Gastric outlet obstruction secondary to a wandering spleen: systematic review and surgical management of a case

INTRODUCTION

A wandering spleen occurs when laxity or absence of the suspensory ligaments allows migration throughout the abdomen. Gastric outlet obstruction resulting from this abnormality is rare. We present a systematic literature search and a case that was managed successfully with surgical intervention at our centre.

METHODS

A systematic search of the PubMed, Embase™, Medline^® and Google Scholar™ databases was carried out employing the combined search terms "gastric outlet obstruction" AND "wandering spleen". Six results were included for final analysis.

RESULTS

All six search results described a single case each. Patients underwent surgical management (open or laparoscopic) after initial investigation utilising a range of modalities. There were no mortalities reported at 90 days. The single case we present was complicated by gastric perforation; the patient made a successful recovery following open splenopexy and stapled wedge resection of the stomach.

CONCLUSIONS

A wandering spleen is a rare diagnosis and there are only six reported cases of gastric outlet obstruction secondary to a wandering spleen in the literature. None report associated gastric perforation. There are a variety of presenting symptoms, intraoperative findings and operative techniques used to address the gastrosplenic abnormality. The case reported by our centre adds to this limited evidence base and demonstrates a successful outcome from definitive surgical management. We highlight the need to seek early gastro-oesophageal expertise if any gastric pathology is found together with anatomical abnormality of the spleen.

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

485 Unexpected Pathological Findings In 189 LVRS Patients: Clinical Relevance

Objectives

LVRS improves survival and quality of life in selected patients with emphysema. In view of the great improvement in the detailed information available from CT, it is important to evaluate the benefit of routine pathological assessment of the resected specimen. We reviewed the histopathological findings in our contemporary LVRS series to determine the rate of pathological findings in addition to emphysema.

Method

Prospectively collected data from a specialised higher volume LVRS centre. The CT and histopathology reports of 189 consecutive LVRS procedures were reviewed. One underwent thoracotomy, 188 were by VATS, of which one was converted to thoracotomy and of which 22 were by a subxiphoid approach. The target reduction volume was 30-50% of the lung.

Results

All patients were reported to have emphysematous changes in both CT and histology. Ten patients, all with radiographic evidence of a lesion preoperatively, had squamous carcinoma (x2), adenocarcinoma, atypical adenomatous hyperplasia (AAH) (x2), squamous metaplasia (x2), carcinoid tumourlet, chondroid hamartoma, and DIPNECH. There were 39 neoplastic histological findings which were not radiologically reported; these were adenocarcinoma (1), AAH (10), squamous metaplasia (7), carcinoid tumourlet (5), squamous dysplasia (3), neuroendocrine hyperplasia (2), and chemodectoma. In addition, 21 inflammatory/infective cases were also reported.

Conclusions

Our systemic retrospective CT and histopathology review of LVRS operations shows that the rate of additional findings is 32%. Of these 83% were not reported on the pre-operative review of the CT. This supports the value of systematic pathological assessment of resected samples.

Comparative evaluation of different molecular methods for DNA extraction from individual Teladorsagia circumcincta nematodes

Background

The purpose of this study was to develop a reliable DNA extraction protocol to use on individual Teladorsagia circumcincta nematode specimens to produce high quality DNA for genome sequencing and phylogenetic analysis. Pooled samples have been critical in providing the groundwork for T. circumcincta genome construction, but there is currently no standard method for extracting high-quality DNA from individual nematodes. 11 extraction kits were compared based on DNA quality, yield, and processing time.

Results

11 extraction protocols were compared, and the concentration and purity of the extracted DNA was quantified. Median DNA concentration among all methods measured on NanoDrop 2000™ ranged between 0.45–11.5 ng/μL, and on Qubit™ ranged between undetectable – 0.962 ng/μL. Median A260/280 ranged between 0.505–3.925, and median A260/230 ranged − 0.005 – 1.545. Larval exsheathment to remove the nematode cuticle negatively impacted DNA concentration and purity.

Conclusions

A Schistosoma sp. DNA extraction method was determined as most suitable for individual T. circumcincta nematode specimens due to its resulting DNA concentration, purity, and relatively fast processing time.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12896-021-00695-6.

P188 Aboriginal and Torres Strait Australians have significantly worse coronary disease, risk factors and 4 year outcomes compared with non-indigenous Australians

Introduction

The Aboriginal and Torres Strait Islander (ATSI) population in Australia appear to present with coronary disease more frequently, have worse risk factors, worse coronary disease and poorer outcomes, however there is limited data available on this population.  The ATSI population represent 8% of the Cairns total population. We undertook to compare these findings and four-year outcomes in ATSI versus non-indigenous patients aged < 50 years old undergoing coronary angiography.

Methods

 

We collected data on all patients aged < 50 years old, who underwent coronary angiography at Cairns Hospital over a two-year period (2014-2016), from the Queensland Coronary Outcomes Registry. Data of patient risk factors and 4 year outcomes were collected using electronic hospital medical records and electronic discharge summaries available on all Queensland patients. Patients residing outside Queensland were excluded.

Results

From 2014-2016, a total of 555 patients < 50 years old underwent coronary angiography. The average age was 43. 322 (58.0%) patients were male and 233 (42.0%) were female. 271 patients (48.8%) identified as ATSI. 

Coronary risk factors - 42.4% of ATSI patients had diabetes vs 13.7 in the non-indigenous group, 58.7% of ATSI patients vs 43.7% had hyperlipidaemia, 61.3% of ATSI patients vs 39.8% were current smokers, 65.3% of ATSI patients vs 42.3% were hypertensive, and 64.2% of ATSI patients vs 50.4% had a family history of premature coronary artery disease. This demonstrates significantly higher incidence of cardiac risk factors in ATSI patients (combined risk factors P = 0.00086).  

When comparing coronary artery disease, as demonstrated by coronary angiography, the ATSI group had significantly more abnormal coronary angiograms - 74.5% compared to the non-indigenous group 42.3% (P = 0.000006). There was not a statistically significant difference between the severity of coronary artery disease between the two populations who had coronary disease, however, the ATSI population demonstrated a higher incidence of triple vessel disease. ATSI patients were more likely to have repeat coronary angiography 11% vs 4%.

In the four-year follow up period, 18.5% of the ATSI population had at least one major adverse cardiac event (MACE), whereas in the non-indigenous group 7.0% had at least one MACE. 

There was not a statistically significant difference between all cause mortality between the two populations.

Conclusion

 

We have shown that Aboriginal and Torres Strait Islanders Australians are more likely to have coronary angiography at a younger age. That Aboriginal and Torres Strait Islanders Australians have a significantly higher incidence of cardiac risk factors, higher incidence of coronary artery disease, and more major cardiac events after undergoing coronary angiography compared to non-indigenous patients. The all cause mortality in this young population was not significantly different.

Quantifying the relationship between symptoms at presentation and the prognosis of sarcoidosis

BACKGROUND

Although it is the general consensus that sarcoidosis patients who present with sarcoidosis-related symptoms have a worse outcome than patients whose disease is detected incidentally without symptoms, this premise has not been rigorously examined.

METHODS

Consecutive patients followed longitudinally at one US university sarcoidosis clinic were questioned concerning the onset and description of sarcoidosis-related symptoms at disease presentation. The patients were classified into those with no sarcoidosis-related symptoms at presentation (NSP group) and those with symptoms at presentation (SP group). The following outcomes were examined in the NSP and SP groups: most recent spirometry, organ involvement, need for sarcoidosis therapy, most recent health related quality of life (HRQOL) as measured by the Sarcoidosis Assessment Tool (SAT), most recent chest imaging Scadding stage results.

RESULTS

660 sarcoidosis patients were analyzed, with 175 in the NSP group and 485 in the SP group. Compared to the NSP group, the SP group had a more frequent requirement for any sarcoidosis treatment, corticosteroid treatment, and non-corticosteroid treatment at some time and within the most recent year of follow up (at least 50% more than the NP group with strong statistical differences with p values all 0.01 or less). In addition, the SP group had significantly more organ involvement (p < 0.001) and several worse SAT domains (p < 0.022) than the NP group. There were no differences between the groups in terms of final spirometry or development of Scadding stage 4 chest radiographs. These findings held even after adjusting for age, sex, race, and time between presentation and the most recent follow-up visit using a multivariable logistic regression framework.

CONCLUSIONS

In our sarcoidosis cohort, compared to the absence of symptoms at presentation, the presence of symptoms was associated with a greater need for treatment, more organ involvement, and worse HRQOL.

Implementing Intensive Insulin Therapy: Development and Audit of the Bath Insulin Protocol

Intensive insulin therapy to control blood glucose has been found to reduce mortality among critically ill patients in a surgical intensive care unit, though a simple prescriptive insulin infusion protocol to achieve this has not been published previously. This study documents the development and routine use of a simple prescriptive intravenous insulin infusion protocol for critically ill patients and compares the results with previous practice. During development the protocol was optimized and practical issues of implementation addressed. The optimized protocol was then used for all ICU admissions, and a prospectively defined retrospective chart audit performed for the first month of use. Results were compared with a similar time period the previous year. In September 2002, 27 admissions were started on the protocol. Blood glucose for the time on the protocol had a median value of 6.2 (IQR 5.9-7.1) mmol/l compared with 9.2 (IQR 8.1-10.2) mmol/l for those on insulin in 2001. Blood glucose for the whole ICU stay for those on the protocol in 2002 had a median value of 6.6 (IQR 6.0-7.4) mmol/l compared with 8.6 (IQR 8.0-9.4) mmol/l in 2001. Blood glucose for all ICU patients in 2002 had a median value of 6.5 (IQR 6.0-7.3) mmol/l compared with 7.2 (IQR 6.3-8.3) mmol/l in 2001.

Three blood glucose recordings were less than 2.2 mmol/l in September 2002. This study provides initial effectiveness and safety data for the Bath Insulin Protocol. Further audits in a larger patient population are now needed.

Modafinil and cognitive enhancement in schizophrenia and healthy volunteers: the effects of test battery in a randomised controlled trial

BACKGROUND

Cognitive deficits in schizophrenia have major functional impacts. Modafinil is a cognitive enhancer whose effect in healthy volunteers is well-described, but whose effects on the cognitive deficits of schizophrenia appear to be inconsistent. Two possible reasons for this are that cognitive test batteries vary in their sensitivity, or that the phase of illness may be important, with patients early in their illness responding better.

METHODS

A double-blind, randomised, placebo-controlled single-dose crossover study of modafinil 200 mg examined this with two cognitive batteries [MATRICS Consensus Cognitive Battery (MCCB) and Cambridge Neuropsychological Test Automated Battery (CANTAB)] in 46 participants with under 3 years' duration of DSM-IV schizophrenia, on stable antipsychotic medication. In parallel, the same design was used in 28 age-, sex-, and education-matched healthy volunteers. Uncorrected p values were calculated using mixed effects models.

RESULTS

In patients, modafinil significantly improved CANTAB Paired Associate Learning, non-significantly improved efficiency and significantly slowed performance of the CANTAB Stockings of Cambridge spatial planning task. There was no significant effect on any MCCB domain. In healthy volunteers, modafinil significantly increased CANTAB Rapid Visual Processing, Intra-Extra Dimensional Set Shifting and verbal recall accuracy, and MCCB social cognition performance. The only significant differences between groups were in MCCB visual learning.

CONCLUSIONS

As in earlier chronic schizophrenia studies, modafinil failed to produce changes in cognition in early psychosis as measured by MCCB. CANTAB proved more sensitive to the effects of modafinil in participants with early schizophrenia and in healthy volunteers. This confirms the importance of selecting the appropriate test battery in treatment studies of cognition in schizophrenia.

Systematic review with meta-analysis: the management of chronic refractory pouchitis with an evidence-based treatment algorithm

BACKGROUND

Restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) is considered the procedure of choice in patients with ulcerative colitis (UC) refractory to medical therapy. The incidence of pouchitis is 40% at 5 years. Ten to 15% of patients with pouchitis experience chronic pouchitis.

AIM

To determine the efficacy of medical therapies for the treatment of chronic refractory pouchitis in patients undergoing IPAA for UC.

METHODS

A systematic computer-assisted search of the on-line bibliographic database MEDLINE and EMBASE was performed between 1966 and February 2016. All original studies reporting remission rates following medical treatment for chronic pouchitis were included. All study designs were considered. Remission was defined according to the individual study. Remission endpoints ranged from 15 days to 10 weeks. Chronic pouchitis was defined by each study.

RESULTS

Twenty-one papers were considered eligible. Results from all studies combined suggested that overall remission was obtained in 59% of patients (95% CI: 44-73%). Antibiotics significantly induced remission in patients with chronic pouchitis with 74% remission rate (95% CI:56-93%), (P < 0.001). Biologics significantly induced remission in patients with chronic pouchitis with 53% remission rate (95% CI:30-76%), (P < 0.001). Steroids, bismuth, elemental diet and tacrolimus all can induce remission but failed to achieve significance. Faecal microbiota transplantation in a single study was not found to achieve remission.

CONCLUSIONS

Treatment of chronic refractory pouchitis remains difficult and is largely empirical. Larger randomised controlled trials will help aid the management of chronic pouchitis.

Not Another ACS Rule Out

CASE

A 50 year old African-American woman with diabetes, hypertension, and hyperlipidemia presented with progressively worsening retro-sternal chest pain, exacerbated by activity and relieved by rest. She also endorsed a thirty-pound unintentional weight loss, and dysphagia. She was dysarthric with left-sided Bell's Palsy and a palpable left axillary lymph node. She had been evaluated at several hospitals in the previous months for similar typical chest pain. Her troponin values were normal, and an EKG showed T-wave inversions in leads I and aVL. On echocardiography, her ejection fraction was 45 percent with anterolateral hypokinesis. She was treated for NSTEMI, and an angiogram showed 95 percent stenosis of the right coronary artery. A modified barium swallow study revealed weakened swallowing with aspiration of thin liquids. An MRI Brain demonstrated scattered T2/ FLAIR hyper-intense foci in the subcortical white matter and focal meningeal thickening. ANA, dsDNA, ANCA, and Lyme antibodies were all negative, and a chest CT showed hilar lymphadenopathy. Cardiac MRI demonstrated scattered foci of delayed enhancement in the mid-myocardium and sub-epicardium without infarction. An endobronchial biopsy of hilar lymph nodes showed two small epithelioid granulomas, consistent with Sarcoidosis. She was started on high-dose corticosteroids with rapid improvement. A repeat modified barium swallow study was normal and a repeat echocardiogram demonstrated recovered ejection fraction of 55 percent with improved wall motion in the septum and apex. Additionally, her left-sided Bell's Palsy and dysarthria improved after several days of therapy.

DISCUSSION

To our knowledge, this report is the third case of multi-organ Sarcoidosis presenting as ACS. This case depicts the simultaneous presentation of neurologic, pharyngeal, pulmonary, and cardiac Sarcoidosis. Myocardial involvement in Sarcoidosis is rare and usually presents as conduction abnormalities with arrhythmia rather than ACS. Though her symptoms were consistent with Sarcoidosis, she had multiple risk factors for coronary atherosclerosis including diabetes, hypertension, and hyperlipidemia. This case highlights the importance of including Sarcoidosis in the differential diagnosis for patients with recurrent typical chest pain of uncertain etiology.

The associations between sex, immigrant status, immigrant concentration and intimate partner violence: evidence from the Canadian General Social Survey

Intimate partner violence (IPV) is an important public health concern, yet little is known about the combined effects of individual- and neighbourhood-level characteristics on IPV among immigrants. The aim of this study is to examine: (1) the association between immigrant status and IPV victimisation and whether sex modifies this association, and (2) the association between the neighbourhood concentration of immigrants and IPV victimisation, and whether immigrant status modifies this association. Our sample of 10,964 males and females comes from the 2009 Canadian General Social Survey. After controlling for covariates, immigrant status was not associated with IPV, and sex significantly modified the association between immigrant status and financial and physical/sexual IPV. Compared to males, second-generation females were less likely to report financial IPV and first-generation females were more likely to report physical/sexual IPV. Immigrant status modified the association between the neighbourhood concentration of immigrants and emotional and physical/sexual IPV. Compared to third-generation males, first-generation males living in neighbourhoods with a higher concentration of immigrants were more likely to report emotional IPV, whereas second-generation males in these neighbourhoods were less likely to report physical/sexual IPV. Interventions to reduce IPV should pay equal attention to individual- and neighbourhood-level influences.

The use of a co-design model in improving timely bleed reporting by adults with haemophilia living in the Auckland region of New Zealand

Many adult patients diagnosed with phenotypically moderate and severe haemophilia living in the Auckland region of New Zealand do not report bleeding episodes within a timeframe that allows for optimal assessment and management. This can result in poor clinical outcomes for patients and poor oversight of the use of expensive clotting factor concentrates. Our goal was to improve both the number and speed at which bleeding episodes were reported to our centre, improving access to care and clinical oversight of the use of expensive factor concentrates and aiding the development of a care partnership with patients. We worked with 70 adult PWH living in the Auckland region of New Zealand with moderate and severe haemophilia A and B. Over a 5-month period between March and July 2013 we used a co-design model to develop and implement a range of strategies to improve the timing and frequency of bleed reporting. Mean bleed reporting time was reduced threefold, with a threefold increase in the number of bleeds reported per month. We reduced the number of bleeding episodes reported outside of a prespecified 48-h time limit by 68%. We significantly improved bleed reporting and time to report, indicating improved access to our services, improved clinical oversight and improved accountability to our national funder. We have achieved a care partnership and a reduction in factor consumption for the study population without compromising the quality of care they receive.

Prospective study of bone scintigraphy as a staging investigation for oesophageal carcinoma

BACKGROUND

About 10 per cent of patients undergoing radical oesophagectomy for transmural (T3) carcinoma with lymph node involvement (N1) develop symptomatic bone metastases within 12 months of surgery. The aim of this study was to evaluate the introduction of targeted preoperative bone scintigraphy.

METHODS

Of 790 patients with oesophageal carcinoma staged between December 2000 and December 2004, 189 were eligible for potentially curative treatment. (99m)Tc-labelled hydroxymethylene diphosphonate bone scintigraphy was performed in those with stage T3 N1 disease (identified by computed tomography and endoscopic ultrasonography) who were suitable for radical treatment.

RESULTS

A total of 115 patients had bone scintigraphy. The histological diagnosis was adenocarcinoma in 82 patients and squamous cell carcinoma in 33. Bone scintigraphy was normal or showed degenerative changes in 93 patients, and abnormal requiring further investigation in 22. Plain radiography, magnetic resonance imaging and biopsy confirmed the presence of bone metastases in 11 patients (9.6 per cent).

CONCLUSION

Bone is frequently the first site of identifiable distant metastatic spread, and bone scintigraphy is recommended to exclude metastatic disease before radical treatment of advanced oesophageal carcinoma.

DNA fusion vaccines incorporating IL-23 or RANTES for use in immunization against influenza

The incorporation of RANTES or IL-23 into DNA vaccines may improve their immunogenicity by the recruitment and activation of dendritic cells. This may also select for a TH1 response counteracting the TH2 response which can predominate when a DNA vaccine is delivered by gene gun. We have immunized mice with various DNA constructs encoding APR/8/34 influenza virus hemagglutinin (HA), either fused to or separate from, IL-23 or RANTES using a gene gun. Those immunized with IL-23/HA fusion constructs and challenged with influenza 27 weeks post-vaccination, tended to have cleared more virus than those vaccinated with HA DNA. Mice immunized with the RANTES/HA fusion construct produced a mixed TH1/TH2 response whereas in HA-vaccinated mice, a TH2 response predominated. Immunization with a plasmid in which HA and RANTES were under the control of separate promoters, failed to generate a mixed TH1/TH2 response suggesting that enhanced antigen uptake via RANTES receptors may contribute to the mixed immune response generated to the fusion construct. Overall these findings provide further evidence that Type 1 cytokines or chemokines, fused to antigen in a DNA vaccine, can influence the nature and the longevity of the immune response and ultimately, its protective capacity.

Beta-glucosylceramide: a novel method for enhancement of natural killer T lymphoycte plasticity in murine models of immune-mediated disorders

BACKGROUND

beta-Glucosylceramide, a naturally occurring glycolipid, exerts modulatory effects on natural killer T (NKT) lymphocytes.

AIM

To determine whether beta-glucosylceramide can alter NKT function in opposite directions, colitis was induced by intracolonic installation of trinitrobenzenesulphonic acid, and hepatocellular carcinoma (HCC) was induced by transplantation of Hep3B cells.

METHODS

The immunological effect of beta-glucosylceramide was assessed by analysis of intrahepatic and intrasplenic lymphocyte populations, serum cytokines and STAT protein expression.

RESULTS

Administration of beta-glucosylceramide led to alleviation of colitis and to suppression of HCC, manifested by improved survival and decreased tumour volume. The beneficial effects were associated with an opposite immunological effect in the two models: the peripheral:intrahepatic CD4:CD8 lymphocyte ratio increased in the colitis model and decreased in the HCC group. The peripheral:intrahepatic NKT lymphocyte ratio decreased in beta-glucosylceramide-treated mice solely in the HCC model. The effect of beta-glucosylceramide was associated with decreased STAT1 and 4 expression, and with overexpression of STAT6, along with decreased interferon gamma levels in the colitis model, whereas an opposite effect was noted in the HCC model.

CONCLUSIONS

beta-glucosylceramide alleviates immunologically incongruous disorders and may be associated with "fine tuning" of immune responses, by changes in plasticity of NKT lymphocytes.

Location of major histocompatibility complex class II molecules in rafts on dendritic cells enhances the efficiency of T-cell activation and proliferation

The existence of major histocompatibility complex (MHC) class II molecules in lipid rafts has been described in dendritic cells (DC); however, the importance of rafts in T-cell activation has not been clarified. In this study, the distribution of the lipid raft components (CD59 and GM1 ganglioside) in human monocyte-derived DC was investigated. DC had an even distribution of these components at the cell surface. In addition, raft-associated GM1 ganglioside colocalized with cross-linked MHC class II. This implies coaggregation of raft components with these MHC molecules, which may be important in the interaction between T cells and antigen-presenting cells. In studies carried out to investigate the effect of the DC : T-cell interaction on raft distribution, we found a clustering of the lipid raft component CD59 on DC at the synaptic interface, with associated activation of the interacting T cell. In an antigen-specific response between DC and CD4+ T-cell clones, disruption of lipid rafts resulted in inhibition of both CD59 clustering and T-cell activation. This was most pronounced when limiting amounts of cognate peptide were used. Together, these data demonstrate the association of MHC class II with lipid rafts during DC : T-cell interaction and suggest an important role for DC lipid rafts in T-cell activation.

Single blind, randomised, comparative study of the Bug Buster kit and over the counter pediculicide treatments against head lice in the United Kingdom

OBJECTIVE

To compare the effectiveness of the Bug Buster kit with a single treatment of over the counter pediculicides for eliminating head lice.

DESIGN

Single blind, multicentre, randomised, comparative clinical study.

SETTING

Four counties in England and one county in Scotland.

PARTICIPANTS

133 young people aged 2-15 years with head louse infestation: 56 were allocated to the Bug Buster kit and 70 to pediculicide treatment.

INTERVENTIONS

Home use of proprietary pediculicides (organophosphate or pyrethroid) or the Bug Buster kit.

MAIN OUTCOME MEASURE

Presence of head lice 2-4 days after end of treatment: day 5 for the pediculicides and day 15 for the Bug Buster kit.

RESULTS

The cure rate using the Bug Buster kit was significantly greater than that for the pediculicides (57% v 13%; relative risk 4.4, 95% confidence interval 2.3 to 8.5). Number needed to treat for the Bug Buster kit compared with the pediculicides was 2.26.

CONCLUSION

The Bug Buster kit was the most effective over the counter treatment for head louse infestation in the community when compared with pediculicides.

Comparison of different microbial bioassays to assess metal-contaminated soils

These experiments compared the sensitivity of four different types of bioassay over time after five metals were added to a wide range of soils at the maximum concentrations in the European Union Sewage Sludge Directive. Three were chronic assays (most probable number of Rhizobium leguminosarum, soil microbial C and Biolog substrate utilization). The fourth bioassay, an acute biosensor, employed a lux-marked luminescent bacterium (Escherichia coli) in the soil pore water. Five metals were added to 23 different soils as a mixture at Zn = 300, Cd = 3, Pb = 300, Cu = 135, and Ni = 75 mg/kg as nitrate salts and compared with unamended controls. Zinc and Cu were the metals most likely to be toxic at the concentrations used here. In the case of Rhizobium, the number of cells in soil was not affected after 11 d; however, by 818 d the numbers had decreased by four orders of magnitude with increasing concentrations of Zn and Cu in soil solution. Microbial biomass also was not affected after 11 d, but significantly decreased with increased Zn (p < 0.001) and Cu (p < 0.01) in soil solution after 818 d. Toxicity to the soil microbial biomass increased with time, whereas the toxicity to the biosensor remained the same. Biolog substrate utilization profiles were not responsive to the concentrations used here.

A confidential study of deaths after emergency medical admission: issues relating to quality of care

In this retrospective pilot study we examine the feasibility of establishing a confidential enquiry into why some patients die after emergency admission to hospital. After excluding those who died in the first hour or who were admitted for palliative care, pairs of physicians were able to collect quantitative and qualitative data on 200 consecutive deaths. Both physicians reported shortfalls of care in 14 patients and one of the pair in 25 patients whose deaths would not have been the expected outcome. In 25, the shortfalls of care may have contributed to their deaths. Major problems were delays in seeing doctors, inaccurate diagnoses, delays in investigations and initiation of treatment. They occurred mostly in those admitted at night. It is possible that establishing the correct diagnosis and starting appropriate treatment may have been delayed in 64% of the 200 patients. The headline figures appear worse than some previous external assessment studies but this study did concentrate on those in whom problems were more likely. Nevertheless, the frequency is too high to be overlooked. In this feasibility study we have demonstrated that it is practicable for local staff to collect and assess data in hospitals and that the types of problems identified are relevant to anyone planning how to organise emergency care. A larger definitive study should be performed.

Predicting arsenic solubility in contaminated soils using isotopic dilution techniques

An isotopic dilution assay was developed to measure radiolabile As concentration in a diverse range of soils (pH 3.30-7.62; % C = 1.00-6.55). Soils amended with 50 mg of As kg(-1) (as Na2HAsO4 x 7H2O) were incubated for over 800 d in an aerated "microcosm" experiment. After 818 d, radiolabile As ranged from 27 to 57% of total applied As and showed a pH-dependent increase above pH 6. The radiolabile assay was also applied to three sets of soils historically contaminated with sewage sludge or mine-spoil. Results reflected the various geochemical forms in which the arsenic was present. On soils from a sewage disposal facility, radiolabile arsenate ranged from 3 to 60% of total As; mean lability was lower than in the equivalent pH range of the microcosm soils, suggesting occlusion of As into calcium phosphate compounds in the sludge-amended soils. In soils from mining areas in the U.K. and Malaysia, radiolabile As accounted for 0.44-19% of total As. The lowest levels of lability were associated with extremely large As concentrations, up to 17,000 mg kg(-1), from arsenopyrite. Soil pore water was extracted from the microcosm experiment and speciated using "GEOCHEM". The solid<==>solution equilibria of As in the microcosm soils was described by a simple model based on competition between HAsO4(2-) and HPO4(2-) for "labile" adsorption sites.

Use of bacterial biosensors to interpret the toxicity and mixture toxicity of herbicides in freshwater

The dose response relationship between seven commonly used herbicides and four luminescence-based bacterial biosensors was characterised. As herbicide concentration increased the light emitted by the test organism declined in a concentration dependent manner. These dose responses were used to compare the predicted vs. observed response of a biosensor in the presence of multiple contaminants. For the majority of herbicide interactions, the relationship was not additive but primarily antagonistic and sometimes synergistic. These biosensors provide a sensitive test and are able to screen a large volume and wide range of samples with relative rapidity and ease of interpretation. In this study biosensor technology has been successfully applied to interpret the interactive effects of herbicides in freshwater environments.

Soil solution extraction techniques for microbial ecotoxicity testing: a comparative evaluation

The suitability of two different techniques (centrifugation and Rhizon sampler) for obtaining the interstitial pore water of soil (soil solution), integral to the ecotoxicity assessment of metal contaminated soil, were investigated by combining chemical analyses and a luminescence-based microbial biosensor. Two different techniques, centrifugation and Rhizon sampler, were used to extract the soil solution from Insch (a loamy sand) and Boyndie (a sandy loam) soils, which had been amended with different concentrations of Zn and Cd. The concentrations of dissolved organic carbon (DOC), major anions (F- , CI-, NO3, SO4(2-)) and major cations (K+, Mg2+, Ca2+) in the soil solutions varied depending on the extraction technique used. Overall, the concentrations of Zn and Cd were significantly higher in the soil solution extracted using the centrifugation technique compared with that extracted using the Rhizon sampler technique. Furthermore, the differences observed between the two extraction techniques depended on the type of soil from which the solution was being extracted. The luminescence-based biosensor Escherichia coli HB101 pUCD607 was shown to respond to the free metal concentrations in the soil solutions and showed that different toxicities were associated with each soil, depending on the technique used to extract the soil solution. This study highlights the need to characterise the type of extraction technique used to obtain the soil solution for ecotoxicity testing in order that a representative ecotoxicity assessment can be carried out.

Measuring symptom change in patients with Parkinson's disease

BACKGROUND

The 39-item Parkinson's disease questionnaire (PDQ-39) is more sensitive to functional change than other measures of health and disability.

AIM

To determine the ability of this scale to change over time and the concurrent validity of some of its subscales.

METHODS

We assessed a cohort of 67 Parkinson's patients for 18 months, using the PDQ-39, the GHQ-28 general health questionnaire and the Office of Population and Census Surveys disability instrument.

RESULTS

The Office of Population and Census Surveys disability instrument and GHQ-28 recorded no significant change, but the PDQ-39 showed marked changes in levels of functioning. We also analysed changes on the PDQ-39 subscales as well as concurrent validity data for several subscales. This showed concurrent validity with the Beck depression and anxiety inventories, the Barthel index and the Royal Postgraduate Medical School severity scale. There was a high level of concurrent validity for all comparisons except for the Barthel index.

CONCLUSION

The PDQ-39 is a sensitive tool for monitoring change in patients with Parkinson's disease. It has high levels of concurrent validity with established measures of mood and motor function.

Computer-generated correspondence for patients attending an open-access chest pain clinic

AIM

To determine whether general practitioners (GPs) prefer structured computer-generated or standard dictated outpatient clinic letters.

DESIGN

Questionnaire survey of all GPs referring patients to an open-access chest pain clinic at a district general hospital in London. The GPs were asked to compare three twinned examples of structured computer-generated and unstructured dictated letters.

RESULTS

Of 93 respondents (response rate 77.5%), 75 (80.6%) preferred the computer-generated letter and 16 (17.2%) preferred the dictated letter (p < 0.0005). The preferred features of the computer-generated letter were its clear presentation, subheadings, and concise information. The computer-generated letter scored significantly higher than the dictated letter: for clarity, mean 8.2 vs 6.5 (p < 0.0005); content, mean 8.5 vs 6.9 (p < 0.0005); and readability, mean 8.2 vs 6.8 (p < 0.0005). The GPs in the survey considered a mean delay of 3.4 days to be acceptable for receiving the letter from the chest pain clinic.

CONCLUSION

GPs prefer structured computer-generated letters to unstructured dictated letters for patients referred to an open-access chest pain clinic. Computer-generated correspondence allows rapid feedback of information to the referring GP, one of the key requirements of open-access clinics.

The leukocyte/neuron cell surface antigen OX2 binds to a ligand on macrophages

The OX2 membrane glycoprotein contains two immunoglobulin superfamily (IgSF) domains and seems likely to interact with other cell surface proteins. A soluble chimeric protein with the two IgSF domains of OX2 engineered onto domains 3 + 4 of rat CD4 antigen was expressed. To detect possible weak interactions, the chimeric protein was coupled to fluorescent covaspheres to provide a highly avid display of OX2. The OX2 covaspheres bound macrophages but not other cell types. The specificity of the interaction was demonstrated by blocking with Fab fragments of the OX2 monoclonal antibody (mAb). A new mAb, MRC OX88, was raised against macrophages which also blocked the interaction and presumably recognizes the ligand. The epitope for the MRC OX2 mAb and a site for ligand binding were mapped to domain 1 by site-directed mutagenesis. The OX2 antigen is present on thymocytes, some lymphocytes, neurons and endothelial cells; thus, it has the potential to mediate interactions between these cell types and macrophages.

The use of administrative data to risk-stratify asthmatic patients

In this article, a simple methodology to risk-stratify asthmatics is presented and validated. Such a model can be used to identify those high risk and more severely ill asthmatics who could benefit the most from case management and increased educational efforts. Using logistic regression, the model was created to predict the probability of an asthma-related admission among all asthmatics who were members of a large HMO during calendar year 1994 (N = 54,573). The model used data from pharmacy, laboratory, and specialist claims, as well as encounter and demographic data available in U.S. Healthcare's administrative database. A member's prior asthma-specific utilization patterns, pharmaceutically determined severity of illness, and length of enrollment in the managed care organization had the most influence on the equation. A cross-validation of the model confirms how administrative data can be used to accurately risk-stratify those with a chronic disease. Finally, some additional research possibilities associated with the identification of high risk subscribers using only administrative data are outlined.

Clinical hypertension in Native Americans: a comparison of 1987 and 1992 rates from ambulatory care data

THE AUTHORS EXAMINED THE PREVALENCE of clinically diagnosed hypertension among all American Indian and Alaska Native outpatients served in Indian Health Service (IHS) facilities in fiscal year 1992, and compared these rates with a similar analysis done in 1987. In this report they provided data on that analysis as well as on the association between hypertension and diabetes. The 1992 overall estimated age-adjusted prevalence of clinically diagnosed hypertension in adults older than age 15 was 10.4%, compared with 10.9% in 1987, a small but significant decrease. Considerable variation exists in hypertension prevalence rates in American Indian communities as analyzed by IHS service area. This report represents an attempt to use ambulatory patient care data to demonstrate a means for ongoing surveillance of a chronic disease for the entire service population of the IHS. This comprehensive data set represents approximately 60% of the entire U.S. American Indian and Alaska Native population. Based on the ongoing nature of this ambulatory patient care data system, this model for hypertension surveillance permits a unique opportunity for longitudinal evaluation of quality improvement efforts for the American Indian and Alaska Native populations served by the IHS.

A sensitive assay for detecting low-affinity interactions at the cell surface reveals no additional ligands for the adhesion pair rat CD2 and CD48

The ligand for the T cell antigen CD2 is CD48 in rodents, but CD58 in humans. The extracellular parts of these three antigens are structurally related in that all contain two immunoglobulin superfamily (IgSF) domains. There have been reports of alternative ligands for CD2 in the human, but not so far in rodents. We describe the analysis of ligands for rat CD2 and CD48 using fluorescent beads capable of displaying a high ligand density and detecting low-affinity interactions like that of CD2 with CD48 (Kd = 60-90 microM). Monovalent chimeric proteins containing the two IgSF domains of rat CD48 or CD2 and domains 3 and 4 of rat CD4 (CD4d3+4) were anchored to fluorescent covaspheres via a CD4 monoclonal antibody (mAb) with the CD48 or CD2 domains available for ligand binding. Multivalent CD48-CD4d3+4 covaspheres gave strong specific binding to rat CD2 expressed on the surface of transfected Jurkat cells. CD48-CD4d3+4 was compared with CD48-IgG and CD48-IgM as tools for detecting binding at the cell surface. Soluble divalent CD48-IgG and decavalent CD48-IgM bound to soluble CD2 with a Koff of around 10(-3) s-1 as determined using a BIAcore biosensor. However, binding to cells by CD48-IgG and CD48-IgM was only detectable when they were immobilized on covaspheres and represented no increase in sensitivity over CD48-CD4 covaspheres when tested for binding to cells expressing high and low levels of CD2. CD48-CD4d3+4 covaspheres only bound to rat cells expressing CD2. In the reverse orientation, bindign of CD2-CD4d3+4 covaspheres was dependent on expression of CD48. Pre-incubation of cells with CD2 or CD48 mAb abolished all binding of CD48-CD4d3+4 or CD2-CD4d3+4, respectively. The data provide no evidence for an alternative ligand for rat CD2 or CD48.

Mating in the monogamous male: behavioral consequences

In monogamous mammals, males typically show selective affiliation with a single mate, high levels of paternal care, and aggression towards conspecifics to protect male and offspring. We have previously described how selective aggression and affiliation increase after mating in the male prairie vole, Microtus ochrogaster. The current studies further explored the behavioral changes that follow mating in the male of this species. The first set of experiments tested males on several behavioral measures after 24 h of either mating, social (but not sexual) exposure, or no social contact. After 24 h of mating, but not after the other two conditions, aggression and affiliation (partner preference) increased as previously reported. In addition, mated animals showed increased exploration of the open arms of a plus maze, consistent with decreased fearfulness. There were no group differences in paternal behavior (which was high in all three conditions) or analgesia (assessed by tail flick latency). To determine the minimum amount of mating necessary for the induction of aggression, males were tested in a resident-intruder paradigm after 1,6, or 24 h of mating. Although 1 h of mating was associated with a transient increase in the frequency of threats and attacks, the full spectrum of enduring aggression was observed only in the males given 24 h of mating. In a final experiment, the behavioral consequences of mating were studied in males of the closely related montane vole (Microtus montanus) which does not pair bond. Males of this nonmonogamous vole species did not show increased aggression, partner preference, or alterations in plus maze exploration following 24 h of mating. These results demonstrate the importance of prolonged mating for the induction of pair bonding in the monogamous male and they suggest that increases in aggression and affiliation are associated with decreased fearfulness in pair bonded males.

Screening of snake venoms for neurotoxic and myotoxic effects using simple in vitro preparations from rodents and chicks

Eight snake venoms designated by the WHO as International Reference Venoms, and one additional venom were assessed for neurotoxic and myotoxic effects in vitro using the chick biventer cervicis and the rat and mouse phrenic nerve-diaphragm preparations. The objective was to determine whether any of the preparations could be used to detect evidence of neurotoxic or myotoxic activity prior to a more detailed examination. Bungarus multicinctus venom at concentrations above 1 microgram ml-1 selectively blocked neuromuscular transmission, with no direct effect on muscle fibres. Naja naja kaouthia and Notechis scutatus venoms selectively blocked neuromuscular transmission at low concentrations, but at higher concentrations both venoms caused direct effects on skeletal muscle resulting in contractures, loss of tension following direct stimulation and a loss in sensitivity to elevated [K+]0. Vipera russelli (Thailand) venom also blocked neuromuscular transmission but it was less potent than the venoms of B. multicinctus, N. n. kaouthia and N. scutatus. It also caused contractures in the chick biventer cervicis muscle. The venoms of Echis carinatus (Iran and Mali), Crotalus atrox, Bothrops atrox asper and Trimeresurus flavoviridis had limited neuromuscular blocking activity, and most of these venoms blocked [K+]0 and cholinoceptor stimulation in the chick muscle. Although both chick and rodent muscles allowed the assessment of neurotoxic and myotoxic activity, the chick biventer cervicis was simpler and more robust in use than either of the rodent phrenic nerve-diaphragm preparations. We propose that the chick biventer cervicis muscle could be used as a standard preparation for the screening of snake venoms for neurotoxic and myotoxic effects, and that it may be possible to use this preparation as a means to check that antivenoms can neutralize neurotoxic and direct myotoxic actions of venoms.