Mercury and selenium concentrations in lanugo of free-ranging California sea lions in the southern Gulf of California, Mexico

Total mercury ([THg]) and selenium ([TSe]) concentrations were determined in California sea lion (Zalophus californianus) lanugo from the Gulf of California in 2021 and 2022. Relationships with sex, morphometrics, and year were evaluated. Following toxicological thresholds of concern for piscivorous mammals, most pups had a [THg] < 10 ppm, one pup (2021) had a [THg] > 20 ppm, no pups had a [THg] > 30 ppm. Females had significantly higher [TSe] than males; sex did not influence [THg]. [THg] and [TSe] in 2022 were significantly higher in the general population and male cohorts compared to 2021. Significant negative correlations were observed between [THg], [TSe], and morphometrics (2021). These results indicate that, compared to other pinniped species, regional California sea lions may have a decreased likelihood of experiencing Hg-related adverse health effects. Year-related changes in element concentrations suggest continued monitoring of this population to assess pinniped, environmental, and potentially, human health.

How the Underlying Etiology of Cirrhosis Impacts Response to SBRT

PURPOSE/OBJECTIVE(S)

In the US, incidence rates of hepatocellular carcinoma (HCC) have more than tripled and death rates have doubled since 1980. In 2022, it is expected for 41,260 new cases to be diagnosed with 30,520 deaths. Many etiologies contribute to the development of HCC including alcoholic cirrhosis, cryptogenic cirrhosis, HCV, HBV, NASH, and genetic disorders like hereditary hemochromatosis. An increasing number of patients are not candidates for curative options such as resection or transplant and the role of alternative liver directed as therapies has increased. SBRT has emerged as a safe and effective option, but there is little known about the outcomes related to the etiology of the HCC. The purpose of this study is to characterize the rates of toxicity and efficacy between different HCC etiologies in patients who were treated with SBRT.

MATERIALS/METHODS

A single institutional database was compiled of all patients with HCC who were treated with SBRT. Patients with HCC etiologies of HCV, alcoholic cirrhosis, or NASH cirrhosis who received SBRT and monitored with liver function tests and imaging (MRI or CT) and were not transplanted were included Demographic information, disease etiology, all treatment courses, lab values, radiologic response, and follow-up were collected on all patients. SPSS was used to analyze the data.

RESULTS

Consecutive patients (n = 37, 43 courses of radiation) who received SBRT between 2013- January 2022 were included. Most patients were male (n = 32, 86.5%) and average age was 64.73 ± 7.42 years (range: 50-82 years). A majority of patients had either HCV or HCV and alcoholic cirrhosis (n = 28, 75.7%) and there were no baseline difference in child Pugh score, tumor size, or number of prior treatments. Most patients were treated with 50Gy/5 fx (n = 26, 70.3%) with 5 others being treated with 45Gy/5fx to meet mean liver constraints. Most patients had a decrease in ALT (n = 22, 59.5%) while almost half of patients had a decrease in AFP (n = 14, 48.3%) at average follow-up of 11.84 ± 5.35 months. There was a significant correlation between HCC etiology and change in bilirubin with patients with HCV being more likely to have increases in total bilirubin (χ2 (6) = 17.5, p < 0.01).

CONCLUSION

Patients with HCV induced cirrhosis may be more fragile and have a significant increased risk of toxicity after SBRT based on total bilirubin changes. Most patients did have a decrease in ALT showing potential for some improvement in liver function with SBRT. However, almost half of patients have some biologic efficacy with SBRT independent of HCC etiology. Further studies should include looking at the biologic differences in the etiologies and what treatment liver-directed therapies may be best for each population.

Effects of Respiratory and Cardiac Motion on Dose to the Left Anterior Descending Artery in Patients Undergoing Radiation Therapy for Locally Advanced Lung Cancer

PURPOSE/OBJECTIVE(S)

Radiation dose to the left anterior descending artery (LAD) appears to be an independent predictor of major cardiac events and all-cause mortality following radiation therapy (RT) for lung cancer. In this study, we characterize the dosimetric effects of respiratory (RM) and cardiac (CM) motion on LAD.

MATERIALS/METHODS

Ten patients with stage IIIA-IVA lung cancer received cine MRIs (25 phases) at expiration which were used to evaluate the CM, and 4D CT scans for the evaluation of RM. Following registration of the expiration images of 4D CTs with MRIs, RT dose was transferred from planning CT datasets to all phases of 4D CTs and cine MRIs. LAD was manually contoured on all scans. The contours from each 4D phase represent LADs over multiple cardiac cycles, thus they are referred to as cLAD from here on. Displacements and dose variations of cLAD between exhale/inhale on 4D CTs and of LAD between systolic and diastolic phases on cine MRIs were analyzed, and paired t-tests were performed to assess the significance of the differences observed.

RESULTS

The following metrics are reported averaged over all patients. Clinical treatment planning CT metrics and doses: Mean dose, max dose, V5 Gy and V15 Gy were 15.0 (±11.3) Gy, 31.1 (±22.1) Gy, 53 (±33)%, 35 (±30)%. The cLAD metrics and dose variations due to respiratory motion (between exhale and inhale): RM amplitude was 0.3±0.2cm (RL 0.3 ± 0.1 cm, AP 0.2 ± 0.2 cm, SI 0.3 ± 0.2 cm). The variations in mean dose, max dose, V5 and V15 were 4.0 (±4.0) Gy, 1.6 (±1.5) Gy, 4.4 (±3.4)%, 4.0 (±3.4)%. Mean, max, V5 Gy and V15 Gy increased or remained unchanged with expiration in 8, 9, 5 and 5 patients, respectively. LAD metrics and dose variations due to cardiac motion (between systole and diastole): CM amplitude was 0.2 ± 0.1 cm (RL 0.2 ± 0.1 cm, AP 0.2 ± 0.1 cm, SI 0.3 ± 0.1 cm). The variations in mean dose, max dose, V5 and V15 were 1.7 (±1.4) Gy, 1.2 (±0.9) Gy, 5.2 (± 6.7)%, 4.6 (± 4.0)%. Mean, max, V5 Gy and V15 Gy increased or remained unchanged with diastole in 7, 7, 8 and 8 patients respectively. Statistical significance: The differences in displacement and dose between respiration and cardiac motion were not statistically significant.

CONCLUSION

Respiratory and cardiac-induced physiological variations of the LAD position have dosimetric consequences comparable in magnitude. Expiration and diastole lead to increased LAD doses. This underscores the importance of considering both the respiratory and the cardiac motion when motion management techniques are considered. 4D CTs inherently include the cardiac motion. However, if breath-hold is used for respiratory motion mitigation, CM might not be captured appropriately due to short tube rotation times. In this case, understanding CM characteristics is important for more accurate assessment of LAD dose.

Cardio-vocal syndrome - How 'benign' condition can turn 'malignant'?

Cardio-vocal syndrome (also called as Ortner's syndrome) is hoarseness of voice due to compression of left recurrent laryngeal nerve secondary to enlarged cardiac chambers and structures. We present two cases of Ortner's syndrome secondary to atrial fibrillation causing enlargement of left atrium compressing the left recurrent laryngeal nerve, and their clinical outcomes.

First Observation of Cyclotron Radiation from MeV-Scale e^{±} following Nuclear β Decay

We present an apparatus for detection of cyclotron radiation yielding a frequency-based β^{±} kinetic energy determination in the 5 keV to 2.1 MeV range, characteristic of nuclear β decays. The cyclotron frequency of the radiating β particles in a magnetic field is used to determine the β energy precisely. Our work establishes the foundation to apply the cyclotron radiation emission spectroscopy (CRES) technique, developed by the Project 8 Collaboration, far beyond the 18-keV tritium endpoint region. We report initial measurements of β^{-}'s from ^{6}He and β^{+}'s from ^{19}Ne decays to demonstrate the broadband response of our detection system and assess potential systematic uncertainties for β spectroscopy over the full (MeV) energy range. To our knowledge, this is the first direct observation of cyclotron radiation from individual highly relativistic β's in a waveguide. This work establishes the application of CRES to a variety of nuclei, opening its reach to searches for new physics beyond the TeV scale via precision β-decay measurements.

Long-term clinical outcomes of cardiac resynchronization therapy with or without defibrillation: impact of the aetiology of cardiomyopathy

Aims

There is a continuing debate as to whether cardiac resynchronization therapy-defibrillation (CRT-D) is superior to CRT-pacing (CRT-P), particularly in patients with non-ischaemic cardiomyopathy (NICM). We sought to quantify the clinical outcomes after primary prevention of CRT-D and CRT-P and identify whether these differed according to the aetiology of cardiomyopathy.

Methods and results

Analyses were undertaken in the total study population of patients treated with CRT-D (n = 551) or CRT-P (n = 999) and in propensity-matched samples. Device choice was governed by the clinical guidelines in the United Kingdom. In univariable analyses of the total study population, for a maximum follow-up of 16 years (median 4.7 years, interquartile range 2.4–7.1), CRT-D was associated with a lower total mortality [hazard ratio (HR) 0.72] and the composite endpoints of total mortality or heart failure (HF) hospitalization (HR 0.72) and total mortality or hospitalization for major adverse cardiac events (MACE; HR 0.71) (all P < 0.001). After propensity matching (n = 796), CRT-D was associated with a lower total mortality (HR 0.72) and the composite endpoints (all P < 0.01). When further stratified according to aetiology, CRT-D was associated with a lower total mortality (HR 0.62), total mortality or HF hospitalization (HR 0.63), and total mortality or hospitalization for MACE (HR 0.59) (all P < 0.001) in patients with ischaemic cardiomyopathy (ICM). There were no differences in outcomes between CRT-D and CRT-P in patients with NICM.

Conclusion

In this study of real-world clinical practice, CRT-D was superior to CRT-P with respect to total mortality and composite endpoints, independent of known confounders. The benefit of CRT-D was evident in ICM but not in NICM.

Optimizing care of ventilated infants by improving weighing accuracy on incubator scales

OBJECTIVES

To determine the accuracy of weighing ventilated infants on incubator scales and whether the accuracy can be improved by the addition of a ventilator tube compensator (VTC) device to counterbalance the force exerted by the ventilator tubing.

STUDY DESIGN

Body weights on integral incubator scales were compared in ventilated infants (with and without a VTC), with body weights on standalone electronic scales (true weight). Individual and series of trend weights were obtained on the infants. The method of Bland and Altman was used to assess the introduced bias.

RESULTS

The study included 60 ventilated infants; 66% of them weighed <1000 g. A total of 102 paired-weight datasets for 30 infants undergoing conventional ventilation and 30 undergoing high frequency oscillator ventilation (HFOV) supported by a SensorMedics oscillator, (with and without a VTC) were obtained. The mean differences and (95% CI for the bias) between the integral and true scale weighing methods was 60.8 g (49.1 g to 72.5 g) without and -2.8 g (-8.9 g to 3.3 g) with a VTC in HFOV infants; 41.0 g (32.1 g to 50.0 g) without and -5.1 g (-9.3 g to -0.8 g) with a VTC for conventionally ventilated infants. Differences of greater than 2% were considered clinically relevant and occurred in 93.8% without and 20.8% with a VTC in HFOV infants and 81.5% without and 27.8% with VTC in conventionally ventilated infants.

CONCLUSIONS

The use of the VTC device represents a substantial improvement on the current practice for weighing ventilated infants, particularly in the extreme preterm infants where an over- or underestimated weight can have important clinical implications for treatment. A large-scale clinical trial to validate these findings is needed.

Risk factors for 30-day readmission following hypoglycemia-related emergency room and inpatient admissions

OBJECTIVE

Hypoglycemia is a serious complication of diabetes treatment. This retrospective observational study characterized hypoglycemia-related hospital emergency room (ER) and inpatient (in-pt) admissions and identified risk factors for 30-day all-cause and hypoglycemia-related readmission.

RESEARCH DESIGN AND METHODS

4476 hypoglycemia-related ER and in-pt encounters with discharge dates from 1/1/2009 to 3/31/2014 were identified in a large, multicenter electronic health record database. Outcomes were 30-day all-cause ER/hospital readmission and hypoglycemia-related readmission. Multivariable logistic regression methods identified risk factors for both outcomes.

RESULTS

1095 (24.5%) encounters had ER/hospital all-cause readmission within 30 days and 158 (14.4%) of these were hypoglycemia-related. Predictors of all-cause 30-day readmission included recent exposure to a hospital/nursing home (NH)/skilled nursing facility (SNF; OR 1.985, p<0.001); age 25-34 and 35-44 (OR 2.334 and 1.996, respectively, compared with age 65-74, both p<0.001); and African-American (AA) race versus all other race categories (OR 1.427, p=0.011). Other factors positively associated with readmission include chronic obstructive pulmonary disease, cerebrovascular disease, cardiac dysrhythmias, congestive heart disease, hypertension, and mood disorders. Predictors of readmissions attributable to hypoglycemia included recent exposure to a hospital/NH/SNF (OR 2.299, p<0.001), AA race (OR 1.722, p=0.002), age 35-44 (OR 3.484, compared with age 65-74, p<0.001), hypertension (OR 1.891, p=0.019), and delirium/dementia and other cognitive disorders (OR 1.794, p=0.038). Obesity was protective against 30-day hypoglycemia-related readmission (OR 0.505, p=0.017).

CONCLUSIONS

Factors associated with 30-day all-cause and hypoglycemia-related readmission among patients with diabetic hypoglycemia include recent exposure to hospital/SNF/NH, adults <45 years, AAs, and several cardiovascular and respiratory-related comorbid conditions.

Repeatability of a cold stress test to assess cold sensitization

BACKGROUND

Non-freezing cold injury (NFCI) is a syndrome in which damage to peripheral tissues occurs without the tissues freezing following exposure to low ambient temperatures.

AIMS

To assess the test-retest reliability of a cold stress test (CST) used to assess cold sensitization.

METHODS

Volunteers with no self-reported history of NFCI undertook the CST on three occasions. Thermal images were taken of the foot and hand before, immediately after and 5min after immersion of the limb in cold water for 2min. Cold sensitization was graded by the two clinicians and the lead author. Spot temperatures from the toe and finger pads were recorded.

RESULTS

There were 30 white and 19 black male participants. The ratings indicated substantial agreement [a Cohen's kappa (κ) value of 0.61-0.8] to within ± one grading category for the hands and feet of the white volunteers and the hands of the black volunteers. Limits of agreement (LoA) analysis for toe and finger pad temperatures indicated high agreement (absolute 95% LoA < 5.5°C). Test-retest reliability for the feet of the black volunteers was not supported by the gradings (κ = 0.38) and toe pad temperatures (absolute 95% LoA = 9.5°C and coefficient of variation = 11%).

CONCLUSIONS

The test-retest reliability of the CST is considered adequate for the assessment of the cold sensitization of the hands and feet of white and the hands of black healthy non-patients. The study should be repeated with patients who have suffered a NFCI.

Variability in cardiac MR measurement of left ventricular ejection fraction, volumes and mass in healthy adults: defining a significant change at 1 year

OBJECTIVE

Variability in the measurement of left ventricular (LV) parameters in cardiovascular imaging has typically been assessed over a short time interval, but clinicians most commonly compare results from studies performed a year apart. To account for variation in technical, procedural and biological factors over this time frame, we quantified the within-subject changes in LV volumes, LV mass (LVM) and LV ejection fraction (EF) in a well-defined cohort of healthy adults at 12 months.

METHODS

Cardiac MR (CMR) was performed in 42 healthy control subjects at baseline and at 1 year (1.5 T Magnetom® Avanto; Siemens Healthcare, Erlangen, Germany). Analysis of steady-state free precession images was performed manually offline (Argus software; Siemens Healthcare) for assessment of LV volumes, LVM and EF by a single blinded observer. A random subset of 10 participants also underwent repeat imaging within 7 days to determine short-term interstudy reproducibility.

RESULTS

There were no significant changes in any LV parameter on repeat CMR at 12 months. The short-term interstudy biases were not significantly different from the long-term changes observed at 1 year. The smallest detectable change (SDC) for LVEF, end-diastolic volume, end-systolic volume and LVM that could be recognized with 95% confidence were 6%, 13 ml, 7 ml and 6 g, respectively.

CONCLUSION

The variability in CMR-derived LV measures arising from technical, procedural and biological factors remains minimal at 12 months. Thus, for patients undergoing repeat annual assessment by CMR, even small differences in LV function, size and LVM (which are greater than the SDC) may be attributed to disease-related factors.

ADVANCES IN KNOWLEDGE

The reproducibility and reliability of CMR data at 12 months is excellent allowing clinicians to be confident that even small changes in LV structure and function over this time frame are real.

An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012

Incident reporting is promoted as a key tool for improving patient safety in healthcare. We analysed 2238 patient safety incidents involving medications submitted from up to 29 critical care units each year in the North West of England between 2009 and 2012; 452 (20%) of these incidents led to harm to patients. Although 1461 (65%) incidents were judged to have been preventable, there was no reduction in the rate of incidents per 1000 days between 2009 and 2012 (5.9 in 2009, 6.6 in 2012). Furthermore, in the 2012 data, there were wide variations in the incident rates between units, the median (IQR [range]) rate per 1000 patient days for individual units being 6.8 (3.8-11.0 [1.3-37.1]). The variation in the percentage that could have been avoided was narrower, with a median (IQR [range]) of 70% (61-80% [38-100%]). The most commonly reported drugs were noradrenaline (161 incidents, 92 with harm), heparins (153 incidents, 29 with harm), morphine (131 incidents, 14 with harm) and insulin (111 incidents, 54 with harm). The administration of drugs was the stage in the process where incidents were most commonly reported; it was also the stage most likely to harm patients. We conclude that the wide range in reported rates between units, and the scope for preventing many incidents, suggest that quality improvement initiatives could improve medication safety in the units studied.

Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010

We categorised and established the rates of patient safety incidents reported during 2009 and 2010 from critical care units in 12 hospital trusts in North-West England. We identified a total of 4219 incidents reported during 127, 467 calendar days of critical care with a median (IQR [range]) of 31 (26-45 [20-57]) incidents per 1000 days per trust. A median (IQR [range]) of 10 (7-13 [3.5-27]) incidents per 1000 days were associated with harm. Pressure sores were the most common cause of harm, with a median (IQR [range]) of 3.9 (1.0-6.6 [0-20.4]) incidents per 1000 days. Only 89 (2.1%) incidents described more than temporary harm, of which 12 were airway related incidents. Five incidents described the use of inappropriate arterial flush solutions. It is possible to compare rates of incident reporting in different trusts over time to determine if different methods of care are associated with different reporting rates. The wide range of reported pressure sore rates suggests that their incidence could be reduced.

Pharmacokinetics of an orally administered methylcellulose formulation of gallium maltolate in neonatal foals

Gallium is a trivalent semi-metal with anti-microbial effects because of its incorporation into crucial iron-dependent reproductive enzyme systems. Gallium maltolate (GaM) provides significant gallium bioavailability to people and mice following oral administration and to neonatal foals following intragastric administration. To study the prophylactic and therapeutic effects of GaM against Rhodococcus equi pneumonia in foals, we developed a methylcellulose formulation of GaM (GaM-MCF) for oral administration to neonatal foals. Normal neonatal foals were studied. Six foals received 20 mg/kg and another six foals received 40 mg/kg of GaM-MCF orally. Serial serum samples were collected and serum gallium concentrations were determined using inductively coupled plasma mass spectroscopy. Gallium was rapidly absorbed (T(max) of 4 h), and a mean C(max) of 0.90 or 1.8 microg/mL was achieved in foals receiving 20 or 40 mg/kg respectively. Marked variability existed in C(max) among foals: only half of the foals receiving 20 mg/kg attained serum concentrations of >0.7 microg/mL, a level suggested to be therapeutic against R. equi by previous studies. Mean elimination half-life was 32.8 or 32.4 h for foals receiving 20 or 40 mg/kg respectively. The results of this study suggest that at least 30 mg/kg orally every 24 h should be considered in future pharmacodynamic and efficacy studies.

Parental attributions of controllability as a moderator of the relationship between developmental disability and behaviour problems

BACKGROUND

Children with developmental disabilities present behaviour problems to a greater extent than do typically developing children. Psychosocial models of child development suggest that parental attributions of child and adult controllability could moderate this relationship between child disability status and behaviour.

METHODS

The influence of parental attributions of adult and child controllability on the relationship between problem behaviours and disability was explored in mothers of children with developmental disabilities (DD) (N = 20) with a mean age of 9 years 3 months (SD 24.6 months), and in mothers of typically developing (TD) children (N = 26) with a mean age of 9 years 4 months (standard deviation 23.7 months). The DD group comprised 11 children with autistic spectrum disorders or other communication impairments, three children with Down Syndrome, one with cerebral palsy, one with attentional problems, and four with specific or complex developmental problems. Child behaviour was measured by the Child Behaviour Checklist. Parental attributions were measured using a modified version of the Parent Attribution Test and mothers were divided into higher and lower controllability groups on the basis of their responses on this test.

RESULTS

Multivariate analysis of variance found significant group × adult controllability interaction effects for 'aggressive behaviour', 'rule-breaking behaviour', as well as borderline significant effects for 'social problems' and 'other problems'. Simple effects analysis suggested that when mothers had lower attributions of adult controllability, there were indeed significantly more problem behaviours in the DD group, but when mothers had attributions of higher adult controllability there was no longer any significant difference in problematic behaviour between the two groups.

CONCLUSIONS

Parental attributions of controllability may moderate the well-established effect of disability on problem behaviour. Implications for parent intervention programmes are discussed.

Community pharmacists' attitudes to their advice-giving role and to the deregulation of medicines

The attitudes of pharmacists towards their advisory role and to the further deregulation of medicines have been surveyed using a postal questionnaire distributed to a randomly selected 20 per cent (227) of all community pharmacies in Scotland (response rate 90 per cent). Half the pharmacists thought that their role had changed since the publication of the Nuffield report in 1987, 81 per cent that their role was restricted by the range of drugs available for over-the-counter sale, and 93 per cent that they would like to see their role extended by the further deregulation of medicines; fifty eight per cent agreed that there should be a nursing formulary and 74 per cent that a corresponding pharmacists' formulary should be established. Pharmacists were also asked to suggest target preparations for deregulation: ninety per cent suggested at least one preparation, with chloramphenicol eye ointment and drops being the most frequently cited.

Colonization of Potato by Colletotrichum coccodes: Effect of Soil Infestation and Seed Tuber and Foliar Inoculation

Colonization of potato (Solanum tuberosum) tissue, including roots, stolons, and above and below ground stems, by Colletotrichum coccodes, the causal agent of black dot, was evaluated following soil infestation, inoculation of seed tubers and foliage, and every combination thereof, in field trials over two growing seasons in North Dakota and Minnesota. A total of 107,520 isolations for C. coccodes performed across four site-years allowed for an extensive comparison of fungal colonization of the host plant and disease severity. The black dot pathogen was detected in potato stems at the first sampling date in all four site-years, as early as 14 days prior to emergence. Colonization of above and below ground stems occurred at a higher frequency than in roots and stolons in all four site-years, resulting in significantly higher relative area under the colonization progress curves (RAUCPCs) (α = 0.05). Although fungal colonization and disease incidence were higher in inoculated and/or infested treatments, sufficient natural inoculum was present to result in substantial levels of disease in noninoculated and noninfested plots. However, noninoculated and noninfested plots displayed the lowest RAUCPC values across three of four site-years and those treatments with multiple inoculation events tended to have higher RAUCPC values. Isolates belonging to vegetative compatibility group (VCG)2 and -5 were recovered from plants sampled in 2004 more frequently than isolates belonging to VCG1 and -3. A significant difference in disease incidence on stems was observed only in North Dakota in 2004 and Minnesota in 2003 (α = 0.05). Noninoculated and noninfested plots displayed the lowest disease incidence, whereas those treatments with more than one inoculation and/or infestation event tended to have higher disease incidence. Results of this study, including the disease severity and yield data, provide a better understanding of colonization of potato plants by C. coccodes and its impact.

Review of patient safety incidents submitted from Critical Care Units in England & Wales to the UK National Patient Safety Agency

We reviewed and classified all patient safety incidents submitted from critical care units in England and Wales to the National Patient Safety Agency for the first quarter of 2008. A total of 6649 incidents were submitted from 141 organisations (median (range) 23 (1-268 incidents)); 786 were unrelated to the critical care episode and 248 were repeat entries. Of the remaining 5615 incidents, 1726 occurred in neonates or babies, 1298 were associated with temporary harm, 15 with permanent harm and 59 required interventions to maintain life or may have contributed to the patient's death. The most common main incident groups were medication (1450 incidents), infrastructure and staffing (1289 incidents) and implementation of care (1047 incidents). There were 2789 incidents classified to more than one main group. The incident analysis highlights ways to improve patient safety and to improve the classification of incidents.

Structural characterization of the interaction of mTOR with phosphatidic acid and a novel class of inhibitor: compelling evidence for a central role of the FRB domain in small molecule-mediated regulation of mTOR

The mammalian target of rapamycin (mTOR) is a large, multidomain protein kinase, which plays a central role in the regulation of cell growth and has recently emerged as an essential target of survival signals in many types of human cancer cells. Here, we report the solution structures of complexes formed between the FKBP12-rapamycin binding (FRB) domain of mTOR and phosphatidic acid, an important cellular activator of the kinase, and between the FRB domain and a novel inhibitor (HTS-1). The overall structure of the FRB domain is very similar to that seen in the ternary complex formed with FKBP12 and the immunosuppressive drug rapamycin; however, there are significant changes within the rapamycin-binding site with important consequences for rational drug design. The surface of the FRB domain contains a number of distinctive features that have previously escaped attention, including a potential new regulatory site on the opposite face to that involved in the binding of rapamycin, which displays the features expected for a specific binding site for a small molecule. The interaction sites for phosphatidic acid and HTS-1 were found to closely match the site responsible for rapamycin binding. In addition, the structures determined for the FRB-phosphatidic acid and FRB-HTS-1 complexes revealed a striking similarity between the conformations of buried portions of the ligands and that seen for the rapamycin backbone in contact with the domain. Our findings further highlight the importance of the FRB domain in small molecule-mediated regulation of mTOR, demonstrate the ability to identify novel inhibitors of mTOR that bind tightly to the rapamycin-binding site in the absence of FKBP12, and identify a potential new regulatory site that may be exploited in the design of new anticancer drugs.

Electronic surveillance of wall-mounted soap and alcohol gel dispensers in an intensive care unit

We describe a battery-powered recording device incorporating a force-sensitive resistor and a microcontroller that records depressions of wall-mounted soap and alcohol gel dispensers. The device has a two-second (2 s) lockout built into it, so that a single record is associated with a single hand-hygiene episode. Recorders were implanted within the wall-mounted dispensers found in two bed areas and the entrance of a 16-bedded intensive care unit. The use of the bed area dispensers was correlated (r) with the dependency of the patient in the open bed area (r=0.5, P<0.01), as assessed using the UK Department of Health critical care minimum data set. Both bed areas and the entrance dispensers showed wide but different fluctuations in use throughout the 24h day. The recording device may help in feedback about soap and gel use for hand-hygiene quality improvement and educational initiatives.

Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of buprenorphine maintenance therapy (BMT) and methadone maintenance therapy (MMT) for the management of opioid-dependent individuals.

DATA SOURCES

Major electronic databases were searched from inception to August 2005. Industry submissions to the National Institute for Health and Clinical Excellence were accessed.

REVIEW METHODS

The assessment of clinical effectiveness was based on a review of existing reviews plus an updated search for randomised controlled trials (RCTs). A decision tree with Monte Carlo simulation model was developed to assess the cost-effectiveness of BMT and MMT. Retention in treatment and opiate abuse parameters were sourced from the meta-analysis of RCTs directly comparing flexible MMT with flexible dose BMT. Utilities were derived from a panel representing a societal perspective.

RESULTS

Most of the included systematic reviews and RCTs were of moderate to good quality, and focused on short-term (up to 1-year follow-up) outcomes of retention in treatment and the level of opiate use (self-report or urinalysis). Most studies employed a trial design that compared a fixed-dose strategy (i.e. all individuals received a standard dose) of MMT or BMT and were conducted in predominantly young men who fulfilled criteria as opiate-dependent or heroin-dependent users, without significant co-morbidities. RCT meta-analyses have shown that a fixed dose of MMT or BMT has superior levels of retention in treatment and opiate use than placebo or no treatment, with higher fixed doses being more effective than lower fixed doses. There was evidence, primarily from non-randomised observational studies, that fixed-dose MMT reduces mortality, HIV risk behaviour and levels of crime compared with no therapy and one small RCT has shown the level of mortality with fixed-dose BMT to be significantly less than with placebo. Flexible dosing (i.e. individualised doses) of MMT and BMT is more reflective of real-world practice. Retention in treatment was superior for flexible MMT than flexible BMT dosing but there was no significant difference in opiate use. Indirect comparison of data from population cross-sectional studies suggests that mortality with BMT may be lower than that with MMT. A pooled RCT analysis showed no significant difference in serious adverse events with MMT compared with BMT. Although treatment modifier evidence was limited, adjunct psychosocial and contingency interventions (e.g. financial incentives for opiate-free urine samples) appeared to enhance the effects of both MMT and BMT. Also, MMT and BMT appear to be similarly effective whether delivered in a primary care or outpatient clinic setting. Although most of the included economic evaluations were considered to be of high quality, none used all of the appropriate parameters, effectiveness data, perspective and comparators required to make their results generalisable to the NHS context. One company (Schering-Plough) submitted cost-effectiveness evidence based on an economic model that had a 1-year time horizon and sourced data from a single RCT of flexible-dose MMT compared with flexible-dose BMT and utility values obtained from the literature; the results showed that for MMT vs no drug therapy, the incremental cost-effectiveness ratio (ICER) was pound 12,584/quality-adjusted life-year (QALY), for BMT versus no drug therapy, the ICER was pound 30,048/QALY and in a direct comparison, MMT was found to be slightly more effective and less costly than BMT. The assessment group model found for MMT versus no drug therapy that the ICER was pound 13,697/QALY, for BMT versus no drug therapy that the ICER was pound 26,429/QALY and, as with the industry model, in direct comparison, MMT was slightly more effective and less costly than BMT. When considering social costs, both MMT and BMT gave more health gain and were less costly than no drug treatment. These findings were robust to deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

Both flexible-dose MMT and BMT are more clinically effective and more cost-effective than no drug therapy in dependent opiate users. In direct comparison, a flexible dosing strategy with MMT was found be somewhat more effective in maintaining individuals in treatment than flexible-dose BMT and therefore associated with a slightly higher health gain and lower costs. However, this needs to be balanced by the more recent experience of clinicians in the use of buprenorphine, the possible risk of higher mortality of MMT and individual opiate-dependent users' preferences. Future research should be directed towards the safety and effectiveness of MMT and BMT; potential safety concerns regarding methadone and buprenorphine, specifically mortality and key drug interactions; efficacy of substitution medications (in particular patient subgroups, such as within the criminal justice system, or within young people); and uncertainties in cost-effectiveness identified by current economic models.

More on RotaShield and intussusception: the role of age at the time of vaccination

BACKGROUND

RotaShield, a vaccine intended to prevent severe rotavirus diarrhea, was withdrawn in July 1999, 9 months after it became available in the United States, because of a temporal association with intussusception events that occurred in vaccinated infants. We explore here the effect of age on the risk of intussusception.

METHODS

We reanalyzed a case-control database of the Centers for Disease Control and Prevention by use of a 21-day window, to define vaccine-associated events. We obtained data on vaccine use from the National Immunization Survey and estimated the age-stratified background incidence of intussusception by use of Healthcare Cost and Utilization Project data. We combined these data to estimate how absolute risk varies with age and to model the projected population-attributable risk associated with 3 different vaccination schedules.

RESULTS

We found that the incidence of intussusception associated with the first dose of vaccine increased with age. Infants > or = 90 days old accounted for 80% of cases of intussusception associated with a first dose but had received only 38% of first doses. Modeling of the recommended schedule of vaccination at ages 2, 4, and 6 months projected 1 intussusception event/11,000-16,000 vaccine recipients; modeling of a 2-dose schedule beginning in the neonatal period projected 1 intussusception event/38,000-59,000 vaccine recipients.

CONCLUSIONS

The practice of initiating immunization after age 90 days, which we call "catch-up" vaccination, contributed disproportionately to the occurrence of intussusception associated with the use of RotaShield. A fully implemented 2-dose vaccination schedule begun during the neonatal period would lead to, at most, a 7% increase in the incidence of intussusception above the annual background incidence.

Short-term safety evaluation of processed calcium montmorillonite clay (NovaSil) in humans

NovaSil clay (NS) provides significant protection from the adverse effects of aflatoxins (AFs) in multiple animal species by decreasing bioavailability from the gastrointestinal tract. It is postulated that NS clay can be safely added to human diets to diminish exposure and health risks from AF contaminated food. To determine the safety and tolerance of NS in humans and establish dosimetry protocols for long-term efficacy studies, a randomized and double-blinded phase I clinical trial was conducted. Volunteers (20-45 yr in age), were clinically screened for confirmation of their health status. Fifty subjects (23 males and 27 females) were randomly divided into two groups: The low-dose group received nine capsules containing 1.5 g/day, and the high-dose group received nine capsules containing 3.0 g/day for a period of 2?wk. NS capsules were manufactured in the same color and size and were distributed to each participant three times a day at designated sites where follow-up was taken to record any side effects and complaints. Blood and urine samples were collected before and after the study for laboratory analysis. All participants completed the trial and compliance was 99.1%. Mild GI effects were reported in some participants. Symptoms included abdominal pain (6%, 3/50), bloating (4%, 2/50), constipation (2%, 1/50), diarrhea (2%, 1/50), and flatulence (8%, 4/50). No statistical significance was found between the two groups for these adverse effects (p > 0.25). No significant differences were shown in hematology, liver and kidney function, electrolytes, vitamins A and E, and minerals in either group. These results demonstrate the relative safety of NS clay in human subjects and will serve as a basis for long-term human trials in populations at high risk for aflatoxicosis.

Restricted entry of R5 HIV Type 1 strains into eosinophilic cells

A cell culture system previously developed by our laboratory demonstrated that T cell-tropic (CXCR4-using) but not macrophage-tropic (CCR5-using) HIV-1 strains productively infected eosinophilic cells. In the current study, an improved model was used to determine the level of this viral restriction by assessing viral entry and coreceptor usage. The model was improved by using AML14.3D10 cells that were engineered to express CCR3 in addition to the major HIV-1 coreceptors, CD4, CXCR4, and CCR5, thus making them more like primary eosinophils. A polymerase chain reaction (PCR) assay was used to detect viral entry. In the PCR assay, primers specific for early reverse transcription products were used to amplify minus strand viral DNA from HIV-1-infected AML14.3D10-CCR3 eosinophilic cells. Coreceptor blocking experiments, using the CXCR4 antagonist AMD3100, were performed to determine coreceptor usage by the CXCR4-using (X4) strain known to productively infect the cells. Virus production was measured by p24 immunoassay. As expected, viral DNA was detected in AML14.3D10-CCR3 cells infected with X4 HIV-1, and cell viability was decreased during maximal viral production. Conversely, viral DNA was not detected in eosinophilic cells exposed to a CCR5-using (R5) HIV-1 strain that is also capable of using CCR3, indicating that R5 HIV-1 is unable to enter eosinophilic cells despite the presence of the appropriate coreceptors. Infection of AML14.3D10-CCR3 cells by HTLV-III(B) was completely inhibited by AMD3100, indicating that X4 HIV-1 enters the AML14.3D10-CCR3 cell line by using the CXCR4 coreceptor exclusively. Since X4 strains predominate during the late stages of HIV-1 infection in many patients, when eosinophil numbers also tend to increase, the ability of these HIV-1 strains to infect eosinophilic cells has important implications for the involvement of eosinophils in the pathogenesis of AIDS.

Comparison of 3 tests to detect acaricide resistance in Boophilus decoloratus on dairy farms in the Eastern Cape Province, South Africa

The susceptibility of the larval offspring of engorged female Boophilus decoloratus, and of the engorged females, collected from cattle on the dairy farms Brycedale, Sunny Grove and Welgevind in the Eastern Cape Province, South Africa, was tested against the acaricides amitraz, chlorfenvinphos and cypermethrin. Resistance was determined by means of the Shaw Larval Immersion Test (SLIT) for larvae and the Reproductive Estimate Test (RET) and Egg Laying Test (ELT) for adults. At Brycedale the tests all indicated resistance to chlorfenvinphos, and RET and ELT indicated resistance to amitraz and emerging resistance to cypermethrin. At Sunny Grove, B. decoloratus was resistant to cypermethrin using SLIT and exhibited emerging resistance to chlorfenvinphos with SLIT and to cypermethrin with both RET and ELT At Welgevind, resistance was recorded against chlorfenvinphos (SLIT) and against cypermethrin (ELT), and emerging resistance against permethrin (RET). The results obtained with RET and ELT were generally comparable, but often differed from those obtained with SLIT. Resistance could be detected within 7 days with ELT compared to 42 days with RET and 60 days with SLIT.

Common loon eggs as indicators of methylmercury availability in North America

Increased anthropogenic mercury (Hg) deposition since pre-industrial times, and subsequent transformation of inorganic Hg to methylmercury (MeHg) in aquatic environments, has created areas in North America where Hg poses a relatively high risk to wildlife, especially long-lived, piscivorous species. From 1995 to 2001, we opportunistically collected 577 eggs abandoned by Common Loons from eight states. Egg-Hg concentrations ranged from 0.07 to 4.42 microg/g (ww) or 0.10 to 19.40 microg/g (dw). Mercury was higher in eastern than in western North America. Female blood-Hg concentrations strongly correlated with those of eggs from the same territory even though the mean intraclutch Hg difference was 25%. In New England, egg volume declined significantly as egg-Hg concentrations increased. Fertility was not related to egg-Hg concentrations. Based on existing literature and this study's findings, egg-Hg risk levels were established and applied to our US data set and an existing Canadian data set. Regionally, we found the greatest risk levels in northeastern North America. With few exceptions, loon eggs are suitable indicators of methylmercury availability on lakes with territorial pairs.

Dryland salinity in Western Australia: managing a changing water cycle

Clearing of agricultural land has resulted in significant changes to the surface and groundwater hydrology. Currently about 10% of agricultural land in Western Australia is affected by dryland salinity and between a quarter and a third of the area is predicted to be lost to salinity before a new hydrological equilibrium is reached. This paper develops a general statement describing the changes to the surface and groundwater hydrology of the wheatbelt of Western Australia between preclearing, the year 2000 and into the future. For typical catchments in the wheatbelt it is estimated that average groundwater recharge and surface runoff have increased about tenfold when comparing the current hydrology to that preclearing. Saline groundwater discharge and flood volumes have also increased significantly. Saline groundwater discharge and associated salt load will probably double in the future in line with the predicted increase in the area of dryland salinity. In addition, future increases in the area of dryland salinity/permanent waterlogging will probably double the volumes in flood events and further increase surface runoff in average years. The outcomes of surface and groundwater management trials have been briefly described to estimate how the hydrology would be modified if the trials were implemented at a catchment scale. These results have been used to formulate possible integrated revegetation and drainage management strategies. The future hydrology and impacts with and without integrated management strategies have been compared.

Assessment of Resistance of Tubers of Potato Cultivars to Phytophthora erythroseptica and Pythium ultimum

Tubers of 34 potato cultivars were examined for their susceptibility to infection by zoospores of Phytophthora erythroseptica and mycelia of Pythium ultimum. Incidence of infected tubers (%) and penetration of rot (mm) were the parameters used to determine the susceptibility of each cultivar. Tubers of cv. Atlantic appeared to have some resistance to infection and colonization by Phytophthora erythroseptica. Cvs. Russet Norkotah and Snowden were the most susceptible to infection by P. erythroseptica. Snowden was found to be highly susceptible to P. erythroseptica, but it was the most resistant to Pythium ultimum. Cvs. FL-1625 and FL-1867 also were less susceptible to P. ultimum than the other cultivars. Cvs. Superior, Itasca, and Dark Red Norland were the most susceptible to P. ultimum. Cultivar susceptibility should be considered when making disease management decisions, particularly in fields where these soilborne diseases are a recurring problem.

Eliciting the smoker's agenda: implications for policy and practice

Existing health promotion messages and advice on smoking cessation focus upon the negative aspects of continuing to smoke and contrast these to the benefits of giving up. Benefits of cessation are invariably linked to reduced risks of illness and disease with the process of cessation framed as a largely positive and certainly a health enhancing one. In this paper we present an analysis of data from a cross-sectional, exploratory study in the city of Aberdeen, Scotland, undertaken with 54 people, aged 18-44, who are or have been smokers. The multiple and often contradictory agendas of everyday life, smoking and health are explored. Participants spoke of the dangers of smoking and the potential benefits of giving up as these are considered by health promotion and medical research. However, many smokers experienced a number of benefits from smoking (such as socialising with others and breaks from boredom), and health and social problems with the process of cessation (for example, weight gain, stress, colds, flu). Participants appeared to query the validity of the risks of continuing to smoke and yet indicate a range of health and social difficulties in giving up. The authors assert that an acknowledgement of the attractive, pleasurable aspects of smoking may be seen as unacceptable and irresponsible but this could well provide an opportunity to relate to the everyday and multiple practices of smoking and smokers themselves as illuminated by this research.

Sensitivity of North American Isolates of Phytophthora erythroseptica and Pythium ultimum to Mefenoxam (Metalaxyl)

A 4-year study (1997 to 2000) was conducted to determine the sensitivities of the potato tuber rot pathogens, Phytophthora erythroseptica and Pythium ultimum, to mefenoxam (metalaxyl). A total of 2,277 tubers showing symptoms of "water rot" were collected from 16 states and 2 Canadian provinces. From these, 849 isolates of P. erythroseptica and 213 isolates of P. ultimum were obtained, and 805 and 190 isolates, respectively, were tested for their ability to grow on V8 medium amended at 0.01 to 100 μg/ml with fungicide. Isolates ranged widely in their responses to mefenoxam. The presence of resistant isolates (EC₅₀ > 100 μg ml^-1) of P. erythroseptica in the potato producing areas of Maine was confirmed. The presence of P. erythroseptica isolates in Idaho and Minnesota resistant to mefenoxam is reported for the first time. The proportion of P. erythroseptica isolates resistant to mefenoxam varied from 2.9 to 36.2% between 1997 and 2000. The proportion of resistant P. ultimum isolates represented only a small proportion of the isolates tested (3.7%). A single resistant P. ultimum isolate was recovered from Washington, whereas most of the resistant isolates obtained (5 of 7) were collected in Minnesota during the final year of the study. This is the first report of resistance in P. ultimum pathogenic to potato tubers. These observations suggest that pink rot and leak could become significant problems in the future, particularly in those areas where resistance has been detected. Our results have implications for the effective management of water rot. Monitoring the sensitivity of the pathogen population to mefenoxam in all production areas should be considered and integrated as a part of the overall disease management strategy.

CDP840. A prototype of a novel class of orally active anti-inflammatory phosphodiesterase 4 inhibitors

The discovery, synthesis and biological activity of a series of triarylethane phosphodiesterase 4 inhibitors is described. Structure-activity relationship studies are presented for CDP840 (29), a potent, chiral, selective inhibitor of PDE 4 (IC(50) 4nM). CDP840 is non-emetic in the ferret at 30mgkg(-1) (po), active in models of inflammation and reverses ozone-induced bronchial hyperreactivity in the guinea pig.

Mouseyes revisited: upgrading a computer program that aids wound measurement

A computer program (Mouseyes) for measuring wounds has been upgraded to incorporate the use of photographic images taken with a digital camera. This evaluation showed that the upgrade produced accurate and reproducible results.

Acaricide resistance profiles of single- and multi-host ticks from communal and commercial farming areas in the Eastern Cape and North-West Provinces of South Africa

A field study (February 2000 to August 2001) was conducted on communal and commercial farms in the Eastern Cape and North-West Provinces of South Africa to detect the levels of tick resistance to commonly used acaricides. The larvae obtained from engorged females of the one-host tick Boophilus decoloratus, the two-host tick Rhipicepalus evertsi evertsi and the three-host ticks Amblyomma hebraeum and Rhipicephalus appendiculatus were tested against various concentrations of amitraz, chlorfenvinphos and cypermethrin using the Shaw Larval Immersion Test method. Ticks from the communal farms showed higher levels of resistance to cypermethrin and some resistance to chlorfenvinphos whilst no resistance was detected against amitraz. However, ticks from commercial farms were equally resistant to amitraz, chlorfenvinphos and cypermethrin. The B. decoloratus populations tested were considerably more resistant to all the acaricides tested than the R. evertsi evertsi, A. hebraeum and R. appendiculatus populations. This supports the hypothesis that single-host ticks develop resistance faster than multi-host ticks. This trend was recorded on most of the farms where single- and multi-host ticks co-existed. It was concluded that the use of acaricides at high frequencies and high concentrations was one of the main causes of tick resistance in the study areas. Possible factors which caused the resistance problems are discussed and acaricide management strategies recommended.

The cost-effectiveness of preoperative testing (basic office assessment vs. urodynamics) for stress urinary incontinence in women

OBJECTIVE

To compare the cost-effectiveness of preoperative testing strategies in women with stress incontinence symptoms, as although urodynamic testing is used to improve the diagnostic accuracy in women with incontinence, the clinical and economic consequences of different levels of testing have not been evaluated.

MATERIALS AND METHODS

Decision analysis was used to evaluate basic office assessment (BOA) and urodynamic testing for women with stress incontinence symptoms who were candidates for primary surgical treatment. Costs were calculated using the Federal Register. Parameter estimates for the effectiveness of treatment for different diagnoses of incontinence were based on published reports. Incremental cost-effectiveness was defined as the cost in dollars per additional patient cured of incontinence.

RESULTS

Urodynamics did not improve the effectiveness of treatment; both strategies of a BOA and urodynamic testing resulted in a cure rate of 96% after initial and secondary treatments. The mean cost of care (including initial and secondary treatments and outcomes) was similar for the two strategies ($5042 for BOA, $5046 for urodynamic testing). With BOA reduced testing costs were balanced by increased costs for patients who failed the initial treatment. Under baseline assumptions, one additional cure of incontinence (incremental cost-effectiveness) using the urodynamic strategy cost $3847, compared with BOA. By sensitivity analyses, BOA was less costly than urodynamics when the prevalence of genuine stress incontinence was > or = 80%.

CONCLUSION

These findings do not support the routine use of urodynamics before surgery in women likely to have genuine stress incontinence, and provide the justification for randomized trials of preoperative testing strategies.

Using an artificial neural network to predict healing times and risk factors for venous leg ulcers

OBJECTIVES

This study aimed to identify the risk factors that influence the healing process of venous leg ulcers treated with compression bandaging, with a view to predicting healing time.

METHOD

A retrospective cohort study was performed on data collected prospectively on 325 consecutive patients presenting with 345 venous ulcers at the Salford Primary Care Trust leg ulcer clinic between January 1997 and December 1999. Use of an artificial neural network (ANN) technique accurately predicted the healing times for 68% of the patients.

RESULTS

The ANN demonstrated that healing was significantly related to a history of previous leg ulceration, 'quite wet' ulcer exudate, high body mass index, large initial total ulcer area, increasing age and male gender.

CONCLUSION

The ability to identify at presentation ulcers that might be resistant to standard therapy would allow early consideration of more radical treatments such as hospitalisation, wound debridement or venous surgery.

The effect of folic acid supplementation on plasma homocysteine in an elderly population

BACKGROUND

Increased plasma homocysteine is associated with coronary artery disease, peripheral vascular disease and venous thrombosis. Folic acid is the most effective therapy for reducing homocysteine levels. The lowest effective supplement of folic acid is not known, particularly for the elderly who have the highest prevalence of these conditions.

AIM

To explore the effects of daily supplements of 0, 50, 100, 200, 400 and 600 microg folic acid on plasma homocysteine in an elderly population.

DESIGN

Randomized double-blind placebo-controlled trial.

METHODS

Participants (n=368) aged 65-75 years were randomly allocated to receive one of the treatments for 6 weeks. Plasma homocysteine was recorded after 3 weeks and 6 weeks of supplementation.

RESULTS

Only the 400 microg and 600 microg groups had significantly lower homocysteine levels compared to placebo (p=0.038 and p<0.001, respectively). Using multiple linear regression and each individual's total folic acid intake (diet plus supplement), a total daily folic acid intake of 926 microg per day would be required to ensure that 95% of the elderly population would be without cardiovascular risk from folate deficiency.

DISCUSSION

A daily folic acid intake of 926 microg is unlikely to be achieved by diet alone. Individual supplementation or fortification of food with folic acid will be required to reach this target.

Long-term results of en bloc transplantation of pediatric kidneys into adults using a vicryl mesh envelope technique

En bloc transplantation of pediatric kidneys into adults is a suitable measure to help correct the shortage of available kidneys. This practice, however, is not widespread because of the high incidence of vascular complications. Our institution has previously described a vicryl mesh technique for en bloc kidneys, with an attempt to reduce the incidence of vascular complications. The purpose of this study was to evaluate the long-term results of recipients with en bloc kidneys stabilized with this technique. The charts of 644 adult renal transplants performed between July 1987 and July 1999 were reviewed. During this period, 14 adult patients have received 14 pairs of en bloc pediatric kidneys using the vicryl mesh technique. All patients received OKT3 as an induction immunosuppression with cyclosporine started 10-14 d after the transplant. The median donor age was 24 months (range 14-84 months), and the median recipient age was 49 yr (range 23-68 yr). The mean recipient weight was 79 kg (range 60-114 kg). The mean cold ischemia time was 14.2 hr. None of the patients developed vascular or urological complications. Delayed graft function and moderate acute rejection occurred in one patient each. At a mean follow-up of 51 months (range 7-96 months), all 14 patients maintained excellent renal function with a mean creatinine of 1.01 mg/dL. Renal measurements pre-operatively and at follow-up ultrasound examinations were available in 9 patients, and the mean length of the kidneys had grown approximately 5.0 cm. These data demonstrate that minimal vascular and immunological complication rates can be achieved with pediatric en bloc kidneys using the vicryl mesh envelope technique.

Decreased expression of cellular prostatic acid phosphatase increases tumorigenicity of human prostate cancer cells

PURPOSE

Understanding cell proliferation regulation in hormone refractory prostate cancer may provide answers for novel solutions. Protein tyrosine phosphatases have been thought to have key roles in regulating cell proliferation and be involved in oncogenesis, although to our knowledge their functional roles in human prostate cancer remain unknown. Human prostatic acid phosphatase (PAcP), a major phosphatase in prostate epithelium, has been shown to function as a neutral protein tyrosine phosphatase in these cells. We evaluated the biological significance of cellular prostatic acid phosphatase expression in human prostate cancer cells.

MATERIALS AND METHODS

Immunohistochemical testing of human prostate cancer archival specimens was done to evaluate the expression of cellular PAcP. Immunoprecipitation and immunoblotting were performed to determine cellular PAcP and SH2 domain-bearing tyrosine phosphatase-1 levels as well as tyrosine phosphorylation of c-ErbB-2/neu in different human prostate cancer cells. The biological behavior of LNCaP derivative sublines was characterized in vitro and in vivo by soft agar analysis and xenograft animal inoculation.

RESULTS

Immunohistochemical staining of human prostate clearly showed that cellular levels of PAcP significantly decreases in prostate cancer cells (p <0.001). The results of biochemical characterization revealed that the cellular level of PAcP but not SHP-1, another differentiation associated protein tyrosine phosphatase, consistently correlated negatively with the growth of several human prostate cancer cell lines. Reintroducing cellular PAcP activity in prostate cancer cells by PAcP complementary DNA transfection resulted in decreased tyrosine phosphorylation of c-ErbB-2/neu, decreased proliferation rates in culture as well as decreased anchorage independent growth in soft agar. The xenograft animal model demonstrated that a higher tumor growth rate as well as larger size is associated with a lower level of cellular PAcP.

CONCLUSIONS

Cellular PAcP can down-regulate prostate cancer cell growth, at least partially by dephosphorylating c-ErbB-2/neu. Therefore, decreased cellular PAcP expression in cancer cells may be involved in prostate cancer progression.

Effects of screening on cervical cancer incidence and mortality in New South Wales implied by influences of period of diagnosis and birth cohort

STUDY OBJECTIVES

Cervical cancer incidence and mortality in NSW during 1972-1996 is examined under counterfactual assumptions to estimate the number of new cervical cancer cases averted and deaths avoided, with projections to 2006.

SETTING

Cervical cancer incident cases and deaths in NSW for 1972-96 were obtained from the NSW Central Cancer Registry, Sydney, Australia.

DESIGN

Data were analysed by age-period-cohort (APC) modelling, using Poisson regression. Projection of incidence to 2006 was based on a linear trend for period effects. A counterfactual scenario was constructed assuming stable period effects (1972-74), but modelled cohort effects. Modelled rates were converted to cases and deaths (using mortality:incidence ratios for cervical cancer), and compared with actual data to estimate cancers prevented and deaths averted due to screening.

RESULTS

Rising cohort effects with recency of birth were found after controlling for age and period of diagnosis, and declining period effects were identified after controlling for age and birth cohort. The estimated cumulated number of new cases of cervical cancer prevented during 1972-1996 was 3440. The cumulated number of averted deaths over 1972-1996, derived from incident cases, was estimated to be 1610 (including actual declines in the M/I ratio). With no change in the M/I ratio from 1972, estimated cumulated mortality averted due to cervical cancer for 1972-1996 was 1210 deaths.

CONCLUSIONS

Cervical screening has prevented a substantial number of new cases of cervical cancer and deaths. In addition, secondary prevention and improved treatment has contributed further to cervical cancer deaths averted.

A short and efficient route to novel scyphostatin analogues

[structure: see text]. Several novel scyphostatin analogues have been prepared in up to 18% yield over five steps from commercially available 4-bromoguaiacol, utilizing an organometallic addition to afford the desired syn-hydroxy-epoxides.

Sentinel node localization in oral cavity and oropharynx squamous cell cancer

OBJECTIVE

To evaluate the feasibility and predictive ability of the sentinel node localization technique for patients with squamous cell carcinoma of the oral cavity or oropharynx and clinically negative necks.

DESIGN

Prospective, efficacy study comparing the histopathologic status of the sentinel node with that of the remaining neck dissection specimen.

SETTING

Tertiary referral center.

PATIENTS

Patients with T1 or T2 disease and clinically negative necks were eligible for the study. Nine previously untreated patients with oral cavity or oropharyngeal squamous cell carcinoma were enrolled in the study.

INTERVENTIONS

Unfiltered technetium Tc 99m sulfur colloid injections of the primary tumor and lymphoscintigraphy were performed on the day before surgery. Intraoperatively, the sentinel node(s) was localized with a gamma probe and removed after tumor resection and before neck dissection.

MAIN OUTCOME MEASURES

The primary outcome was the negative predictive value of the histopathologic status of the sentinel node for predicting cervical metastases.

RESULTS

Sentinel nodes were identified in 9 previously untreated patients. In 5 patients, there were no positive nodes. In 4 patients, the sentinel nodes were the only histopathologically positive nodes. In previously untreated patients, the sentinel node technique had a negative predictive value of 100% for cervical metastasis.

CONCLUSIONS

Our preliminary investigation shows that sentinel node localization is technically feasible in head and neck surgery and is predictive of cervical metastasis. The sentinel node technique has the potential to decrease the number of neck dissections performed in clinically negative necks, thus reducing the associated morbidity for patients in this group.

Cervical screening by socio-economic status in Australia

OBJECTIVES

To examine differentials and time trends in self-reported Pap test rates by socio-economic status (SES) from the 1989/90 and 1995 Australian National Health Surveys (NHS).

METHODS

The unit record data for females were extracted from the two NHSs and combined. The outcome variable of interest was 'having a Pap test in the past three years'. The principal study factor was SES measured as individual characteristics and SES of area of residence. Migrant status, rurality, year of survey and age were controlled for in logistic regression models.

RESULTS

Self-reported rates of having a Pap test in the past three years were higher in women from higher compared with lower SES groups. Compared with women with a bachelor or higher degree, the odds of reporting having a Pap test in the past three years in women with no post-school qualification was 0.86 (p<0.0005). Women with a gross annual income of less than $20,000 had significantly lower odds (OR=0.79) compared with women earning $40,000 or more. Blue collar (OR=0.84) and not employed (OR=0.73) women also had significantly lower odds compared to the referent white collar group.

CONCLUSION

This study reveals differentials in Pap screening behaviour by individual measures of SES in Australia. Area-based SES measures under-estimated the SES differentials in Pap test rates compared with individual measures. Derived population attributable fractions reveal that about a quarter of self-reported under-screening is accounted for by low SES when measured individually, compared to 8% when SES is measured ecologically.