Surgery under siege: A case study of leg amputation in 18th century Louisbourg, Nova Scotia, Canada

OBJECTIVE

Paleopathological analysis of a below-knee amputation was conducted to explore the sociocultural reasons why the amputation took place.

MATERIALS

Older adolescent male (18-21 years) from the New Englander mass burial at the 18th century Fortress of Louisbourg.

METHODS

Macroscopic assessment and archival data.

RESULTS

A surgical amputation of the right tibia and fibula, distal to the knee was identified. The cross-sectional diaphysis of the leg has kerf marks and a splinter (breakaway point) at the posterior-lateral border of the tibia suggesting the leg gave way from its own weight or was manually removed once most of the sawing was complete.

CONCLUSIONS

Archival records suggest frostbite from prolonged exposure to freezing temperatures and trauma from unsafe working conditions at the Fortress were the main causes that led to amputation.

SIGNIFICANCE

This case study highlights the importance of contextualizing cases of amputation to understand factors leading to the amputation procedure and techniques used in the past, and the social and living conditions of the individual.

LIMITATIONS

Observations were restricted to skeletal material as soft tissue decomposed and there was no material evidence suggestive of amputation associated with this individual in their grave.

SUGGESTIONS FOR FUTURE RESEARCH

Full trauma assessment of the Fortress of Louisbourg skeletal collection to provide additional insight into injury sustained at Louisbourg and 18th century surgical practices.

Experiences of UK and Irish family carers of people with profound and multiple intellectual disabilities during the COVID-19 pandemic

BACKGROUND

People with profound and multiple intellectual disabilities (PMID) have high and intensive support needs that ordinarily place significant strain on family carers. This was further heightened by the removal of many external supports during the COVID-19 pandemic. We sought to explore the experiences of family carers of people with PMID during the COVID-19 pandemic and understand what the longer-term impact might be on their lives.

METHODS

Focus group interviews (n = 32) were conducted with family carers (n = 126) from the four countries of the UK and the Republic of Ireland. Participants were asked questions relating to their experiences of the COVID-19 pandemic, coping strategies, and challenges faced. All focus groups were conducted using the online platform, Zoom. These were audio recorded, transcribed verbatim and analysed employing inductive thematic analysis.

FINDINGS

Three main themes were generated from the data including (1.0) COVID-19 as a double-edged sword (2.0), The struggle for support (3.0), Constant nature of caring. These included 11 subthemes. (1.1) 'COVID-19 as a catalyst for change', (1.2) 'Challenges during COVID-19: dealing with change', (1.3) 'Challenges during COVID-19: fear of COVID-19', (1.4); 'The online environment: the new normal' (2.1) 'Invisibility of male carers', (2.2) 'Carers supporting carers', (2.3) 'The only service you get is lip service: non-existent services', (2.4); 'Knowing your rights' (3.1) 'Emotional response to the caring role: Feeling devalued', (3.2) 'Emotional response to the caring role: Desperation of caring', (3.3) 'Multiple demands of the caring role.'

CONCLUSIONS

The COVID-19 pandemic presented immense challenges to family carers of people with PMID but also provided some opportunities. Families had already struggled to receive many of the supports and services to which they were entitled to only to have these removed at the onset of the pandemic. The experiences of male carers have been largely absent from the literature with this research showing they want to be included in decision making and require tailored support services. Service providers should see the end of the COVID-19 pandemic as providing opportunity to re-examine current provision and design services with family carers. As the direct threat from COVID-19 diminishes and the experiences of those who lived through this period come to the fore, there is a need to re-examine current models and provision of support to family carers to better meet their needs.

Characterization of fennel germplasm for physiological persistence and drought recovery: Association with biochemical properties

In the perennial medicinal plant fennel (Foeniculum vulgare), persistence over years, production stability, and successful post-drought recovery are as important as plant productivity. Characterization of productivity, post-drought recovery, persistency and their association with phytochemical properties has not yet been performed in fennel. In this study, 64 fennel genotypes (from 23 different countries) from four subspecies/varieties including F. vulgare ssp. piperitum, F. vulgare var. vulgare and F. vulgare var. dulce and F. vulgare var. azoricum were evaluated in the field over four years (2015-2018), then was assessed for post-drought recovery over the next two years (2019-2020). High genotypic variation was observed among genotypes and subspecies. Based on the GC-MS analysis, trans-anethole (22.4-90.6%), estragole (2.1-25.8%), fenchone (4.9-19.8%), and limonene (0.5-11.9%) are major components in the essential oils of the studied germplasm. The highest persistence and the lowest average post-drought recovery belonged to ssp. piperitum. This subspecies also had the highest amount of limonene, fenchone, and estragole and the lowest amount of trans-anethole compared to other subspecies. The highest essential oil content and stability was observed in var. dulce. Seed yield and persistence were found to be negatively associated, suggesting that selection for more productivity may indirectly promote less persistent genotypes. Post-drought recovery was negatively associated with two main phytochemical compounds of essential oil, fenchone and estragole, but positively associated with trans-anethole. Persistence had negative correlation with estragole content. Results indicated that indirect selection for post-drought recovery and persistence may be possible through selection for phytochemical properties. The negative correlation between some essential oil components may indicate that some are isomers, which can limit the ability to select for certain combinations. Superior genotypes identified in this study can be used to construct populations for future studies and as parents of crosses to develop new varieties.

Evaluating a novel approach to stimulate open science collaborations: a case series of "study-a-thon" events within the OHDSI and European IMI communities

OBJECTIVE

We introduce and review the concept of a study-a-thon as a catalyst for open science in medicine, utilizing harmonized real world, observation health data, tools, skills, and methods to conduct network studies, generating insights for those wishing to use study-a-thons for future research.

MATERIALS AND METHODS

A series of historical study-a-thons since 2017 to present were reviewed for thematic insights as to the opportunity to accelerate the research method to conduct studies across therapeutic areas. Review of publications and experience of the authors generated insights to illustrate the conduct of study-a-thons, key learning, and direction for those wishing to conduct future such study-a-thons.

RESULTS

A review of six study-a-thons have provided insights into their scientific impact, and 13 areas of insights for those wishing to conduct future study-a-thons. Defining aspects of the study-a-thon method for rapid, collaborative research through network studies reinforce the need to clear scientific rationale, tools, skills, and methods being collaboratively to conduct a focused study. Well-characterized preparatory, execution and postevent phases, coalescing skills, experience, data, clinical input (ensuring representative clinical context to the research query), and well-defined, logical steps in conducting research via the study-a-thon method are critical.

CONCLUSIONS

A study-a-thon is a focused multiday research event generating reliable evidence on a specific medical topic across different countries and health systems. In a study-a-thon, a multidisciplinary team collaborate to create an accelerated contribution to scientific evidence and clinical practice. It critically accelerates the research process, without inhibiting the quality of the research output and evidence generation, through a reproducible process.

Impact of the COVID-19 pandemic on family carers of those with profound and multiple intellectual disabilities: perspectives from UK and Irish Non-Governmental Organisations

BACKGROUND

Family carers of people with profound and multiple intellectual disabilities (PMID) experienced a reduction in healthcare services due to the COVID-19 pandemic. Many subsequently turned to Non-Governmental Organisations who worked to support families. However, little research has sought to capture the experiences of family carers or identify effective interventions which might support them. To address these concerns we explored the views of Non-Governmental sector workers across the UK and Ireland who supported families people with PMID during the COVID-19 pandemic. We also sought to explore their views on the characteristics of online support programmes for family carers.  METHODS: This study employed a qualitative design using focus groups with participants (n = 24) from five Non-Governmental Organisations across the UK and Ireland. A focus group guide included questions on challenges, supports, coping and resources which helped during lockdown restrictions. Focus groups were held online, were audio recorded and transcribed verbatim. The resulting transcripts were pseudonymised and subjected to thematic analysis.

FINDINGS

Four themes were identified (i) 'mental and emotional health', (ii) 'they who shout the loudest' (fighting for services), (iii) 'lack of trust in statutory services' and (iv) 'creating an online support programme'. Mental and emotional health emerged as the most prominent theme and included three subthemes named as 'isolation', 'fear of COVID-19' and 'the exhaustion of caring'.

CONCLUSIONS

The COVID-19 pandemic has increased the vulnerability of family carers who were already experiencing difficulties in accessing services and supports for their families. While Non-Governmental Organisations have been a crucial lifeline there is urgent need to design services, including online support programmes, in partnership with family carers which adequately address their needs.

Identification of a unique anti-Ro60 subset with restricted serological and molecular profiles

Anti-Ro60 is one of the most common and clinically important serum autoantibodies that has a number of diagnostic and predictive capabilities. Most diagnostic laboratories report this simply as a qualitative positive/negative result. The objective of this study was to examine the clinical and serological relevance of a novel subset of anti-Ro60 in patients who display low levels of anti-Ro60 (anti-Ro60^low ). We retrospectively identified anti-Ro60 sera during a 12-month period at a major immunopathology diagnostic laboratory in Australia. These all were anti-Ro60-precipitin-positive on the diagnostic gold standard counter-immuno-electrophoresis (CIEP). Lineblot immunoassay was used to stratify patients into either anti-Ro60^low or anti-Ro60^high subsets. We compared the medical and laboratory parameters associated with each group. Enzyme-linked immunosorbent assay (ELISA) and mass spectrometry techniques were used to analyse the serological and molecular basis behind the two subsets. Anti-Ro60^low patients displayed less serological activity than anti-Ro60^high patients with less intermolecular spreading, hypergammaglobulinaemia and less tendency to undergo anti-Ro60 isotype-switching than anti-Ro60^high patients. Mass spectrometric typing of the anti-Ro60^low subset showed restricted variable heavy chain subfamily usage and amino acid point mutations. This subset also displayed clinical relevance, being present in a number of patients with systemic autoimmune rheumatic diseases (SARD). We identify a novel anti-Ro60^low patient subset that is distinct from anti-Ro60^high patients serologically and molecularly. It is not clear whether they arise from common or separate origins; however, they probably have different developmental pathways to account for the stark difference in immunological maturity. We hence demonstrate significance to anti-Ro60^low and justify accurate detection in the diagnostic laboratory.

THU0212 FIRST LINE TREATMENT WITH CONVENTIONAL SYNTHETIC DISEASE MODIFYING ANTIRHEUMATIC DRUGS IN RHEUMATOID ARTHRITIS: A MULTINATIONAL POPULATION-BASED COHORT FROM 14 REAL WORLD HEALTHCARE DATABASES AND 9 COUNTRIES - REALITY VERSUS GUIDELINES

Background:

Treatment guidelines recommend early initiation of csDMARDs following diagnosis of rheumatoid arthritis (RA), with methotrexate (MTX) as first-line therapy. Scarce evidence exists on adherence to this guidance

Objectives:

To characterize first-line csDMARD treatment during the first year following an RA diagnosis.

Methods:

14 real world databases (3 Primary care, 6 primary/secondary care records, 5 claims) from 9 countries were included, all mapped to the OMOP common data model.

Patients were included on the earliest event of: 1st diagnosis of RA or 1st DMARD prescription with an RA diagnosis within 30 days. Patients were >18 years-old, required 1+ year pre-index data, and at least 1-year follow-up. Study period covered 2000-2018. Previous users of DMARDs or non-RA inflammatory arthritis history were excluded. Only MTX, Hydroxychloroquine (HCQ), Sulfasalazine (SSZ) and Leflunomide (LEF) were available in all databases.

Results:

We identified 323,547 eligible participants. Large variation was observed internationally (Figure 1). MTX as first-line monotherapy ranged from 33.3% to 74.5%, and in combination with HCQ from 2.1% to 6.7%. Three additional csDMARDs were used as first-line: HCQ in 10.1% to 30.2%, SSZ in 0.9% to 28.7%, and LEF in 1.8% to 15.2%.

Figure 1.

First line csDMARD treatment during 1yr from first observed RA diagnosis

Conclusion:

We report wide heterogeneity of first-line csDMARDs regimens internationally. Despite recommendations for MTX to be first line therapy, data suggest that a large proportion of patients receive alternative csDMARD.

Disclosure of Interests: :

Anthony G Sena Shareholder of: J&J shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Full-time employment salary from Janssen, Employee of: Janssen employee, Paid instructor for: Janssen employee, Speakers bureau: Janssen employee, Denis Granados: None declared, Nigel Hughes Shareholder of: J&J shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen employee, Paid instructor for: Janssen employee, Speakers bureau: Janssen employee, WALID FAKHOURI Shareholder of: E Lilly Shares, Employee of: Eli Lilly and Company, Antje Hottgenroth Shareholder of: Eli Lilly shares, Employee of: Lilly Deutschland GmbH, Raivo Kolde: None declared, Sulev Reisberg: None declared, Carmen Olga Torre: None declared, Talita Duarte-Salles: None declared, Yesika Díaz: None declared, Jose Felipe Golib-Dzib Grant/research support from: Full-time employment salary from Janssen, Employee of: Yes, Janssen employee, Paid instructor for: Janssen Employee, Speakers bureau: Janssen Employee, Emily S. Brouwer Shareholder of: J&J shares, Takeda shares, Grant/research support from: Full-time employment salary from Janssen, Consultant of: Janssen employee, Employee of: Janssen employee, Paid instructor for: Janssen Employee, Speakers bureau: Janssen Employee, Edward Burn: None declared, Jennifer Lane: None declared, David Vizcaya Employee of: Bayer, Sara Bruce Wirta Employee of: Janssen-Cilag Sweden AB, Marcel de Wilde: None declared, Katia Verhamme: None declared, Peter Rijnbeek: None declared, Elke Theander Employee of: Janssen-Cilag Sweden AB, Katerina Chatzidionysiou Consultant of: AbbVie, Pfizer, Lilly., Daniel Prieto-Alhambra Grant/research support from: Professor Prieto-Alhambra has received research Grants from AMGEN, UCB Biopharma and Les Laboratoires Servier, Consultant of: DPA’s department has received fees for consultancy services from UCB Biopharma, Speakers bureau: DPA’s department has received fees for speaker and advisory board membership services from Amgen, Patrick Ryan: None declared

Abstract P4-16-08: A regional audit of 6-hour monitoring for administration related reactions during the first administration of subcutaneous trastuzumab

Introduction

In 2012, Subcutaneous Trastuzumab (TSC) was introduced as an alternative to Intravenous Trastuzumab (TIV) for HER2+ breast cancer. The pivotal HannaH study demonstrated that TSC was non-inferior to TIV, was preferred by patients, and serious administration related reactions (ARRs) were not reported. However, the Summary of Product Characteristics (SPC) advises that patients be observed for ARRs for 6 hours post-first administration (and 2 hours post-subsequent administrations), similar to TIV.

Aim

To assess the frequency and tolerability of ARRs during the 6-hour observation period post first administration of TSC in patients with HER2+ breast cancer.

Method:

A retrospective audit of TSC was conducted in Southwest Ireland across five centers from 2014-2016. Patient charts were reviewed to record ARRs reported on the first-administration or at subsequent visit. In addition a subset of patients were interviewed regarding their recollection of ARRs with first or subsequent injections.

Results:

The study is ongoing having identified 192 patients. These centers have administered 2111 TSC injections in total, associated with 4998 hours of observation as per SPC. From the 385 injections given over the first two TSC administrations, 13 injections (3.4%) were associated with ARRs within 24 hours. Nine patients (2.3%) experienced injection site reactions immediately post injection, one injection site pain (0.3%), and one experienced petechiae on subsequent exposure (0.3%). Three patients experienced pyrexia and dry cough 24 hours post-injection and were hospitalized for respiratory tract infection. There were no reactions experienced between 2 and 6 hours post-first injection. There were no serious ARRs. Telephone interviews are ongoing and these results will be reported.

Conclusion:

ARRs related to TSC are usually immediate, mild and self-limiting. Observing patients for 6 hours post-first injection and 2 hours post-subsequent injections represents an inefficient use of healthcare resources.

Citation Format: Karmali S, Hughes N, Kinneally A, Kroes J, Cook J, Killian M, Shafiq T, O'Mahony D, Bird B, O'Connor M, O'Reilly S, Galiauskas R, Murphy CG. A regional audit of 6-hour monitoring for administration related reactions during the first administration of subcutaneous trastuzumab [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-16-08.

Revisiting classic MRI findings of venous malformations: Changes in protocols may lead to potential misdiagnosis

Introduction Magnetic resonance imaging (MRI) is most sensitive and specific for characterizing venous malformations (VMs). VMs typically demonstrate central enhancement on delayed-contrast imaging. Fluid-fluid levels (FFLs) are uncommon in VMs and common in lymphatic malformations (LMs). Technology has advanced since the initial description of these findings. Rates of detection of these MRI findings in VMs may have changed as MRI technology and techniques have evolved. Methods and methods A prospectively maintained database from a multidisciplinary vascular anomalies clinic was reviewed to identify patients with final diagnosis of VM or LM. Patients with reviewable contrast-enhanced MRIs were selected, reviewing the oldest MRI studies in the database against the newest MRI studies to identify equal numbers of patients from the temporal extremes. Imaging was reviewed to assess for presence of FFLs. Enhancement was quantified by measuring signal in the same location of the lesion both on pre- and postcontrast sequences Results Forty patients were identified for analysis. Twenty studies with sufficient archived imaging for review were performed between 1995 and 2006; 20 such studies were performed between 2011 and 2012. The new imaging cohort had higher rates of FFL visualization ( p = 0.001). Correlation was found between time to imaging following contrast and degree of enhancement ( p < 0.001). Inverse correlation was found between scan date and time to contrast ( p = 0.001) and scan date and enhancement ( p = 0.021). Conclusion FFLs should no longer be considered exclusionary for the diagnosis of VMs. Timing following contrast administration should be maximized to increase degree of enhancement to confirm the diagnosis of VMs.

Abstract P3-12-04: Is 6 hour monitoring for administration related reactions after first administration of subcutaneous trastuzumab necessary? A single institution audit

Background: Subcutaneous (sc) trastuzumab has demonstrated non-inferiority to intravenous (iv) trastuzumab and is preferred by patients and providers. Serious administration related reactions (ARRs) such as hypotension, respiratory distress etc. were not reported in the pivotal HannaH study. However, the summary of product characteristics (SPC) advises that patients should be observed for ARRs for 6 hours post the first injection (and 2 hours post subsequent injections), similar to the iv formulation.

Methods: We conducted an audit of patients commencing sc trastuzumab at our institution. Medical notes of each patient were reviewed to record adverse events reported on the day of first administration or at the subsequent visit. In addition all patients were interviewed by telephone and questioned regarding adverse events with first or subsequent injections.

Results: 39 patients were identified, 32 had received prior iv trastuzumab. Patients received a mean of 12 injections. In total patients received 470 sc trastuzumab injections, associated with a recommended 1,096 hours of observation as per SPC. 3 injections (0.6%) were associated with ARRs within 24 hours, all on the first cycle. 2 patients (5%) experienced injection site reactions immediately post injection and 1 patient had injection site pain during the injection. 1 patient experienced pyrexia and dry cough 24 hours post injection and was hospitalized for respiratory tract infection. No patient experienced a reaction between 2 and 6 hours post first injection. There were no serious ARRs.

Conclusions: ARRs related to sc trastuzumab are usually immediate, mild and self-limiting. Observing patients for 6 hours post first injection and 2 hours post subsequent injections represents an inefficient use of healthcare resources.

Citation Format: Karmali S, Hughes N, Galiauskas R, Cook J, Murphy K, Bird BR, Murphy CG. Is 6 hour monitoring for administration related reactions after first administration of subcutaneous trastuzumab necessary? A single institution audit [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-12-04.

Predictors of either rapid healing or refractory reflux oesophagitis during treatment with potent acid suppression

BACKGROUND

Little is known regarding patient characteristics that influence the speed of reflux oesophagitis (RO) healing.

AIM

To investigate patient characteristics that may influence RO healing rates.

METHODS

A post hoc analysis of clinical trial data for potent acid suppression treatment of RO (esomeprazole or AZD0865) was conducted. Group A underwent endoscopy at baseline, week 2 and 4, and group B at baseline, week 4 and 8. Group A patients were sub-grouped as 'rapid' (healed at 2 weeks) or unhealed at 2 weeks. Group B patients were sub-grouped as 'slow' (healed at 8 weeks, not at 4 weeks) or 'refractory' (not healed at 8 weeks). Logistic regression analysis was performed only for comparisons within group A.

RESULTS

At 2, 4 and 8 weeks, RO had healed in 68%, 65% and 61% of patients unhealed at previous endoscopy, respectively. Low-grade [vs. high-grade (C or D)] RO was the only independent predictor of rapid healing in group A after logistic regression analysis. Significantly more rapid healers had low grade RO (A or B) at baseline than patients with refractory RO (84% vs. 49%; P < 0.001), and significantly more refractory patients had frequent regurgitation at baseline than slow healers (80% vs. 63%; P = 0.039).

CONCLUSIONS

Low- (vs. high-) grade RO determines the most rapid benefit from acid suppression. Roughly two-thirds of patients healed with each time increment of potent acid suppression therapy. This suggests that some unhealed patients may still heal with continued therapy and that truly refractory RO is rare. (ClinicalTrials.gov: NCT00206245).

Hypoxia modulates the activity of a series of clinically approved tyrosine kinase inhibitors

BACKGROUND AND PURPOSE

Hypoxia in tumours is known to cause resistance to conventional chemotherapeutic drugs. In contrast, little is known about the effects of hypoxia on targeted anti-cancer drugs. This study evaluated the effect of hypoxia on a series of clinically approved tyrosine kinase inhibitors (TKIs).

EXPERIMENTAL APPROACH

The effect of hypoxia (0.1% oxygen) on the activity of conventional cytotoxic drugs (5-fluorouracil, doxorubicin and vinblastine), the hypoxia-activated prodrug tirapazamine and 9 TKIs was determined in a panel of cell lines. Where hypoxia had a marked effect on chemosensitivity, Western blot analysis was conducted to determine the effect of hypoxia on target expression and the effect of TKIs on cell signalling response under aerobic and hypoxic conditions.

KEY RESULTS

Three patterns of chemosensitivity were observed: resistance under hypoxia, equitoxic activity against hypoxic and aerobic cells, and preferential cytotoxicity to hypoxic cells. Significant hypoxia selectivity (independent of HIF1) was observed in the case of dasatinib and this correlated with the ability of dasatinib to inhibit phosphorylation of Src at tyrosine 530. Sorafenib was significantly less effective under hypoxic conditions but resistance did not correlate with hypoxia-induced changes in Raf/MEK/ERK signalling.

CONCLUSIONS AND IMPLICATIONS

Hypoxia influences the activity of TKIs but in contrast to conventional cytotoxic drugs, preferential activity against hypoxic cells can occur. The search for hypoxia-targeted therapies has been long and fruitless and this study suggests that some clinically approved TKIs could preferentially target the hypoxic fraction of some tumour types.

The first 100 thrombolysis cases in a novel Scottish mesh telestroke system

Stroke thrombolysis has been a major driver for change within stroke services. However, until recently its widespread application has been limited to tertiary centres. Transfer to tertiary care can lead to significant delays in thrombolysis. We developed a novel mesh telestroke network, which allows stroke specialists to make videoconference-based thrombolysis decisions either from one of three stroke units or from home. We report data on the first 100 patients treated using this model and retrospectively review the first 100 strokes thrombolysed with tissue plasminogen activator across three stroke units. Prospectively collected data were extracted from the Stroke Audit In Lanarkshire database. Case notes were retrieved for clarification when necessary. Outcome measures were timings from symptom onset to infusion, post-thrombolysis symptomatic intracerebral haemorrhage and death. Fifty-one percent of cases were assessed by telestroke link. Median symptom onset to thrombolysis was 160 min (IQR 125–190). There were two symptomatic intracerebral haemorrhages, both in patients assessed face-to-face. Overall mortality was 14%. Our experience of tissue plasminogen activator is comparable to UK data extracted from SITS-MOST in overall timings and complication rates. This model of telemedicine could be replicated to provide safe thrombolysis to areas with challenging infrastructure, geography or insufficient stroke specialist cover.

Genotype and phenotype correlations in 417 children with congenital hyperinsulinism

CONTEXT

Hypoglycemia due to congenital hyperinsulinism (HI) is caused by mutations in 9 genes.

OBJECTIVE

Our objective was to correlate genotype with phenotype in 417 children with HI.

METHODS

Mutation analysis was carried out for the ATP-sensitive potassium (KATP) channel genes (ABCC8 and KCNJ11), GLUD1, and GCK with supplemental screening of rarer genes, HADH, UCP2, HNF4A, HNF1A, and SLC16A1.

RESULTS

Mutations were identified in 91% (272 of 298) of diazoxide-unresponsive probands (ABCC8, KCNJ11, and GCK), and in 47% (56 of 118) of diazoxide-responsive probands (ABCC8, KCNJ11, GLUD1, HADH, UCP2, HNF4A, and HNF1A). In diazoxide-unresponsive diffuse probands, 89% (109 of 122) carried KATP mutations; 2% (2 of 122) had GCK mutations. In mutation-positive diazoxide-responsive probands, 42% were GLUD1, 41% were dominant KATP mutations, and 16% were in rare genes (HADH, UCP2, HNF4A, and HNF1A). Of the 183 unique KATP mutations, 70% were novel at the time of identification. Focal HI accounted for 53% (149 of 282) of diazoxide-unresponsive probands; monoallelic recessive KATP mutations were detectable in 97% (145 of 149) of these cases (maternal transmission excluded in all cases tested). The presence of a monoallelic recessive KATP mutation predicted focal HI with 97% sensitivity and 90% specificity.

CONCLUSIONS

Genotype to phenotype correlations were most successful in children with GLUD1, GCK, and recessive KATP mutations. Correlations were complicated by the high frequency of novel missense KATP mutations that were uncharacterized, because such defects might be either recessive or dominant and, if dominant, be either responsive or unresponsive to diazoxide. Accurate and timely prediction of phenotype based on genotype is critical to limit exposure to persistent hypoglycemia in infants and children with congenital HI.

In situ randomised trial investigating abrasive effects of two desensitising toothpastes on dentine with acidic challenge prior to brushing

OBJECTIVES

To determine if brushing dentine with 2 moderate RDA desensitising toothpastes, results in a significant dentine wear difference and whether this difference continues to be relevant when preceded with an erosive challenge.

METHODS

An in situ, single centre, single blind, randomised, split mouth study, evaluated the difference in abrasion of 2 toothpastes (SFM - Sensodyne Fresh Mint(®) RDA 70; CPHM - Crest Pro-Health Clean Mint(®) RDA 120) in 28 healthy volunteers. Two toothpaste treatments were administered 3×/day, for each of the two 15 day periods, subjects wearing bi-lateral, lower buccal appliances each with 4 dentine sections. A 2 min extra-oral acidic challenge preceded toothbrushing for 2 study arms. Contact profilometry measured samples at baseline, days 5, 10 and 15.

RESULTS

Brushing with SFM was significantly less abrasive than brushing with CPHM at all time points, with or without a preceding acidic challenge (p<0.0001). The additional dentine loss arising from the erosive challenge prior to brushing with each paste was linear with time and independent of abrasive effect.

CONCLUSIONS

The desensiting toothpastes' RDA, directly related to dentine loss with toothbrushing. An acidic challenge prior to brushing did not negate the benefits of reduced wear from the lower RDA paste compared to the higher RDA paste. When brushing eroded dentine, the additional wear appeared independent of abrasive effect. Dentine hypersensitivity sufferers should be recommended to use a low-moderate RDA toothpaste, not to brush more than 2×/day and not immediately following an acidic challenge.

Randomized in situ clinical study comparing the ability of two new desensitizing toothpaste technologies to occlude patent dentin tubules

OBJECTIVE

To compare the ability of two new desensitizing toothpaste technologies (one a 5% NovaMin-based toothpaste and the other an 8% arginine-based toothpaste) to occlude patent dentin tubules in a clinical environment relative to a negative control of water and a control toothpaste after four days of twice-daily brushing and dietary acidic challenges.

METHODS

The study design was a single-center, single-blind, randomized, split-mouth, four-treatment, two-period, crossover, in situ clinical study. Healthy subjects wore two lower intra-oral appliances, retaining four dentin samples for four treatment days for each period of the clinical study. Samples were brushed twice daily with a test product (days 1-4), with an additional acidic challenge introduced on two selective days. Scanning electron microscopy (SEM) images were taken of the dentin surface, and dentinal tubule occlusion assessed using a categorical scale.

RESULTS

The results demonstrated that the 5% NovaMin toothpaste was statistically superior at occluding patent dentin tubules compared to water (p = 0.009) and the control toothpaste (p = 0.02) at day 4. In contrast, the treatment effect resulting from the 8% arginine toothpaste did not demonstrate the same degree of occlusive propensity, showing no significant difference to the water and control toothpaste at the day 4 time point.

CONCLUSION

Application of the 5% NovaMin toothpaste to dentin showed better dentin tubule occlusion and retention abilities in an oral environment under dietary acid challenge conditions, more so than the 8% arginine toothpaste technology. Given modern dietary habits and practices, these results highlight differences in the acid resistance properties of occlusion technologies, and a potential impact on clinical performance.

Clinical in situ study investigating abrasive effects of two commercially available toothpastes

The aim of this study was to determine if the abrasive effect on dentine of two commercially available toothpastes, known to vary in their in vitro abrasive levels, can be differentiated in an in situ model after 10 days, assessed by contact profilometry. This was a single centre, single blind, randomized, split mouth, two treatment, in situ study, in 34 healthy subjects, evaluating the abrasive effects of two marketed desensitizing toothpastes, (Colgate Sensitive Multi Protection toothpaste - C; Sensodyne Total Protection - S). Subjects wore bi-lateral, lower buccal appliances, each fitted with four dentine sections which were power brushed three times a day with the treatment regimen. Each subject received two toothpaste treatments for 10 days during the treatment period. Samples were measured at baseline and day 10 by contact and non-contact profilometry and day 5 by contact profilometry. Thirty-four subjects were included in the efficacy analysis. Results from contact profilometry showed statistically significant (P < 0.0001) dentine loss compared to baseline at day 5 and 10 for both pastes. At each time point, C showed statistically significantly greater dentine loss than S, P < 0.0001. After 10 days treatment, the difference in dentine loss between the pastes was 1.4 microm. The non-contact profilometry data showed similar trends. After 10 days of treatment, C showed statistically significantly greater dentine loss than S, with treatment difference of 0.9 microm, P = 0.0057. The methodology used has successfully differentiated between the abrasivity of the two pastes in respect of dentine surface loss over time in an in situ environment.

The need for a transparent, ethical, and successful relationship between academic scientists and the pharmaceutical industry: a view of the Group for the Respect of Ethics and Excellence in Science (GREES)

This paper provides recommendations for fair and unbiased relationship between academic scientists and the pharmaceutical industry.

INTRODUCTION

Real or perceived problems in the relationship between academics and the industry have been the subject of much recent debate. It has been suggested that academic clinicians should sever all links with the industry-a view that is rarely challenged.

METHODS

Academic experts and members of the pharmaceutical industry were invited to an expert consensus meeting to debate this topic. This meeting was organized by the Group for the Respect of Ethics and Excellence in Science. Conflict of interest, competing interest, right and duties of academic scientist, authorship, and staff and student education were discussed.

RESULTS

Guidelines for a transparent, ethical, strong, and successful partnership between the academic scientist and the pharmaceutical industry have been provided.

CONCLUSIONS

The Group support interactions between the industry and clinicians provided that it is transparent and ethical.

The composition of hydrogels for cartilage tissue engineering can influence glycosaminoglycan profile

The injectable and hydrophilic nature of hydrogels makes them suitable candidates for cartilage tissue engineering. To date, a wide range of hydrogels have been proposed for articular cartilage regeneration but few studies have quantitatively compared chondrocyte behaviour and extracellular matrix (ECM) synthesis within the hydrogels. Herein we have examined the nature of ECM synthesis by chondrocytes seeded into four hydrogels formed by either temperature change, self-assembly or chemical cross-linking. Bovine articular cartilage chondrocytes were cultured for 14 days in Extracel, Pluronic F127 blended with Type II collagen, Puramatrix and Matrixhyal. The discriminatory and sensitive technique of fluorophore-assisted carbohydrate electrophoresis (FACE) was used to determine the fine detail of the glycosaminoglycans (GAG); hyaluronan and chondroitin sulphate. FACE analysis for chondroitin sulphate and hyaluronan profiles in Puramatrix closely matched that of native cartilage. For each hydrogel, DNA content, viability and morphology were assessed. Total collagen and total sulphated GAG production were measured and normalised to DNA content. Significant differences were found in total collagen synthesis. By day 14, Extracel and Puramatrix had significantly more total collagen than Matrixhyal (1.77+/-0.26 microg and 1.97+/-0.26 microg vs. 0.60+/-0.26 microg; p<0.05). sGAG synthesis occurred in all hydrogels but a significantly higher amount of sGAG was retained within Extracel at days 7 and 14 (p<0.05). In summary, we have shown that the biochemical and biophysical characteristics of each hydrogel directly or indirectly influenced ECM formation. A detailed understanding of the ECM in the development of engineered constructs is an important step in monitoring the success of cartilage regeneration strategies.

Mobile radiography at a music festival

Limb injuries are common at music festival sites and traditionally patients seen by on-site medical services require referral to hospital emergency departments for radiographic exclusion of bony injury. This takes clinical personnel off site, increases demand on local emergency departments and is inconvenient for revellers. This is an audit of the use of a portable digital radiography system at the Virgin music festival in Staffordshire over a 3-year period.

Traumatic extrathoracic lung herniation

We report a case of traumatic extrathoracic lung herniation. This is a rare injury that is potentially life threatening. The imaging features, associated injuries and complications are discussed to facilitate rapid recognition for best patient outcome. Uniquely, we demonstrate the injury with a three-dimensional reconstructed minimum intensity projection.

Adherence to treatment of osteoporosis: a need for study

Adherence to anti-osteoporosis medications is currently low and is associated with poor anti-fracture efficacy. This manuscript reviews the potential design of clinical studies that aim to demonstrate improved adherence, with new chemical entities to be used in the management of osteoporosis.

INTRODUCTION

Several medications have been unequivocally shown to decrease fracture rates in clinical trials. However, in real life settings, long-term persistence and compliance to anti-osteoporosis medication is poor, hence decreasing the clinical benefits for patients.

METHODS

An extensive search of Medline from 1985 to 2006 retrieved all trials including the keywords osteoporosis, compliance, persistence or adherence followed by a critical appraisal of the data obtained through a consensus expert meeting.

RESULTS

The impact of non-adherence on the clinical development of interventions is reviewed, so that clinicians, regulatory agencies and reimbursement agencies might be better informed of the problem, in order to stimulate the necessary research to document adherence.

CONCLUSION

Adherence to therapy is a major problem in the treatment of osteoporosis. Both patients and medication factors are involved. Adherence studies are an important aspect of outcomes studies, but study methodologies are not well developed at the moment and should be improved. Performing adherence studies will be stimulated when registration authorities accept the result of these studies and include the relevant information in Sect. 5.1 of the summary of product characteristics. Reimbursement authorities might also consider such studies as important information for decisions on reimbursement.

Adults with terminal illness: a literature review of their needs and wishes for food

Food refusal can be a source of conflict between dying people and their caregivers. This review examines: the nature and purpose of food; some reasons for and implications of anorexia in terminal illness; ethical principles underpinning responses to declining appetite and food refusal; social transactions between dying people and their caregivers in relation to needs and wishes for food; and the need for further empirical research. The nature and purpose of food in human societies has been studied extensively by anthropologists but the knowledge gained is not often imported into health care practice, where eating is seen from a medical rather than an anthropological perspective. Food refusal may be a consequence of anorexia which is the result of physiological or psychological changes or it may be a deliberate choice in acceptance of impending death. Ethical principles underpinning responses to declining appetite and food refusal have been studied extensively and clear guidance obtained about what would be appropriate behaviour in given circumstances. There is little published empirical work on social transactions between dying people and their caregivers in relation to needs and wishes for food. As the contribution made to effective care-giving by high-quality interpersonal relationships is widely recognized, further knowledge about how best to sustain such relationships in these important circumstances would be useful. Moreover, as such interpersonal relationships often occur in an institutional context, it may be that more can be learnt from close examination of social transactions about how best to structure organizational processes to maximize autonomy and comfort for patients at the end of life. Further research is indicated.

Aorto-left renal vein fistula: is there a place for endovascular management?

PURPOSE

To describe the endovascular treatment of an aorto-left renal vein fistula.

METHODS AND RESULTS

A 77-year-old man with multiple comorbidities presented with low back pain, hematuria, cyanosis, and a pulsatile abdominal mass. Imaging confirmed a 7-cm abdominal aortic aneurysm with a contained rupture into the left renal vein. Owing to the patient's high surgical risk, a Talent Endoluminal Stent-Graft was implanted to satisfactorily exclude the aneurysm. Hemodynamic stability and normal renal function were restored; however, continued perfusion of the sac prompted an attempt to percutaneously repair the renal vein defect. This effort failed, so open laparotomy was necessary.

CONCLUSIONS

Although total endovascular management was not successful in this case, the initial use of a minimally invasive approach allowed the patient's clinical status to improve and lower the risk of subsequent surgery.

The role of physician assistants in the delivery of medical care

Although the physician assistant (PA) profession is slightly more than 30 years old, in its short history, it has had a significant impact on the delivery of quality medical care in the United States. There are approximately 34,000 PAs currently in clinical practice. The purpose of this article is to describe the role physician assistants play in the delivery of medical care and the benefits they bring to the health system and to patients.

Acute airway obstruction during spinal anaesthesia for caesarean section

A 30-year-old primiparous Caucasian woman with known placenta praevia required an emergency caesarean section for a mild antepartum haemorrhage at the onset of spontaneous term labour. Following intravenous prehydration with 500 ml gelatin colloid (Haemaccel trade mark ), spinal anaesthesia was induced in the sitting position with 2.6 ml of 0.5% hyperbaric bupivacaine (13 mg). The patient was then placed in the recumbent position with left lateral tilt, whereupon she suddenly became dyspnoeic. A generalized erythematous urticarial rash with associated facial, periorbital, glossal and perioral oedema became evident. Although maternal blood pressure remained within normal limits, emergency conversion to general anaesthesia with tracheal intubation was necessary to secure the airway. Laryngoscopy revealed gross submucosal, epiglottic and pharyngeal oedema, characteristics of the syndrome of angioneurotic oedema, which may complicate an anaphylactoid reaction. After the airway was secured with a cuffed endotracheal tube, caesarean section proceeded uneventfully and a healthy male infant was delivered. Maternal facial and airway oedema subsided and extubation was performed in intensive care 2 h later. Life-threatening airway obstruction often accompanies angioneurotic oedema. Since parturients have a higher incidence of difficult airway management than the general population, anaphylactoid reactions presenting as angioneurotic oedema pose a particular challenge for the anaesthetist. The lower incidence of allergy associated with hydroxyethyl starch (Hetastarch) may make it a more appropriate choice of colloid in this setting. However, the balance of evidence now suggests that vasopressors, particularly ephedrine, are superior to fluids for maintenance of blood pressure during regional anaesthesia for caesarean section.

Evidence that galactanase A from Pseudomonas fluorescens subspecies cellulosa is a retaining family 53 glycosyl hydrolase in which E161 and E270 are the catalytic residues

A genomic library of Pseudomonas fluorescens subsp. cellulosa DNA was screened for galactanase-positive recombinants. The nine galactanase positive phage isolated contained the same galactanase gene designated galA. The deduced primary structure of the enzyme (galactanase A; GalA) encoded by galA had a Mr of 42 130 and exhibited significant sequence identity with a galactanase from Aspergillus aculeatus, placing GalA in glycosyl hydrolase family 53. The enzyme displayed properties typical of an endo-beta1, 4-galactanase and exhibited no activity against the other plant structural polysaccharides evaluated. Analysis of the stereochemical course of 2,4-dinitrophenyl-beta-galactobioside (2,4-DNPG2) hydrolysis by GalA indicated that the galactanase catalyzes the hydrolysis of glycosidic bonds by a double displacement general acid-base mechanism. Hydrophobic cluster analysis (HCA) suggested that family 53 enzymes are related to the GH-A clan of glycosyl hydrolases, which have an (alpha/beta)8 barrel structure. HCA also predicted that E161 and E270 were the acid-base and nucleophilic residues, respectively. Mutants of GalA in which E161 and E270 had been replaced with alanine residues were essentially inactive against galactan. Against 2,4-DNPG2, E161A exhibited a much lower Km and kcat than native GalA, while E270A was inactive against the substrate. Analysis of the pre-steady-state kinetics of 2,4-DNPG2 hydrolysis by E161A showed that there was an initial rapid release of 2,4-dinitrophenol (2,4-DNP), which then decayed to a slow steady-state rate of product formation. No pre-steady-state burst of 2,4-DNP release was observed with the wild-type enzyme. These data are consistent with the HCA prediction that E161 and E270 are the acid-base and nucleophilic catalytic residues of GalA, respectively.

A survey of knowledge and use of folic acid among women of child-bearing age in Dublin

BACKGROUND

The Medical Research Council vitamin trial highlighted the importance of folic acid in the prevention of neural tube defects. Since 1993, the Irish Department of Health has recommended periconceptional folic acid supplements. The objective of this study was to document the knowledge and behaviour of women in child-bearing years to periconceptional folic acid.

METHODS

A cross-sectional community-based survey was conducted in Dublin using an interviewer administered questionnaire.

RESULTS

A total of 335 women took part in the study, a response rate of 84 per cent. Approximately two-thirds (213/ 335, 63.6 per cent) had heard of folic acid. Knowledge was significantly associated with higher social class and higher education (p < 0.05). Few (18/335, 5.4 per cent), had been advised to take folic acid before pregnancy. Only 9/335 (2.7 per cent) of the women in the study were currently taking folic acid supplements. Three-quarters (75.9 per cent) of the group would be willing to take periconceptional folic acid supplements if they believed it would reduce the risk of malformations. The majority (77.4 per cent) would prefer to take folic acid in tablet form rather than have it added to food.

CONCLUSIONS

This study shows that few women in child-bearing years in Dublin have been advised on folic acid, and very few are taking supplements. However, if advised appropriately the majority would be willing to take periconceptional folic acid in tablet form.

Key residues in subsite F play a critical role in the activity of Pseudomonas fluorescens subspecies cellulosa xylanase A against xylooligosaccharides but not against highly polymeric substrates such as xylan

In a previous study crystals of Pseudomonas fluorescens subspecies cellulosa xylanase A (XYLA) containing xylopentaose revealed that the terminal nonreducing end glycosidic bond of the oligosaccharide was adjacent to the catalytic residues of the enzyme, suggesting that the xylanase may have an exo-mode of action. However, a cluster of conserved residues in the substrate binding cleft indicated the presence of an additional subsite, designated subsite F. Analysis of the biochemical properties of XYLA revealed that the enzyme was a typical endo-beta1,4-xylanase, providing support for the existence of subsite F. The three-dimensional structure of four family 10 xylanases, including XYLA, revealed several highly conserved residues that are on the surface of the active site cleft. To investigate the role of some of these residues, appropriate mutations of XYLA were constructed, and the biochemical properties of the mutated enzymes were evaluated. N182A hydrolyzed xylotetraose to approximately equal molar quantities of xylotriose, xylobiose, and xylose, while native XYLA cleaved the substrate to primarily xylobiose. These data suggest that N182 is located at the C site of the enzyme. N126A and K47A were less active against xylan and aryl-beta-glycosides than native XYLA. The potential roles of Asn-126 and Lys-47 in the function of the catalytic residues are discussed. E43A and N44A, which are located in the F subsite of XYLA, retained full activity against xylan but were significantly less active than the native enzyme against oligosaccharides smaller than xyloseptaose. These data suggest that the primary role of the F subsite of XYLA is to prevent small oligosaccharides from forming nonproductive enzyme-substrate complexes.

Mannanase A from Pseudomonas fluorescens ssp. cellulosa is a retaining glycosyl hydrolase in which E212 and E320 are the putative catalytic residues

Mannanase A (MANA) from Pseudomonas fluorescens, a member of glycosyl hydrolase family 26, was hyperexpressed in Escherichia coli and purified to homogeneity. Analysis of the stereochemical course of mannotetraose hydrolysis by purified MANA showed that the configuration of the anomeric carbon was retained on cleavage of the middle glycosidic bond. These data suggest that the mannanase hydrolyzes mannooligosaccharides by a double-displacement general acid-base mechanism. By hydrophobic cluster analysis (HCA), two glutamate and two aspartate residues were shown to be conserved in all of the glycosyl hydrolase family 26 enzymes analyzed. In addition, HCA suggested that family 26 was related to the GH-A clan (families 1, 2, 5, 10, 30, 35, 39, and 42) of (alpha/beta)8-barrel glycosyl hydrolases, which led to the prediction that E320 and E212 constitute the catalytic nucleophile and acid-base residues, respectively. To investigate the role of these amino acids, site-directed mutagenesis was used to replace the two aspartates with alanine and glutamate, while the two conserved glutamates were changed to alanine and aspartate. The mutant enzymes were purified and their biochemical properties were analyzed. The data showed that neither the D-->A nor the D-->E mutation resulted in a dramatic decrease in enzyme activity, suggesting that the two aspartate residues did not play a pivotal role in catalysis. In contrast, modification of either of the glutamate residues to alanine caused a dramatic decrease in kcat against carob galactomannan, azo-carob galactomannan, mannotetraose and 2,4-dinitrophenyl beta-mannobioside (2,4-DNPM). The E320A mutation did not alter the apparent K(m) (K(m)) of MANA against these substrates, while E212A resulted in a 27-fold decrease in K(m) against 2,4-DNPM. Pre-steady-state kinetics of 2,4-DNPM hydrolysis by E212A showed that there was a rapid burst of 2,4-dinitrophenol release. Circular dichroism and fluorescence spectroscopy indicated that there were no significant differences between the structures of the mutant and wild-type forms of MANA. These data are consistent with E212 and E320 constituting the catalytic acid-base and nucleophile residues of MANA, respectively.

Reversal of parkinsonian symptoms by intrastriatal and systemic manipulations of excitatory amino acid and dopamine transmission in the bilateral 6-OHDA lesioned marmoset

We have investigated the potential of alleviating parkinsonian symptoms by manipulating excitatory amino acid (EAA) transmission, by several different pharmacological means, in a novel primate model of parkinsonism. The model is based on a two-stage bilateral 6-hydroxydopamine lesion procedure in marmosets, which produces a stable but marked parkinsonian condition. Parkinsonian symptoms were reversed in a dose-dependent manner by systemic administration of levodopa and intrastriatal injections of apomorphine administered into either the caudate nucleus or the putamen. (R)-HA-966, a partial agonist for the NMDA receptor associated glycine site, also alleviated parkinsonian symptoms when injected intrastriatally but not when injected systemically. Systemic injection of enadoline, a kappa opiate which blocks release of EAAs, reduced parkinsonian symptoms when injected systemically, though it did not restore completely normal motor behaviour. In contrast, ifenprodil, an antagonist for the NMDA receptor-associated polyamine modulatory site, when injected systemically at an optimal dose, resulted in apparently normal motor behaviour. These data suggest that attenuation of EAA transmission could be used to treat parkinsonism.