Monitoring Cochlear Health With Intracochlear Electrocochleography During Cochlear Implantation: Findings From an International Clinical Investigation

OBJECTIVES

Electrocochleography (ECochG) is emerging as a tool for monitoring cochlear function during cochlear implant (CI) surgery. ECochG may be recorded directly from electrodes on the implant array intraoperatively. For low-frequency stimulation, its amplitude tends to rise or may plateau as the electrode is inserted. The aim of this study was to explore whether compromise of the ECochG signal, defined as a fall in its amplitude of 30% or more during insertion, whether transient or permanent, is associated with poorer postoperative acoustic hearing, and to examine how preoperative hearing levels may influence the ability to record ECochG. The specific hypotheses tested were threefold: (a) deterioration in the pure-tone average of low-frequency hearing at the first postoperative follow-up interval (follow-up visit 1 [FUV1], 4 to 6 weeks) will be associated with compromise of the cochlear microphonic (CM) amplitude during electrode insertion (primary hypothesis); (b) an association is observed at the second postoperative follow-up interval (FUV2, 3 months) (secondary hypothesis 1); and (c) the CM response will be recorded earlier during electrode array insertion when the preoperative high-frequency hearing is better (secondary hypothesis 2).

DESIGN

International, multi-site prospective, observational, between groups design, targeting 41 adult participants in each of two groups, (compromised CM versus preserved CM). Adult CI candidates who were scheduled to receive a Cochlear Nucleus CI with a Slim Straight or a Slim Modiolar electrode array and had a preoperative audiometric low-frequency average thresholds of ≤80 dB HL at 500, 750, and 1000 Hz in the ear to be implanted, were recruited from eight international implant sites. Pure tone audiometry was measured preoperatively and at postoperative visits (FUV1 and follow-up visit 2 [FUV2]). ECochG was measured during and immediately after the implantation of the array.

RESULTS

From a total of 78 enrolled individuals (80 ears), 77 participants (79 ears) underwent surgery. Due to protocol deviations, 18 ears (23%) were excluded. Of the 61 ears with ECochG responses, amplitudes were < 1 µV throughout implantation for 18 ears (23%) and deemed "unclear" for classification. EcochG responses >1 µV in 43 ears (55%) were stable throughout implantation for 8 ears and compromised in 35 ears. For the primary endpoint at FUV1, 7/41 ears (17%) with preserved CM had a median hearing loss of 12.6 dB versus 34/41 ears (83%) with compromised CM and a median hearing loss of 26.9 dB ( p < 0.014). In assessing the practicalities of measuring intraoperative ECochG, the presence of a measurable CM (>1 µV) during implantation was dependent on preoperative, low-frequency thresholds, particularly at the stimulus frequency (0.5 kHz). High-frequency, preoperative thresholds were also associated with a measurable CM > 1 µV during surgery.

CONCLUSIONS

Our data shows that CM drops occurring during electrode insertion were correlated with significantly poorer hearing preservation postoperatively compared to CMs that remained stable throughout the electrode insertion. The practicality of measuring ECochG in a large cohort is discussed, regarding the suggested optimal preoperative low-frequency hearing levels ( < 80 dB HL) considered necessary to obtain a CM signal >1 µV.

Cervical musculoskeletal and sensorimotor impairments 4 weeks to 6 months following mild traumatic brain injury: An observational cohort study

BACKGROUND

Clinically relevant scores of neck disability have been observed in adults post mild traumatic brain injury (mTBI), even in those who initially report to be recovered. Potentially cervical musculoskeletal and/or cervical sensorimotor impairments may underlie these persistent symptoms post mTBI.

OBJECTIVE

To determine whether cervical impairments exist beyond expected recovery times following concussion compared to healthy controls (HC).

STUDY DESIGN

Observational cohort study.

METHODS

Participants aged 18-60 years consisting of 39 HC, and 72 individuals, 4 weeks to 6 months post mTBI of which 35 considered themselves asymptomatic (Asymp), and 37 symptomatic (Symp). Cervical outcome measures included range and velocity of motion, flexor muscle endurance, presence of at least one dysfunctional cervical joint, joint position error -neutral and torsion, movement accuracy, smooth pursuit neck torsion test (SPNT) and balance.

RESULTS

Individuals in the Symp mTBI group demonstrated significantly reduced: flexion and rotation range, rotation velocity, flexor endurance and movement accuracy as well as increased postural sway and a higher percentage had positive cervical joint dysfunction (p < 0.01]. The mTBI group who considered themselves recovered (Asymp)demonstrated significantly lower rotation range, flexor endurance, and a higher percentage had positive cervical joint dysfunction and positive SPNT (p < 0.05) compared to HCs.

CONCLUSION

Individuals reporting symptoms post mTBI demonstrated cervical spine musculoskeletal and sensorimotor impairments beyond expected recovery times. Those not reporting symptoms had fewer but some cervical impairments. The need for a comprehensive neck assessment should be considered, perhaps even in those not reporting symptoms.

An Antibody Targeting ICOS Increases Intratumoral Cytotoxic to Regulatory T-cell Ratio and Induces Tumor Regression

The immunosuppressive tumor microenvironment constitutes a significant hurdle to immune checkpoint inhibitor responses. Both soluble factors and specialized immune cells, such as regulatory T cells (Treg), are key components of active intratumoral immunosuppression. Inducible costimulatory receptor (ICOS) can be highly expressed in the tumor microenvironment, especially on immunosuppressive Treg, suggesting that it represents a relevant target for preferential depletion of these cells. Here, we performed immune profiling of samples from tumor-bearing mice and patients with cancer to demonstrate differential expression of ICOS in immune T-cell subsets in different tissues. ICOS expression was higher on intratumoral Treg than on effector CD8 T cells. In addition, by immunizing an Icos knockout transgenic mouse line expressing antibodies with human variable domains, we selected a fully human IgG1 antibody called KY1044 that bound ICOS from different species. We showed that KY1044 induced sustained depletion of ICOS^high T cells but was also associated with increased secretion of proinflammatory cytokines from ICOS^low effector T cells (T_eff). In syngeneic mouse tumor models, KY1044 depleted ICOS^high Treg and increased the intratumoral T_Eff:Treg ratio, resulting in increased secretion of IFNγ and TNFα by T_Eff cells. KY1044 demonstrated monotherapy antitumor efficacy and improved anti-PD-L1 efficacy. In summary, we demonstrated that using KY1044, one can exploit the differential expression of ICOS on T-cell subtypes to improve the intratumoral immune contexture and restore an antitumor immune response.

The Efficiency of Increasing the Capacity of Physiotherapy Screening Clinics or Traditional Medical Services to Address Unmet Demand in Orthopaedic Outpatients: A Practical Application of Discrete Event Simulation with Dynamic Queuing

BACKGROUND

Hospital outpatient orthopaedic services traditionally rely on medical specialists to assess all new patients to determine appropriate care. This has resulted in significant delays in service provision. In response, Orthopaedic Physiotherapy Screening Clinics and Multidisciplinary Services (OPSC) have been introduced to assess and co-ordinate care for semi- and non-urgent patients.

OBJECTIVES

To compare the efficiency of delivering increased semi- and non-urgent orthopaedic outpatient services through: (1) additional OPSC services; (2) additional traditional orthopaedic medical services with added surgical resources (TOMS + Surg); or (3) additional TOMS without added surgical resources (TOMS - Surg).

METHODS

A cost-utility analysis using discrete event simulation (DES) with dynamic queuing (DQ) was used to predict the cost effectiveness, throughput, queuing times, and resource utilisation, associated with introducing additional OPSC or TOMS ± Surg versus usual care.

RESULTS

The introduction of additional OPSC or TOMS (±surgery) would be considered cost effective in Australia. However, OPSC was the most cost-effective option. Increasing the capacity of current OPSC services is an efficient way to improve patient throughput and waiting times without exceeding current surgical resources. An OPSC capacity increase of ~100 patients per month appears cost effective (A$8546 per quality-adjusted life-year) and results in a high level of OPSC utilisation (98 %).

CONCLUSION

Increasing OPSC capacity to manage semi- and non-urgent patients would be cost effective, improve throughput, and reduce waiting times without exceeding current surgical resources. Unlike Markov cohort modelling, microsimulation, or DES without DQ, employing DES-DQ in situations where capacity constraints predominate provides valuable additional information beyond cost effectiveness to guide resource allocation decisions.

Disease modifying agent related skin reactions in multiple sclerosis: prevention, assessment, and management

Background: The objective for this article is to highlight some of the adverse skin manifestations associated with injectable disease modifying therapy for multiple sclerosis (MS). Early identification and intervention can often lead to minimal consequences and prolonged patient tolerance and compliance with these agents. A t the University of Texas Southwestern Medical C enter at Dallas and Texas Neurology in Dallas we actively follow appro ximately 5000 MS patients. The majority of our patients with relapsing-remitting MS (RRMS) or secondary progressive MS (SPMS) are treated with one of the currently available disease modifying agents (DMA s). O ur experience with these patients, and the challenges they face in continuing long-term treatment, constitutes the basis of our proposed treatment strategies. Conclusion: Skin reactio ns in response to injectable DMA therapy in MS are generally mild. However, some reactio ns can evolve into potentially serious lesions culminating in infection, necro sis, and in some circumstances requiring surgical repair.

A workplace exercise versus health promotion intervention to prevent and reduce the economic and personal burden of non-specific neck pain in office personnel: protocol of a cluster-randomised controlled trial

INTRODUCTION

Non-specific neck pain is a major burden to industry, yet the impact of introducing a workplace ergonomics and exercise intervention on work productivity and severity of neck pain in a population of office personnel is unknown.

RESEARCH QUESTION

Does a combined workplace-based best practice ergonomic and neck exercise program reduce productivity losses and risk of developing neck pain in asymptomatic workers, or decrease severity of neck pain in symptomatic workers, compared to a best practice ergonomic and general health promotion program?

DESIGN

Prospective cluster randomised controlled trial.

PARTICIPANTS AND SETTING

Office personnel aged over 18 years, and who work>30 hours/week.

INTERVENTION

Individualised best practice ergonomic intervention plus 3×20 minute weekly, progressive neck/shoulder girdle exercise group sessions for 12 weeks.

CONTROL

Individualised best practice ergonomic intervention plus 1-hour weekly health information sessions for 12 weeks.

MEASUREMENTS

Primary (productivity loss) and secondary (neck pain and disability, muscle performance, and quality of life) outcome measures will be collected using validated scales at baseline, immediate post-intervention and 12 months after commencement.

PROCEDURE

640 volunteering office personnel will be randomly allocated to either an intervention or control arm in work group clusters.

ANALYSIS

Analysis will be on an 'intent-to-treat' basis and per protocol. Multilevel, generalised linear models will be used to examine the effect of the intervention on reducing the productivity loss in dollar units (AUD), and severity of neck pain and disability.

DISCUSSION

The findings of this study will have a direct impact on policies that underpin the prevention and management of neck pain in office personnel.

Preliminary evaluation of dorsal muscle activity during resisted cervical extension in patients with longstanding pain and disability following anterior cervical decompression and fusion surgery

OBJECTIVES

To compare mechanical activity (deformation and deformation rate) of the dorsal neck muscles between individuals with longstanding symptoms after anterior cervical decompression and fusion (ACDF) surgery and healthy controls.

DESIGN

Preliminary cross-sectional study.

SETTING

Neurosurgery clinic.

PARTICIPANTS

Ten individuals {mean age 60 [standard deviation (SD) 7.1]} who had undergone ACDF surgery 10 to 13 years previously and 10 healthy age- and sex-matched controls.

MAIN OUTCOMES

Mechanical activity of the different layers of dorsal neck muscles, measured at the C4 segment using ultrasonography (speckle tracking analysis) during a standardised, resisted cervical extension task.

RESULTS

A significant group×muscle interaction was found for muscle deformation (P<0.03) but not for deformation rate (P>0.79). The ACDF group showed significantly less deformation of the semispinalis capitis muscle during the extension task compared with the control group [mean 3.12 (SD 2.06) and 6.64 (SD 4.17), respectively; mean difference 3.34 (95% confidence interval -0.54 to 7.21)].

CONCLUSIONS

As the semispinalis capitis muscle is a powerful neck extensor, the finding of altered activation following ACDF surgery lends support to the inclusion of exercise to train neck muscle performance in the management of these patients.

Otitis media among high-risk populations: can probiotics inhibit Streptococcus pneumoniae colonisation and the risk of disease?

Otitis media is the second most common infection in children and the leading cause for seeking medical advice. Indigenous populations such as the Inuits, indigenous Australians and American Indians have a very high prevalence of otitis media and are considered to be high-risk populations. Streptococcus pneumoniae, one of the three main bacterial causes of otitis media, colonises the nasopharynx prior to disease development. In high-risk populations, early acquisition of high bacterial loads increases the prevalence of otitis media. In these settings, current treatment strategies are insufficient. Vaccination is effective against invasive pneumococcal infection but has a limited impact on otitis media. Decreasing the bacterial loads of otitis media pathogens and/or colonising the nasopharynx with beneficial bacteria may reduce the prevalence of otitis media. Probiotics are live microorganisms that offer health benefits by modulating the microbial community and enhancing host immunity. The available data suggest that probiotics may be beneficial in otitis media. This review discusses the potential use of probiotics to reduce pathogen colonisation and decrease the prevalence of otitis media, providing justification for further investigation.

Therapeutic aerosol bioengineering of targeted, inhalable microparticle formulations to treat Mycobacterium tuberculosis (MTb)

Therapeutic aerosol bioengineering (TAB) of Mycobacterium tuberculosis (MTb) therapies using inhalable microparticles offers a unique opportunity to target drugs to the site of infection in the alveolar macrophages, thereby increasing dosing in the lungs and limiting systemic exposure to often toxic drugs. Previous work by us used sophisticated, high content analysis to design the optimal poly(lactide-co-glycolic) acid (PLGA) microparticle for delivery of drugs to alveolar macrophages. Herein, we applied this technology to three different anti-MTb drugs. These formulations were then tested for encapsulation efficiency, drug-release, in vitro killing against MTb and aerosol performance. Methods for encapsulating each of the drugs in the PLGA microparticles were successfully developed and found to be capable of controlling the release of the drug for up to 4 days. The efficacy of each of the encapsulated anti-MTb drugs was maintained and in some cases enhanced post-encapsulation. A method of processing these drug-loaded microparticles for inhalation using standard dry powder inhaler devices was successfully developed that enabled a very high respirable dose of the drug to be delivered from a simple dry powder inhaler device. Overall, TAB offers unique opportunities to more effectively treat MTb with many potential clinical and economic benefits resulting.

Hospice provision and usage amongst young people with neuromuscular disease in the United Kingdom

AIM

To identify the nature of services for children and young people with progressive neuromuscular disorders (NMD) provided by Children's Hospices in the UK.

METHODS

A questionnaire requesting aggregate data on the number of patients with a neuromuscular condition was sent to all children's hospices in the UK, in addition, specific data was collected on services for young people with DMD presenting to a single local hospice.

RESULTS

87% of eligible hospices responded (27/31). 756 young people with an NM condition were being cared for by the hospices. These patients accounted for a mean of 17% of the total hospice population (range 5-35%). The age at which young people were required to leave the children's hospices varied from 18 up to 35 years. 73% of 'visits' were described as 'planned stays'. Although 'end of life care' is provided, few young people with NMD died in a hospice.

CONCLUSIONS

Children and young people with NMD form a large proportion of the Children's Hospice's caseload. Many valued services provided by children's hospices are not available through NHS funding. The lack of similar adult based services is a concern as increasing numbers of young people are surviving into adulthood.

Direct ovarian - uterine transfer of progesterone increases embryo survival in gilts

This study employed a unilateral ovariectomy model to investigate the relevance of the local supply of progesterone (ovary) compared with the systemic supply of progesterone, in terms of embryo survival in the ipsilateral uterine horn as opposed to the contralateral uterine horn. Thirty gilts were unilaterally ovariectomised (ULO) during the luteal stage of their first oestrous cycle. Half of the ULO gilts were fed at 1.2 maintenance requirement (M), while the other half were fed at 2.4 M. Across ULO gilts 0.8 more embryos survived in the ipsilateral horn compared with the contralateral horn at Day 35 of gestation (P < 0.05). In ULO gilts on the 2.4 M feed level the difference (+1.3; P < 0.05) between the ipsi- and contralateral horn was more pronounced than on the 1.2 M feed level (+0.4; NS). The higher feed level reduced circulating levels of systemic progesterone on Day 5 of pregnancy but not embryo survival at Day 35. However, post-implantation embryo survival was lower on the low feed level. In conclusion, these data indicate that local progesterone supply from the ovaries to the uterus contributes to the probability of embryo survival.

Atypical imaging appearances of intracranial meningiomas

Meningiomas are the commonest primary, non-glial intracranial tumours. The diagnosis is often correctly predicted from characteristic imaging appearances. This paper presents some examples of atypical imaging appearances that may cause diagnostic confusion.

Seminal plasma regulates ovarian progesterone production, leukocyte recruitment and follicular cell responses in the pig

Seminal plasma (SP) acts to influence the uterine endometrium after mating, activating synthesis of embryotrophic cytokines and inflammatory changes that condition the tract for embryo implantation and establishing pregnancy. The objective of this study was to investigate in pigs whether the ovary might also be responsive to SP exposure. Prepubertal gilts were synchronised with exogenous gonadotrophins and received transcervical treatment with pooled boar SP or PBS; then the ovarian tissue was recovered at 34 h (preovulation) and on days 5 and 9 after treatment. The ovarian response was assessed by measuring ovulation rate, number and size of corpora lutea, ovarian leukocyte populations, progesterone production in vivo, as well as responses of retrieved granulosa cells cultured in vitro. In SP-treated gilts, leukocyte recruitment into the ovarian tissues was increased fourfold at 34 h, with macrophages comprising the most abundant cell lineage. There was no effect of SP on the number of oocytes ovulated; however, the weight of corpora lutea was increased in SP-treated gilts. SP also induced an increase in plasma progesterone content seen from day 5 to at least day 9 after treatment. In addition, granulosa cells and thecal tissue retrieved from preovulatory follicles of SP-treated gilts were more responsive in vitro to growth factor- and gonadotrophin-stimulated cell proliferation and progesterone synthesis. These results suggest that uterine exposure to SP influences immune cell trafficking in the ovary and enhances steroidogenesis in early pregnancy. The effects of SP on ovarian function potentially contribute to reproductive success in the pig.

Steroids for idiopathic sudden sensorineural hearing loss

BACKGROUND

Idiopathic sudden sensorineural hearing loss (ISSHL) is a clinical diagnosis characterised by a sudden deafness of cochlear or retrocochlear origin in the absence of a clear precipitating cause. Steroids are commonly prescribed to treat this condition. There is no consensus on their effectiveness.

OBJECTIVES

To determine the effectiveness and the side-effect profile of steroids in the treatment of idiopathic sudden sensorineural hearing loss.

SEARCH STRATEGY

We searched the Cochrane Ear, Nose and Throat Disorders Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2004), MEDLINE (1966 to December 2004) and EMBASE (1974 to December 2004). Reference lists of all trials were also manually searched.

SELECTION CRITERIA

We identified all randomised controlled trials (with or without blinding) in which steroids were evaluated in comparison with either no treatment or a placebo. Trials including the use of steroids in combination with another treatment were considered if the comparison control group also received the same other treatment. The full text articles of all the retrieved trials of possible relevance were reviewed by the two authors and the inclusion criteria applied independently. Any differences in opinion about which studies to include in the reviews were resolved by discussion.

DATA COLLECTION AND ANALYSIS

Trials were graded for methodological quality using the Cochrane approach. The data extraction was performed in a standardised manner by one author and rechecked by the other author, and where necessary investigators were contacted to obtain the missing information. Meta-analysis was neither possible nor considered appropriate because of the heterogeneity of the populations studied, the differences in steroid formulations, dosages and duration of the treatment. The quality of the result of each study was analysed and reported individually. A narrative overview of the result is presented.

MAIN RESULTS

Only two trials satisfied the inclusion criteria and both were of low methodological quality. One trial showed a lack of effect of oral steroids in hearing improvement compared with the placebo control group. The other trial showed a significant improvement of hearing in 61% of the patients receiving oral steroid and in only 32% of the patients from the control group (combination of placebo treated group and untreated control group). There was no clear evidence presented in the former study about any harmful side effects of the steroids. The latter study declared that no patients suffered from adverse effects from the steroid treatment.

AUTHORS' CONCLUSIONS

The value of steroids in the treatment of idiopathic sudden sensorineural hearing loss remains unclear since the evidence obtained from randomised controlled trials are contradictory in outcome, in part because the studies are based upon too small a number of patients.

Influence of semen on inflammatory modulators of embryo implantation

Insemination transmits to the female reproductive tract constituents of seminal plasma that target uterine epithelial cells to activate a cascade of inflammatory and immunological changes. Experiments in rodents show seminal factor signalling acts to 'condition' the female immune response to tolerate the conceptus, and to organise molecular and cellular changes in the endometrium to facilitate embryo development and implantation. The active factors in seminal plasma are identified as members of the transforming growth factor-beta family, with the relative balance of active moieties influencing the precise character of the female tract response. Experiments in rodents show that disruption of seminal plasma priming causes foetal growth retardation and changes in placental structure, with long-term consequences for the growth of the neonate. Recent studies indicate a similar physiological function and molecular basis for seminal plasma actions in the pig. In gilts, seminal plasma elicits an endometrial response characterised by recruitment of inflammatory leukocytes and induction of several pro-inflammatory cytokines and cyclo-oxygenase-2. The consequences are evident throughout the pre-implantation period of early pregnancy with altered leukocyte populations and cytokine parameters seen for at least 9 days. Exposure to semen also alters the dynamics in pre-implantation embryo development with an increase in the number of embryos and in their viability. Furthermore seminal plasma influences the temporal kinetics of ovulation, corpus luteum development and steroid production in the ovary. Dissecting the actions of seminal plasma may facilitate development of strategies to ensure maximal fertility and reduce embryo mortality in the pig.

Further evaluation of an EMG technique for assessment of the deep cervical flexor muscles

A novel surface electromyographic (EMG) technique was recently described for the detection of deep cervical flexor muscle activity. Further investigation of this technique is warranted to ensure EMG activity from neighbouring muscles is not markedly influencing the signals recorded. This study compared deep cervical flexor (DCF) muscle activity with the activity of surrounding neck and jaw muscles during various anatomical movements of the neck and jaw in 10 volunteer subjects. DCF EMG activity was recorded with custom electrodes inserted via the nose and fixed by suction to the posterior mucosa of the oropharynx. Surface electrodes were placed over the sternocleidomastoid, anterior scalene, masseter and suprahyoid muscles. Positioned in supine, subjects performed isometric cranio-cervical flexion, cervical flexion, right and left cervical rotation, jaw clench and resisted jaw opening. Across all movements examined, EMG amplitude of the DCF muscles was greatest during neck movements that would require activity of the DCF muscles, particularly during cranio-cervical flexion, their primary anatomical action. The actions of jaw clench and resisted jaw opening demonstrated significantly less DCF EMG activity than the cranio-cervical flexion action (p<0.05). Across all other movements, the neighbouring neck and jaw muscles demonstrated greatest EMG amplitude during their respective primary anatomical actions, which occurred in the absence of increased EMG amplitude recorded from the DCF muscles. The finding of substantial EMG activity of the DCF muscles only during neck actions that would require their activity, particularly cranio-cervical flexion, and not during actions involving the jaw, provide further assurance that the majority of myoelectric signals detected from the nasopharyngeal electrode are from the DCF muscles.

284. Leukocyte trafficking in the ovary of mice immunised with recombinant murine cyclomegalovirus expressing murine zona pellucida 3

Inoculation of female BALB/c mice with recombinant murine cytomegalovirus encoding murine zona pellucida antigen (MCMV-ZP3) confers infertility characterised by depletion in ovarian tertiary follicles by day 21 post inoculation followed by a progressive depletion in primordial follicles.1 Cell mediated immune responses begin as early as day 10 post immunisation with MCMV-ZP32 with the recruitment of leukocytes before serum antibody can be clearly detected in mice. The physiological mechanisms leading to infertility in inoculated mice are being progressively delineated with the role of leukocyte subsets implicated in early pathological changes in ovarian architecture. The aim of this study was to investigate the effect of MCMV-ZP3 infection on leukocytes including T cells recruited into the ovary following infection with recombinant virus. Fifteen BALB/c female mice were randomly allocated into three groups of five animals at 6 weeks of age. Group one received an injection of PBS, group two and three received intraperitoneal inoculations of 2 × 104 pfu of MCMV and MCMV-ZP3 respectively. Ovaries were retrieved at day 10, 21 and 35 post inoculation and one ovary from each mouse was sectioned for immunohistochemical analysis of resident leukocytes using mAb CD45 reactive with all leukocyte lineages and mAb for CD4 and CD8 positive T cells. MCMV-ZP3 inoculation increased the abundance of ovarian leukocytes including CD4 and CD8 positive T cells for all time points post immunisation except for CD8 positive T cells 21 days post infection (Table 1). These results suggest that leukocytes, including T cells, are involved in causing early changes in the ovary post infection with MCMV-ZP3 that lead to the depletion of existing ovarian follicles leading to life long infertility in mice. Further experiments are underway to investigate the role of antibody and changes in leukocyte populations in the ovary as the course of infection with recombinant virus progresses. This study is funded by the Cooperative Research Centre for Pest Animal Control. (1)Lloyd ML, et al. (2003). Biol. Reprod. 68, 2024–32.(2)O’Leary S, et al. (2004). Reprod. Fertil. Devel. 16(Supplement), 77.

Seminal plasma regulates endometrial cytokine expression, leukocyte recruitment and embryo development in the pig

In pigs, uterine exposure to the constituents of semen is known to increase litter size but the underlying physiological mechanisms remain undefined. Studies in rodents and humans implicate immune modulating moieties in seminal plasma as likely candidates, acting through enhancing the receptivity of the female tract. In this study, the acute and longer term effects of seminal plasma on cytokine expression and leukocyte abundance in the pig endometrium during early pregnancy have been characterised. The reproductive tracts of gonadotrophin-primed pre-pubertal gilts treated with intrauterine infusions of either pooled seminal plasma or phosphate-buffered saline (PBS) were retrieved at 34 h, or on day 5 and day 9 after treatment. Seminal plasma elicited an endometrial inflammatory infiltrate comprised of predominantly macrophages and major histocompatibility complex class II+-activated macrophages and dendritic cells. The abundance of these cells was greatest at the pre-ovulatory (34 h) time-point and their increase relative to PBS-treated tissues was maintained until day 9 after seminal plasma treatment. Seminal plasma induced the expression of the cytokines, granulocyte macrophage colony-stimulating factor, interleukin-6 and monocyte chemoattractant protein-1, and the eicosanoid-synthesising enzyme cyclo-oxygenase-2. Expression was maximal 34 h after treatment but altered expression patterns as a consequence of seminal plasma induction persisted through early pregnancy. These changes were accompanied by altered dynamics in pre-implantation embryo development with an increase in the number of embryos and in their viability after seminal plasma treatment. Together, these findings implicate factors in seminal plasma in programming the trajectory of uterine cytokine expression and leukocyte trafficking during early pregnancy and in regulating pre-implantation embryo development in the pig.

Recent advances in therapeutic exercise for the neck: implications for patients with head and neck pain

There have been recent advances in the rehabilitation of the muscles that control the head and neck. These advances are based on evidence of specific neck muscle dysfunction in individuals with persistent head and neck pain. Traditional rehabilitation strategies have focused predominantly on muscle strength and endurance under high loads. New evidence suggests that in people with neck pain there are underlying neuromuscular problems that may require more immediate attention and may not be adequately addressed by simple strength and high-load endurance retraining. Evidence of altered coordination between the deep and superficial neck muscles, greater neck muscle fatigue under sustained low loads, and deficits in kinaesthetic sense have been identified in symptomatic individuals. There is evidence to indicate that addressing these muscle control problems, with specific gentle exercise strategies, results in a reduction in neck pain and associated symptoms.

Sensitization to the Psychosis-Inducing Effects of Cocaine Compared with Measures of Cocaine Craving and Cue Reactivity

A previous study has suggested that sensitization to the psychosis-inducing effects of cocaine may be a marker of vulnerability to relapse in cocaine addiction. In this report, cocaine-dependent subjects participating in a study on naturally occurring and cue-induced cocaine craving were interviewed about prior experience of cocaine-induced psychosis and the degree to which this effect had become more frequent or severe or had occurred at lower cumulative doses. Sensitization to cocaine-induced psychosis was negatively correlated with baseline measures of drug dependence severity and indices of cocaine craving over the preceding 24 hours but not with measures of cocaine cue reactivity.

223.Ovarian pathology in mice following immunisation with recombinant murine cytomegalovirus expressing murine zona pellucida 3

Immunocontraception is a promising biological control for wild mice in Australia, having the potential to reduce the socioeconomic cost of plagues with minimal environmental impact. Inoculation of BALB/c mice with recombinant murine cytomegalovirus encoding murine zona pellucida antigen (mCMV-ZP3) confers total infertility characterised by depletion in ovarian tertiary follicles by Day 21 post inoculation followed by a progressive depletion in primordial follicles (1). The mechanisms underlying ovarian pathology are largely unknown but are likely to involve antibody mediated and cell mediated immune responses. The immune pathology may also be facilitated by acute responses involving antibody binding to ZP in growing follicles resulting in recruitment of inflammatory cells and oocyte destruction. The aim of this study was to investigate the effect of mCMV–ZP3 infection on leukocyte infiltration and expression of oocyte-derived signalling molecules in ovarian tissue. Fifteen BALB/c female mice were randomly allocated into three groups of 5 animals. Group one received an injection of PBS, group two and three received intraperitoneal inoculations of 2�×�104�p.f.u. of mCMV and mCMV-ZP3 respectively. Ovaries were retrieved at Day 7 post inoculation and one ovary from each mouse was sectioned for immunohistochemical analysis of resident leukocytes using mAb CD45 reactive with all leukocyte lineages. The other ovary was processed for real time quantitative RT-PCR analysis of growth and differentiation factor 9 (GDF-9) and connexin 43 (Cx43) expression. mCMV-ZP3 inoculation increased the abundance of ovarian leukocytes (P�=�0.08), significantly increased expression of Cx43 mRNA (p<0.05), but did not alter GDF-9 mRNA expression. These results suggest that changes in expression of ovarian regulators due to ZP3 immunisation begins early after recombinant MCMV infection in mice, and implicates leukocyte infiltration in the mechanism leading to permanent ovarian failure. Further experiments are underway to investigate the dynamics of leukocyte trafficking and expression of oocyte-derived signals as the course of infection progresses. This study is funded by the Cooperative Research Centre for Pest Animal Control. (1) Lloyd, M. L., et al. (2003). Biology of Reproduction 68(6): 2024-32.

222.Characterisation of the infertility effect induced by a recombinant murine cytomegalovirus expressing murine zona pellucida 3

A recombinant mouse virus, murine cytomegalovirus, that has been engineered to encode the fertility antigen murine zona pellucida 3 (mZP3), is being developed for fertility control in mice. A single inoculation of the recombinant virus induces complete infertility in female BALB/c mice which persists for the breeding life of the animal. The extent of this autoimmune response was unexpected especially as the incorporation of mZP3 appears to have immunologically attenuated the growth of the recombinant virus. The histological features of the infection are an initial depletion in tertiary follicles by 21 days post inoculation followed by a progressive depletion of primordial follicles, leading to an almost complete absence of follicles by 150 days post-infection. High titre, long lasting, zona pellucida-specific antibody is present in infertile BALB/c mice although infertility has not been linked with either a critical titre or a dominant immunoglobulin isotype. However, our evidence suggests that anti-ZP3 antibody plays a primary role in infertility since antibodies are detected in vivo bound to the zona pellucida of ovaries from recombinant virus-infected mice, and passively transferred antibody from infected animals induces infertility in the absence of recombinant virus. In addition, an experiment in which immunoglobulin-deficient mice remained fertile after inoculation with the recombinant virus indicates that antibody is crucial for the immunocontraceptive effect to occur. Other immune mechanisms are also being explored.

261.Probiotic Lactobacillus in seminal plasma

Commensal bacteria of the Lactobacillus genus are implicated in beneficial 'probiotic' roles in the gut and other mucosal tissues. Their presence reduces the incidence of pathogenic infections, both passively and via production of antimicrobial substances, and through Toll-like receptor-mediated activation of cytokine expression in host tissues. Lactobacilli are present in the female reproductive tract but have not been examined in the male. This study aimed to investigate, by selective culture techniques and real-time quantitative PCR, the prevalence in boar seminal plasma of Lactobacilli compared with other pathogenic bacteria. Using acidified Rogosa Agar, Lactobacilli were cultured from 3/3 fresh semen samples and were found to be most prevalent in the first fraction of the ejaculate. For PCR, DNA was extracted from reference bacterial cultures and archived seminal plasma samples from 40 healthy boars. Bacterial species-specific primers targeting Lactobacillus 16s and 16s-23s rDNA sequences, and Staphylococcus aureus, Pseudomonas aeruginosa, and Bacillus-specific Sau3AI, oprL, and 16s rDNA genes respectively, were used in real-time PCR assays employing SYBRgreen (Applied Biosystems) technology. Lactobacilli were detected in 22/40 (55%) of seminal plasma samples, while pathogenic bacteria were detected in <10% of samples (Staphylococcus aureus, 1/40; Pseudomonas aeruginosa, 2/40; and Bacillus, 3/40). The Lactobacillus content of individual boars ranged from 1.5 to 15 × 106 cells/mL, and within boars, content varied within 30% of the mean value in successive samples over a 6-month period. We conclude that Lactobacilli are present in abundance in boar seminal plasma compared to other potentially pathogenic bacteria. These bacteria may protect the male tract from pathogen infection, and after ejaculation, may influence the female immune response to male antigens. Ongoing studies will investigate whether Lactobacilli abundance in seminal plasma correlates with boar fertility, and examine the potential value of improving reproductive performance in pigs and other species by administration of probiotic agents.

230.Novel immune modulation to improve reproductive outcomes in pigs

Early embryonic mortality is a major factor limiting litter size and profitability in the pig industry. Pregnancy success requires an immunologically receptive reproductive tract, generated in response to exposure to immune modulating factors in the seminal plasma (SP). Both the short-term pro-inflammatory response of the endometrium to SP and to a novel immune-modulating product, mycobacterial cell wall extract (MCWE; 'Equimune', Bioniche Animal Health) and the reproductive outcomes from a large-scale farrowing trial are described. In the first experiment, 15 Large White gilts (24 weeks of age) were randomly allocated to three intrauterine treatments administered at onset of gonadotrophin-induced oestrus: (1) 80 mL PBS (control); (2) 80 mL SP; or (3) 80 mL PBS containing 500 �g MCWE. Gilts were slaughtered 32–34 h later and reproductive tracts retrieved. Luminal fluid leukocytes were assessed following fixation using DIFF-Quik stain, and indicated the proportion of lymphocytes increased with SP and MCWE treatment compared to the control group (14.0% and 17.0% v. 9.3%; P < 0.05), and the proportion of monocytes decreased (12.3% and 15.0% v. 25.0%; P < 0.05). In the second experiment, Large White or Large White/Landrace crossbred females (n�=�161) were artificially inseminated twice, following standard industry practice, after detection of standing oestrus. Stratified for parity and breed, each was allocated to a treatment group: (a) Control: standard AI dose 1st and 2nd insemination; (b) 500 μg MCWE added to 2nd insemination; or (c) 500 μg MCWE included in the 1st and 2nd insemination. The overall pregnancy rate was 91%, with no significant effect of treatment on litter size, average piglet bodyweight at birth or litter variability. Although the use of MCWE at the time of AI did not improve reproductive outcome, significant potential remains in utilising its immune stimulating properties in 'priming' the reproductive tract, followed by mating at the next oestrus. This approach may improve gilt farrowing rates, thus increase overall herd productivity and efficiency.

Quantitative Electroencephalographic Studies of Cue-Induced Cocaine Craving

Quantitative electroencephalographic (qEEG) profiles were studied in cocaine dependent patients in response to cocaine cue exposure. Using neurometric analytical methods, the spectral power of each primary bandwidth was computed and topographically mapped. Additional measures of cue-reactivity included cocaine craving, anxiety and related subjective ratings, and physiological measures of skin conductance, skin temperature, heart rate, and plasma Cortisol and HVA levels. Twenty-four crack cocaine-dependent subjects were tested for their response to tactile, visual and audio cues related to crack cocaine or neutral items. All measures were analyzed for significant difference by comparing cocaine versus neutral cue conditions. An increase in cocaine craving, anxiety and related subjective ratings, elevated plasma Cortisol levels, and a decrease in skin temperature, were induced by cocaine cue exposure.

Distinct qEEG profiles were found during the paraphernalia handling and video viewing (eyes-open), and guided imagery (eyes-closed), phases of cocaine cue exposure. During paraphernalia handling and video viewing, there was an increase in beta activity accompanied by a drop in delta power in the frontal cortex, and an increase in beta mean frequency in the occipital cortex. In contrast, during guided imagery there was an increase in theta and delta power in the frontal cortex, and an increase in beta power in the occipital cortex. Correlation analyses revealed that cue-induced anxiety during paraphernalia handling and video viewing was associated with reduced high frequency and enhanced low frequency EEG activity. These findings demonstrated that EEG activation during cue-induced cocaine craving may be topographically mapped and subsequently analyzed for functional relevance.

Genetic variation in the 5q31 cytokine gene cluster confers susceptibility to Crohn disease

Linkage disequilibrium (LD) mapping provides a powerful method for fine-structure localization of rare disease genes, but has not yet been widely applied to common disease. We sought to design a systematic approach for LD mapping and apply it to the localization of a gene (IBD5) conferring susceptibility to Crohn disease. The key issues are: (i) to detect a significant LD signal (ii) to rigorously bound the critical region and (iii) to identify the causal genetic variant within this region. We previously mapped the IBD5 locus to a large region spanning 18 cM of chromosome 5q31 (P<10(-4)). Using dense genetic maps of microsatellite markers and single-nucleotide polymorphisms (SNPs) across the entire region, we found strong evidence of LD. We bound the region to a common haplotype spanning 250 kb that shows strong association with the disease (P< 2 x 10(-7)) and contains the cytokine gene cluster. This finding provides overwhelming evidence that a specific common haplotype of the cytokine region in 5q31 confers susceptibility to Crohn disease. However, genetic evidence alone is not sufficient to identify the causal mutation within this region, as strong LD across the region results in multiple SNPs having equivalent genetic evidence-each consistent with the expected properties of the IBD5 locus. These results have important implications for Crohn disease in particular and LD mapping in general.

Effects of a novel potential antidepressant on the behavior and cortisol levels of isolated guinea pig pups

A novel, potential antidepressant, E-6006 citrate (E-6039), dose-dependently reduced the vocalizations emitted by isolated guinea pig pups. The (+)-E-6006, but not the (-)-E-6006, enantiomer also reduced vocalizing. There were no reliable effects of E-6039 on locomotor activity, crouching, or other behavioral measures, but both E-6039 and the (+)-E-6006 enantiomer elevated plasma cortisol levels during isolation. The contrasting effects of E-6039 on vocalizations and plasma cortisol are discussed in terms of E-6039's putative ability to inhibit release of substance P. The reduction in the vocalizations of isolated guinea pig pups corroborates positive results with this drug in other antidepressant screens utilizing mice and rats, and provides further support for the potential of E-6039 as an antidepressant compound.

Dissociative identity disorder and the nurse-patient relationship in the acute care setting: an action research study

This paper presents the results of an action research study into the acute care experience of Dissociative Identity Disorder. The study, which was grounded in principles of critical social science, utilized focus group interviews and narrative construction. Nurses and patients are under-represented in all clinical evaluation and their voices need to be heard if services are to be truly collaborative. Findings of the study extend intrapsychic theories of trauma to emphasize the interpersonal relationship between nurse and person who can work together to facilitate recovery from trauma, make connections both intra and interpersonally and build resilience.

Antegrade intramedullary fixation of displaced fifth metacarpal fractures

We report a new and simple modification for antegrade insertion of intramedullary K-wires used in the treatment of displaced fifth metacarpal fractures. This method of fixation was performed on six patients all of whom had excellent results when reviewed clinically and radiologically with a mean follow-up of 9 months.

Pre-operative awareness for children with implantable ports

Implantable central venous access devices CVADs have increased in their use. A Portacath makes venous access quicker and reduces the trauma associated with siting a peripheral cannula. Children with cystic fibrosis have benefited from the use of the Portacath. This study explored the information requirements of twenty six children with cystic fibrosis, and their families who already had an implantable port fitted. Nineteen families had received no written information relating to having a Portacath and seventeen wanted more information. The development of a book was thought appropriate to compliment the other educational strategies already in use.

Analysis of the carbapenem gene cluster of Erwinia carotovora: definition of the antibiotic biosynthetic genes and evidence for a novel beta-lactam resistance mechanism

Members of two genera of Gram-negative bacteria, Serratia and Erwinia, produce a beta-lactam antibiotic, 1-carbapen-2-em-3-carboxylic acid. We have reported previously the cloning and sequencing of the genes responsible for production of this carbapenem in Erwinia carotovora. These genes are organized as an operon, carA--H, and are controlled by a LuxR-type transcriptional activator, encoded by the linked carR gene. We report in this paper the genetic dissection of this putative operon to determine the function of each of the genes. We demonstrate by mutational analysis that the products of the first five genes of the operon are involved in the synthesis of the carbapenem molecule. Three of these, carABC, are absolutely required. In addition, we provide evidence for the existence of a novel carbapenem resistance mechanism, encoded by the CarF and carG genes. Both products of these overlapping and potentially translationally coupled genes have functional, N-terminal signal peptides. Removal of these genes from the Erwinia chromosome results in a carbapenem-sensitive phenotype. We assume that these novel beta-lactam resistance genes have evolved in concert with the biosynthetic genes to ensure 'self-resistance' in the Erwinia carbapenem producer.

The intradural cervical plexus. An absent cervical nerve root

Whilst dissecting the intradural and peripheral pathways of the spinal accessory n. (Sp. XI) as part of a larger study into its microsurgical anatomy, we have discovered an unusual and previously unreported anatomical variant. In one cadaver the intradural C2 dorsal n. root was completely absent on the left side. Considerable speculation surrounds the function of the spinal accessory n. in human subjects. Recent anatomical and clinical studies have drawn attention to the intradural plexus-like morphology of the Sp. XI and raised the possibility of integration of pro-prioception and motor control of the neck musculature at this level. The general anatomy of the Sp. XI is reviewed along with current ideas from recent studies.

Comparison of computer interface devices for persons with severe physical disabilities

This research employed a descriptive case study design to compare subjects' performance using three computer input devices: the Tongue Touch Keypad, the HeadMaster, and the mouthstick. The sample consisted of four students with severe physical disabilities enrolled in an adaptive computer class at a community college. Components of performance examined were input speed, accuracy, and level of perceived exertion. Subjects' acceptance of each of the interface devices was also examined. Results showed input speed to be the fastest with the mouthstick, followed by the HeadMaster and then the Tongue Touch Keypad. Accuracy of input did not vary significantly. Three subjects rated the Tongue Touch Keypad as requiring the lowest rate of perceived exertion, followed by the HeadMaster and then the mouthstick. Overall performance did not necessarily affect subjects' acceptability ratings of the devices. Information from this study will assist therapists in evaluating the effectiveness and desirability of computer interface devices for patients.