the same task.

RESULTS

Both FH+ participants and controls had low and equivalent scores on anxiety and depression self-rating scales. Compared to controls, the FH+ participants showed overall lower risk taking, although like controls they made more risky choices as the odds of a favourable outcome increased. No other measures of decision making differed between the two groups.

CONCLUSIONS

Young people at increased familial risk of depression have altered risk taking that is not accounted for by current affective symptomatology. Lowered risk taking might represent an impairment in reward seeking, which is one of several changes in reward-based behaviours seen in acutely depressed patients; however, our findings suggest that decreased reward seeking could be part of a risk endophenotype for depression.

Effects of low dose tryptophan depletion on emotional processing in dieters

Biased processing of ED-relevant stimuli (eg Fairburn, Shafran, & Cooper, 1999) and 5-HT function (Kaye, Fudge, & Paulus, 2009) are implicated in vulnerability to and the maintenance of eating disorders (EDs), but it is not known if these findings are connected: Could manipulating 5-HT function affect the processing of ED-relevant stimuli? To address this question we assessed emotional processing in female dieters (T+n=12, T-n=14) following acute low dose tryptophan depletion. ATD increased interference in the masked condition of the emotional Stroop to all negative emotional stimuli, in the absence of any other differences in emotional processing. These results suggest that ATD affects the processing of some negative (including ED-relevant) stimuli, and that reduced 5-HT function may be involved in some aspects of psychological vulnerability to EDs.

The public health response to the re-emergence of syphilis in Wales, UK

During the 1990s, cases of infectious syphilis were uncommon in Wales. In 2002, an outbreak occurred in a sexual network of men who have sex with men (MSM) attending a sauna. A multidisciplinary outbreak control team was convened to raise awareness of the outbreak among MSM and health professionals, assess the extent of outbreak, and initiate surveillance measures. It is likely that early intensive control efforts dampened the epidemic curve. However, since 2006 the number of cases has increased steadily to a peak of four cases per 100,000 population in 2008. The majority of cases continue to occur in MSM (81% in 2009) and in those attending genitourinary (GU) medicine clinics in south east Wales (76%). Traditional sexual networks such as saunas, bars/clubs and cruising grounds remain frequently reported, but Internet-based networks are assuming increasing importance. Public health interventions have been sustained, using traditional partner notification, health promotion initiatives, and more innovative Internet network tracing methods.

A cognitive neuropsychological model of antidepressant drug action

The psychological mechanisms by which antidepressant drugs act to improve mood remain underspecified. In this paper we consider the evidence to suggest that early changes in emotional processing underlie subsequent mood improvement following antidepressant treatment. Negative biases in information processing are consistently found in depression, and we argue that primary mode of action of antidepressant drugs may be to remediate these biases providing a more positive social environment in which the patient can relearn emotional associations fostering later improvement in mood. Evidence from behavioural and functional magnetic resonance imaging studies supports this hypothesis. Experimental medicine models developed under this premise have the potential to screen for new treatments, to predict individual treatment response and to consider the effects of pharmacological vs psychological treatments.

Effective use of an audit tool devised to optimize the management of syphilis in an integrated sexual health clinic

The objective of this study was to audit the management of syphilis in our integrated sexual health clinic according to the British Association for Sexual Health and HIV (BASHH) guideline using the ‘Treponemal Infection Care’ (TIC) audit tool devised by our clinic. The case notes of patients diagnosed with all stages of syphilis during an 18-month period were reviewed. At the time of diagnosis, the departmental TIC proforma was filled in: this proforma details BASHH auditable outcomes. The case notes of 83 patients diagnosed with syphilis during the audit period were reviewed. The majority of patients were men (76), men who had sex with men (69), HIV-negative (59) and were British (68). In line with current guidance all patients had a baseline Venereal Disease Research Laboratory (VDRL) titre at the start of treatment (target: 100%) and 97% of diagnosed patients completed treatment (target: 95%). A ‘response to treatment’ according to the decrease in VDRL was demonstrated in 50 (60%) patients with two (2%) patients failing to respond according to these criteria. However, 19 (23%) patients failed to return for their VDRL tests before demonstrating an adequate response to treatment, despite repeated attempts to contact them by letter and telephone. Fifty-four patients had at least 50% of their partners documented as traceable. Of those who were contactable, 100% attended for screening or treatment (target: 60%). In conclusion, our department performed well against BASHH auditable outcome targets. The introduction of the TIC proforma greatly facilitated the ease of audit and is a valuable tool within our clinic setting, which may have positively influenced our audit outcomes. Further action is required to highlight the importance of follow-up VDRLs to patients.

Phase II trial of bevacizumab and everolimus in the treatment of patients with metastatic melanoma: Preliminary results

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Background: Metastatic melanoma remains resistant to therapy. Anti-angiogenesis agents and m-TOR inhibitors have shown modest activity as single agents. In this multicenter phase II trial, we evaluated the combination of bevacizumab and everolimus in the treatment of patients with metastatic melanoma. Methods: Patients with unresectable metastatic melanoma with ECOG PS 0–2 were eligible. Up to 2 previous treatment regimens were allowed; patients previously treated with angiogenesis or m-TOR inhibitors were excluded. Additional eligibility requirements: adequate organ function, no CNS involvement, standard bevacizumab exclusions. All patients received bevacizumab 15mg/kg IV q 3 weeks, and everolimus 10mg po daily. Patients were evaluated every 6 weeks, and treatment continued until disease progression. Results: Between February 2008 and October 2008, 56 patients were enrolled; the first 31 patients are included in this interim report. The median age was 71 years (range 36 to 89 years); 19 patients (61%) had visceral metastases; 0/1/2 previous regimens, 12/11/8 patients; ECOG PS 0/1/2, 17/11/1. 28 patients (90%) received at least 6 weeks of treatment; 3 patients withdrew prior to 6 weeks (toxicity, 2 patients; intercurrent illness, 1 patient). 1 of 28 evaluable patients (4%) had a PR. However, 19 additional patients (68%) had stable disease (15 of these patients had measurable decrease in tumor size), for a disease control rate of 72%. 14 patients remain on treatment, after treatment durations of 2 - 7.5 months. After a median followup of 5 months, the median progression-free survival is 3.5 months (95% CI 2.4 - 5.4 months). Bevacizumab/everolimus was generally well tolerated. 1 patient withdrew because of interstitial pneumonitis (reversible) and 1 patient had a fatal MI, possibly bevacizumab-related. Grade 3 mucositis occurred in 13%; other grade 3 toxicities occurred in < 10% of patients. Conclusions: The combination of bevacizumab and everolimus was well tolerated and has activity in patients with metastatic melanoma. Updated results in all 56 patients will be presented.

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Acute post-streptococcal glomerulonephritis associated with prolonged hypocomplementaemia

The case of a 6-year-old boy who presented with acute post-streptococcal glomerulonephritis is reported. C3 levels and complement alternative pathway activity remained low for at least 10 months after presentation, before returning to normal. There was no evidence of other renal disease. This case highlights that hypocomplementaemia in acute post-streptococcal glomerulonephritis may persist for several months, and that prolonged hypocomplementaemia does not exclude this diagnosis.

The natural history of fludarabine-refractory chronic lymphocytic leukemia patients who fail alemtuzumab or have bulky lymphadenopathy

The natural history and outcome of salvage treatment for patients with fludarabine-refractory chronic lymphocytic leukemia who are either refractory to alemtuzumab ("double-refractory") or ineligible for alemtuzumab due to bulky lymphadenopathy ("bulky fludarabine-refractory") have not been described. We present the outcomes of 99 such patients (double-refractory n = 58, bulky fludarabine-refractory n = 41) undergoing their first salvage treatment at our center. Patients received a variety of salvage regimens including monoclonal antibodies (n = 15), single-agent cytotoxic drugs (n = 14), purine analogue combination regimens (n = 21), intensive combination chemotherapy (n = 36), allogeneic stem cell transplantation (SCT; n = 4), or other therapies (n = 9). Overall response to first salvage therapy other than SCT was 23%, with no complete responses. All four patients who underwent SCT as first salvage achieved complete remission. Early death (within 8 weeks of commencing first salvage) occurred in 13% of patients, and 54% of patients experienced a major infection during therapy. Overall survival was 9 months, with hemoglobin < 11 g/dL (hazard ratio 2.3), hepatomegaly (hazard ratio 2.4), and performance status > or = 2 (hazard ratio 1.9) being significant independent predictors of inferior survival.

A single dose of citalopram increases fear recognition in healthy subjects

We have previously shown that a single dose of intravenous citalopram in healthy volunteers enhances the detection of fearful facial expressions, suggesting an effect of acute selective serotonin re-uptake inhibitor (SSRI) treatment on the processing of anxiety-related stimuli. The aim of the present study was to confirm and extend this finding by studying the effects of a single dose of oral citalopram on a range of tasks designed to assess different aspects of emotional processing. A total of 32 healthy volunteers were randomly allocated to double-blind treatment with either citalopram 20 mg orally or placebo. Participants then completed a series of tasks assessing emotional aspects of attention (visual-probe task), perception (categorization of facial affect), memory (emotional memory task) and reactivity to threat (emotion potentiated startle). Relative to placebo-treated subjects, participants treated with citalopram demonstrated improved recognition of fearful faces and increased baseline startle response. However, the citalopram group also showed an attentional bias towards positive words. Our data suggest that acute oral citalopram increases the processing of anxiety-related stimuli in healthy volunteers. This mechanism could underlie the known tendency of SSRIs to increase anxiety in patients early in treatment. Our data also suggests that some of the positive biases in emotional processing produced by SSRI treatment might be detectable at the beginning of treatment.

Pathogenicity of Xanthomonas translucens from Annual Bluegrass on Golf Course Putting Greens

Bacterial wilt of Poa annua has been seen increasingly in the Northeast and mid-Atlantic United States in the past few years. The disease causes severe injury to putting greens and can kill large stands of turfgrass. For some time, however, both the bacterial origin of the disease and the causal agent were in doubt. In order to investigate the identity of the causal agent, isolation of the pathogen was undertaken and pathogenicity was confirmed using Koch's postulates on P. annua. Additional pathogenicity trials then were undertaken to determine the host range of the causal bacterium. Ability of the bacterium to cause disease was restricted to P. annua var. annua and P. attenuata. However, the bacterium was able to survive asymptomatically in vascular systems of P. annua var. reptans and P. trivialis. Experiments to determine the optimal growth temperature of the organism demonstrated that the bacterial growth peaked between 30 and 35°C. Fatty acid analysis suggested that the bacterium might be a species of Xanthomonas but was inconclusive. Ribosomal RNA analysis demonstrated significant similarity to the American Type Culture Collection isolate of Xanthomonas translucens pv. poae at 99.8%. Comparison of the host range to previously reported data agrees with our molecular findings and indicates that the likely casual organism of bacterial wilt of annual bluegrass is X. translucens pv. poae.

Sustained efficacy of nevirapine in combination with two nucleoside analogues in the treatment of HIV-infected patients: a 48-week retrospective multicenter study

BACKGROUND

Nevirapine, a nonnucleoside analogue, has demonstrated suppression of human immunodeficiency virus (HIV) replication alone and in combination therapy. However, the durable suppression of HIV with nevirapine when used along with other nucleosides in HIV-infected patients who are treated in clinical practice needs further evaluation.

PURPOSE

To evaluate the sustained efficacy of nevirapine in combination with two nucleoside analogues in the treatment of HIV-infected patients in routine clinical practice.

DESIGN

A multicenter study from January 1997 to December 2000, with follow-up through 48 weeks, was conducted at four different genitourinary medicine clinics in the United Kingdom. Forty-four HIV-infected patients received nevirapine and two nucleoside analogues. Information from case notes regarding age, sex, side effects, viral load, and CD4 lymphocyte counts at baseline, 24 weeks, and 48 weeks was collected and analyzed. Virologic suppression, defined as HIV RNA concentration of less than 400 copies/mL at Weeks 24 and 48, was considered as the main outcome measure.

RESULTS

Out of 44 patients, 41 were men with a mean age of 39.3 years (95% CI 36.7-41.8). The baseline viral load was 2.11 x 10(2) to 9.74 x 10(5) copies/mL (median 7.7 x 10(4) and CD4 counts 6 to 605 cells/dL (M = 247; 95% CI 198-295). Of 39 patients who completed 48 weeks of treatment, viral load suppression was attained in 31 patients (79.4%; 95% CI 66.8-92.0) at 24 weeks and in 27 patients (69.2%; 95% CI 54-83) at 48 weeks. The CD4 lymphocyte count increased in 32 (82%) patients (mean 106 cells/dL, 95% CI 73-139, p =.0001, Wilcoxon signed rank test) after 24 weeks and in 33 (84.6%) patients (mean 160 cells/dL, 95% CI 115-204, p =.0001, Wilcoxon signed rank test) after 48 weeks of treatment. Of 20 patients whose baseline viral load was <100000, 16 had viral load suppressed at 24 weeks and 15 at 48 weeks (p =.6, chi-square test).

CONCLUSION

A regime of nevirapine with two nucleoside analogues provided durable suppression of plasma viral load in HIV infected patients, with significant improvement in the CD4 cell count.

Systemic neutrophil activation in acute preschool viral wheeze

BACKGROUND

In preschool children, attacks of wheeze are usually triggered by viral colds. The inflammatory substrate in preschool viral wheeze (PVW) is unclear, but epidemiological data suggest that most PVW is not caused by allergic inflammation. We therefore speculated that the neutrophils are an important effector cell. Systemic neutrophil activation is the first stage for the development of pulmonary neutrophilia. Markers of neutrophil activation are shedding of the adhesion molecule L-selectin from the cell surface, upregulation of Mac-1 expression, and an increase in serum soluble L-selectin.

AIMS

To obtain evidence for systemic neutrophil activation during PVW.

METHODS

Preschool children (1-5 years) admitted to hospital with acute PVW (n = 20) and normal controls (n = 18) were studied. Adhesion molecule expression on CD16 positive neutrophils was determined in both groups and expressed as molecules of equivalent fluorochrome (MEF). Serum soluble L-selectin was analysed by ELISA.

RESULTS

Compared with controls, children with PVW had reduced neutrophil L-selectin expression (median MEF (IQR): 69 (11 to 96) units versus 136 (109 to 163) units, p < 0.001) and higher serum soluble L-selectin (2.8 (2.3 to 3.1) versus 2.4 (2.2 to 2.6) micro g/ml, p = 0.04). There was no significant difference in neutrophil Mac-1 expression.

CONCLUSION

Systemic neutrophil activation is associated with acute PVW.

Rheumatoid arthritis: a primary care approach

PURPOSE

To provide primary care providers with guidelines on the evaluation, diagnosis and management of patients with rheumatoid arthritis (RA).

DATA SOURCES

Research-based articles in the medical literature, review articles, and clinical practice is a chronic inflammatory disease that affects mainly synovial joints. Diagnosis is based primarily on clinical examination. Clinical criteria developed by the American Rheumatism Association can help the primary care provider recognize this potentially devastating disease and facilitate early referral to a rheumatologist for treatment.

IMPLICATIONS FOR PRACTICE

Patients with RA should be treated early and aggressively. Laboratory tests are not essential to confirm the diagnosis of RA. The clinical usefulness of the rheumatoid factor could be increased by restricting the test to patients who have a high probability of RA based on clinical symptoms.

Definition of peptide binding motifs amongst the HLA-A*30 allelic group

HLA class I molecules present endogenously processed peptide ligands for surveillance by the T-cell receptor. This potentially immunogenic surface of HLA and peptide is a consequence of the polymorphism found within the HLA molecule and its preference for ligand binding together with peptide conformation within the binding groove. To investigate the relation between the polymorphic differences between some closely related HLA alleles and their effect on peptide preference, transfectants were established, each containing one of four allelic variants of HLA-A*30. Peptides from all four transfectants were eluted, and both individual ligands and peptide pools were sequenced. The data shows two distinct peptide motifs which distinguish A*3001 from the other three known A*30 variants. Differences in preferences at minor positions within the peptide sequence were noted between A*3002, A*3003 and A*3004, providing additional evidence of the implications of sequence polymorphism to HLA function.

Identification of diminished tissue culture invasiveness among multiple antibiotic resistant Salmonella typhimurium DT104

Salmonella infections continue to cause gastrointestinal and systemic disease throughout the world. Salmonella typhimurium further poses a major health concern due to its apparent enhanced ability to acquire multiple antibiotic resistance genes. Currently it is unclear if multiresistant S. typhimurium are more or less pathogenic than non-resistant counterparts. Using an in vitro invasion assay, we evaluated the relative pathogenicity of over 400 multiresistant S. typhimurium isolates. Our studies failed to identify any <<<<hyperinvasive>>>> isolates. However, we identified 12 isolates exhibiting invasive phenotypes that were constrained relative to controls. These <<<<hypoinvasive>>>> strains were found in a variety of phagetypes all possessing at least a hexaresistant profile. Further studies revealed that the alterations in invasion were not due to changes in adherence. Limited studies exploring in vivo virulence revealed a mildly decreased ability to cause murine lethality for the hypoinvasive strain examined. These results indicate that the ability to cause disease is not increased but is rather mildly attenuated for certain isolates of multiresistant S. typhimurium.

Effect of Carbon Amendment and Soil Moisture on Tylenchorhynchus spp. and Hoplolaimus galeatus

The effect of amending soil held at 3 different moisture levels with glucose, unsulfured molasses, or nutrient broth (0.3, 0.7, 3.2, 7.1 g carbon/100 g) on Tylenchorhynchus claytoni and T. dubius was investigated. When soil was held under saturated or flooded conditions in the absence of carbon amendments for 7 days, Tylenchorhynchus populations were 19% and 16%, respectively, of the controls. Carbon amendments at all levels tested precipitated a further decline in the nematode population to 1% or less of the unamended controls in 7 days. Two applications of molasses (7.4%, w/w) 3 days apart to nematode-infested soil held in Conetainers under mist for 7 days reduced Tylenchorhynchus spp. and Hoplolaimus galeatus densities to 7% and 3%, respectively, of the controls. Nematode densities in turfgrass field plots also declined following irrigation and repeated drenching with a molasses solution. Based on the observed decline in redox potential and pH in saturated soil, especially following carbon amendment, we propose that the activity of anaerobic fermentative bacteria was responsible for the reduction in nematode densities.

Pathogenicity of Bacillus thuringiensis variety kurstaki to Ixodes scapularis (Acari: Ixodidae)

Pathogenicity of the entomopathogenic bacterium Bacillus thuringiensis variety kurstaki de Barjac & Lemille was tested against the black-legged tick, Ixodes scapularis Say. Engorged larvae dipped in a solution of 10(8) spores per milliliter showed 96% mortality 3 wk after infection. The LC50 value for engorged larve (concentration required to kill 50% of ticks) was 10(7) spores per milliliter. B. thuringiensis shows considerable potential as a microbial control agent for the management of I. scapularis.

Pathogenicity of the entomopathogenic fungus Metarhizium anisopliae (Deuteromycetes) to Ixodes scapularis (Acari: Ixodidae)

The entomopathogenic fungus Metarhizium anisopliae is highly pathogenic to the black-legged tick, Ixodes scapularis. Spore concentrations of 10(8)/ml for engorged larvae and 10(7)/ml for engorged females resulted in 100% tick mortality, 2 wk postinfection. The LC50 value for engorged larvae (concentration to kill 50% of ticks) was 10(7) spores/ml. Metarhizium anisopliae shows considerable potential as a microbial control agent for the management of Ixodes scapularis.

HLA and cancer: implications for cancer immunotherapy and vaccination

Both animal models and studies in humans indicate that the immune response has enormous potential for the treatment of cancer, and that HLA plays a central role in this. This role is likely to become increasingly important in years to come, as effective strategies for immunotherapy of cancer are developed. In the last few years, much of the focus of tumour immunology has been on the identification and characterization of tumour-associated antigens that represent HLA-restricted tumour-specific targets. In the next few years the emphasis is likely to change, such that the HLA type and antigen profile of an individual's tumour may define the most appropriate form of therapy for the patient. The ability of tumour cells to down-regulate or lose expression of some or all HLA molecules may prove to be a major barrier to the effectiveness of such treatments. The next few years should show whether the potential of the advances in tumour immunology made over the last decade can be realized, or whether the application of these advances as therapeutic strategies falls short of their promise.

Implementation of an osteoporosis research program with a mobile dual-energy X-ray absorptiometry unit: the Montana/Wyoming experience

To expedite recruitment, and subject participation, for a large clinical osteoporosis therapy trial utilizing the bisphosphonate ibandronate, an integrated network of 13 satellite clinical sites was developed, linked by a mobile clinic vehicle transporting a dual-energy X-ray absorptiometry (DXA) unit. A predominantly rural area of the United States (Montana, northern Wyoming) was accessed for the project, due to the large pool of potential subjects living in this area who were not yet involved in osteoporosis clinical studies. The results of the project to date (through 10 months) confirm the feasibility of such a study design, with 1774 subjects screened by DXA for the study, and 280 (15.8%) accepted. The mobile DXA unit has functioned according to specifications for a stationary DXA machine, with the stability of spine phantom measurements over 10 months assessed as a coefficient of variation of 0.46%. The success of the project validates the concept of performing clinical osteoporosis therapy trials in previously underutilized rural community settings, facilitated by a satellite site network and mobile clinic.

Does being unusual and dangerous mean you are mad?

This article is, essentially, an examination of what the medical profession and society generally mean by the term 'mad', and what relevance 'madness' has to modern psychiatry. It suggests that 'madness' differs from 'mental illness' and that psychiatry only deals with the latter. It concludes that for any rigorous, rational approach to psychiatry to be attempted an accepted framework of what constitutes mental illness must be used. This is the important role of ICD 10 and DSM IV which help to ensure that psychiatrists do not act as 'moral gaolers of the state'.

Emergency hormonal contraception usage in genitourinary medicine clinic attenders

OBJECTIVE

To assess the indications for usage of emergency hormonal contraception amongst a population of London genitourinary medicine clinic attenders.

METHODS

In a prospective study, 150 consecutive women receiving emergency hormonal contraception (EHC) were enrolled. The attending doctor completed a questionnaire of patient details and prescribed EHC with prophylactic prochlorperazine. Follow-up was arranged three weeks later, at which time outcomes and side-effects of therapy were recorded. For those women who did not reattended as planned case notes were reviewed at three months.

RESULTS

Of 150 women surveyed, 100 (66%) reported contraceptive method failure, 48 (32%) had used no contraception at the time of last sexual intercourse and two requested EHC after sexual assault. Ninety three (62%) reported condom failure, 7 (5%) oral contraceptive pill failure. Seventy five (50%) had used EHC before (range 1-10 times). Seventy one (47%) women reattended within three months. Five (3.3%) of the 150 women were pregnant; none of these cases had experienced nausea or vomiting whilst taking EHC. Side-effects were reported by 22 (31%) of the 71 patients who reattended. Nine (6%) women had been followed-up in the family planning advisory clinic. Of the 71 women who reattended, 39 (55%) reported that their preferred future method of contraception would be condoms. Of the 150 women 19 (13%) underwent tests for sexually transmissible infections within one month of presentation.

CONCLUSIONS

EHC usage in this population was associated with a failure rate of at least 3.3% and an overall side effect rate of 31%. Despite requests for emergency contraception because of condom failure many elected to continue using condoms as their preferred method of contraception. The majority of women (53%) did not return for follow-up or family planning advice, and so we believe that future contraceptive plans must be addressed at the time EHC is prescribed.

Mechanisms of loss of HLA class I expression on colorectal tumor cells

For several years this laboratory has studied the expression of HLA class I on established colorectal tumor cell lines and on fresh tumors. We review here the mechanisms by which colorectal tumor cells may lose surface expression of HLA class I molecules. Several independent mechanisms have been identified, including loss or mutations in beta 2-microglobulin genes, loss of HLA heavy chain genes, selective lack of expression of HLA alleles, and regulatory defects in HLA expression including loss of expression of the peptide transporters associated with antigen processing (TAP). The data suggest that colorectal tumor cells may evade tumor specific, HLA restricted immune attack by loss of HLA class I expression through a number of mechanisms.

Mechanisms of allele-selective down-regulation of HLA class I in Burkitt's lymphoma

Burkitt lymphomas (BL) that arise in HLA-AII-positive individuals are characterized by selective loss/down-regulation of the HLA AII polypeptide. We have investigated the molecular basis of such down-regulation by comparing 5 pairs of BL lines and Epstein-Barr virus (EBV)-transformed lymphoblastoid cell lines (LCL) derived from the normal B cells of the same individuals. The presence of apparently intact HLA AII genes was confirmed in all 5 BL/LCL pairs by polymerase chain reaction (PCR) typing and by Southern-blot hybridization with HLA A locus-specific probes. Northern-blot analysis with locus- and allele-specific probes revealed a significantly lower expression or absence of AII-specific mRNA in all 5 BL lines compared to the corresponding LCLs. Up-regulation of AII-specific mRNA was achieved by IFN alpha treatment of 2 BL lines with low HLA AII expression (BL-28 and BL-72) while the treatment had no effect in 3 BL lines (WWI-BL, WW2-BL and BL41) that did not express the endogenous gene. HLA AII expression was restored by transfection of the gene in WWI-BL whereas transfectants of BL-41 remained AII-negative. An HLA-AII-promoter-driven chloramphenicol acetyl transferase reporter gene (pAIICAT) was active in WWI-BL but not in BL-41. HLA-AII was expressed in hybrids of BL-41 with an AII-positive LCL, while expression of the endogenous HLA AII gene could not be restored by fusion of BL-41 with an AII-negative LCL, although an adequate set of transcription factors was present in the hybrid. Our results suggest that genetic defects and lack of transcription factors may contribute to the selective down-regulation of HLA AII in BL cells.

Comparison of serum CA 72-4 and CA 19-9 levels in gastric cancer patients and correlation with recurrence

BACKGROUND

This longitudinal prospective study evaluates the serum levels of the tumor markers CA 72-4 and CA 19-9, alone or in combination, in gastric cancer patients.

PATIENTS AND METHODS

Serum tumor markers CA 72-4 and CA 19-9 were measured in 52 patients who had gastric adenocarcinomas and 32 with benign gastric disorders. Serial measurements of these markers were carried out in 30 cancer patients at a median follow-up time of 38 months.

RESULTS

CA 72-4 and CA 19-9 had sensitivities of 42% and 46% for the preoperative detection of gastric cancer. Sensitivity for the two combined was 63%. CA 72-4 provided 100% specificity, compared to 72% for CA 19-9. Postoperatively, 17 cancer patients remained disease-free. Sixteen of these maintained normal levels of CA 72-4, and 10 of CA 19-9. Thirteen patients developed recurrent disease. In 9, serum CA 72-4 levels rose from near-normal after surgery and reached diagnostic values approximately 6 months before clinical diagnosis of recurrence. Only 3 patients exhibited such a pattern with CA 19-9.

CONCLUSIONS

CA 72-4 is a reliable marker in gastric cancer. Postoperative serial sampling of CA 72-4 may facilitate early identification of recurrences.

Identification of conserved antigenic components for a cytotoxic T lymphocyte-inducing vaccine against malaria

Several cellular and humoral mechanisms probably play a role in natural immunity to Plasmodium falciparum malaria, but the development of an effective vaccine has been impeded by uncertainty as to which antigens are targeted by protective immune responses. Experimental models of malaria have shown that cytotoxic T lymphocytes (CTL) which kill parasite-infected hepatocytes can provide complete protective immunity against certain species of Plasmodium in mice, and studies in The Gambia have provided indirect evidence that CTL play a protective role against P falciparum in humans. By using an HLA-based approach, termed reverse immunogenetics, we have previously identified peptide epitopes for CTL in liver-stage antigen-1 and the circumsporozoite protein of P falciparum. We have extended this work to identify CTL epitopes for HLA class I antigens that are found in most individuals from Caucasian and African populations. Most of these epitopes are in conserved regions of P falciparum. CTL peptide epitopes were found in a further two antigens, thrombospondin-related anonymous protein and sporozoite threonine and asparagine rich protein, indicating that a subunit vaccine designed to induce a protective CTL response may need to include parts of several parasite antigens. However, CTL levels in both children with malaria and in semi-immune adults from an endemic area were low suggesting that boosting these low levels by immunisation might provide substantial or even complete protection against infection and disease.

Activity of extracts of Kigelia pinnata against melanoma and renal carcinoma cell lines

Serial dilutions of standardised water, ethanol, and dichloromethane extracts of the stembark and fruits of Kigelia pinnata were tested for their growth inhibitory effects against four melanoma cell lines and a renal cell carcinoma line (Caki-2) using two different (MTT and SRB) assays. Lapachol, a possible constituent of these extracts, together with known therapeutic antineoplastic agents, was also tested in the same way. The IC50 of each extract was measured after extracts were diluted to 100 micrograms/ml in 1% ethanol or water. Significant inhibitory activity was shown by the dichloromethane extract of the stembark and lapachol (continuous exposure). Moreover, activity was dose-dependent, the extract being less active after 1 h exposure. Chemosensitivity of the melanoma cell lines to the stembark was greater than that seen for the renal adenocarcinoma line. In marked contrast, sensitivity to lapachol was similar amongst the five cell lines. Lapachol was not detected in the stembark extract.

Immunoscintigraphy of primary colorectal cancers with indium-111 monoclonal antibody B72.3

Immunoscintigraphy with CYT-103, an 111indium-labelled immunoconjugate of B72.3, was evaluated in 10 patients before surgery for suspected or biopsy-proven primary colorectal cancer. The imaging results were compared with computed tomography (CT) findings at surgery, histopathology and immunohistochemistry. There were no adverse reactions following the administration of 1.0 mg 111In-CYT-103. Surgical and pathological findings identified 15 sites of disease (10 primary and five metastatic) and all but one lesion (severe dysplasia) were malignant. CT detected nine of 14 sites of malignancy compared to 12 as identified by immunoscintigraphy. It failed to detect two primary lesions and one case of peritoneal metastasis, all of which were imaged by CYT-103. Both imaging modalities failed to detect two of three cases with lymph node metastases and the dysplastic lesion (true negatives). The results indicate that 111In-CYT-103 imaging exhibits high sensitivity and specificity in the detection of primary and secondary lesions in patients with colorectal cancer.

Cocaine inhibits hippocampal long-term potentiation

Long-term potentiation (LTP) is a form of synaptic plasticity that may underlie learning and memory. The experiments reported here demonstrate that cocaine blocks the induction of LTP at the excitatory synapses in the CA1 region of the hippocampus, but does not appear to do so by blocking NMDA receptors or channels. Once LTP had been established, however, cocaine had no effect on the potentiated response. Cocaine was also able to block LTP initiated by superfusing slices with 25 mM TEA. The ability to block LTP was shared by the local anesthetics lidocaine and procaine, but not by tetrodotoxin, suggesting that the blockade of sodium channels alone did not disrupt LTP. Biochemical experiments demonstrated that cocaine can inhibit phosphorylation of purified Synapsin I by Ca2+/calmodulin-dependent protein kinase II. This effect, presumably mediated by effects on calmodulin, is a previously unreported action of cocaine, and suggests that cocaine at high dose levels might disrupt types of learning that are mediated by an LTP-like mechanism.

Development of synapsin I and synapsin II in intraocular hippocampal transplants

Previous studies have indicated that the appearance of synaptic vesicle-associated proteins known as the synapsins is one indicator of synapse formation. In this study, the levels and morphological distribution of synapsin I and synapsin IIa and IIb were studied in intraocular hippocampal transplants and in situ in the intact hippocampus. No detectable levels of either synapsin I or synapsin II were found in the fetal brain. The in situ levels of the synapsins exhibited parallel increases rapidly after birth, reaching peak levels at 8 weeks, after which a slight decline was noted in synapsin I and synapsin IIb. In hippocampal transplants, a comparable increase in the synapsins was seen during the first 8 weeks in oculo. It is likely that the synapse formation in the hippocampal transplants represents synapses from neurons within the transplant, as well as from various peripheral ganglia that send collaterals into the graft. Peripheral and central synapses express different synapsin I: synapsin IIa and IIb ratios. When the ratios of the synapsin proteins in hippocampal transplants were examined ratios essentially identical to those seen in the normal hippocampus were found, despite the numerous peripheral neurites innervating the grafts. Immunohistochemical studies supported the immunoblot data, showing no detectable immunofluorescence with synapsin antibodies in fetal or newborn hippocampal formation. The density of immunoreactive profiles increased substantially both in transplants and in the hippocampal formation in situ during the first 2 postnatal months. In conclusion, the present data demonstrate that hippocampal transplants in oculo can develop significant levels of the synapsins and that there is no time lag in development in these levels compared to the hippocampal formation in situ.

A sensitive assay for detection and measurement of neutralising antibody to human immunodeficiency virus

An assay based on the inhibition of syncytium formation in C8166 cells was developed to measure low levels of neutralising antibody (NT-AB) to human immunodeficiency virus (HIV) and to detect cross-reactivity between virus strains. The relationship between virus challenge and antibody titre was represented by a tripartite curve which was essentially linear over moderate levels of virus input. Based on these findings, antibody titres were standardised against 100 TCID50 of challenge virus. However, lower virus inocula were found to detect minimum levels of antibody. Reproducibility of antibody titres between tests was high, with variation generally lying within one dilution step. The improved sensitivity of the technique allowed detection of NT-ABs in animals immunised with immune-stimulating complexes (ISCOMS) incorporating HIV antigens. Consistent levels of cross-reactivity between HIV strains was demonstrated, indicating the presence of distinct viral groups, from which dominant isolates may be chosen for use in vaccination studies.