The SARS-CoV-2 viral load in COVID-19 patients is lower on face mask filters than on nasopharyngeal swabs

Face masks and personal respirators are used to curb the transmission of SARS-CoV-2 in respiratory droplets; filters embedded in some personal protective equipment could be used as a non-invasive sample source for applications, including at-home testing, but information is needed about whether filters are suited to capture viral particles for SARS-CoV-2 detection. In this study, we generated inactivated virus-laden aerosols of 0.3–2 microns in diameter (0.9 µm mean diameter by mass) and dispersed the aerosolized viral particles onto electrostatic face mask filters. The limit of detection for inactivated coronaviruses SARS-CoV-2 and HCoV-NL63 extracted from filters was between 10 to 100 copies/filter for both viruses. Testing for SARS-CoV-2, using face mask filters and nasopharyngeal swabs collected from hospitalized COVID-19-patients, showed that filter samples offered reduced sensitivity (8.5% compared to nasopharyngeal swabs). The low concordance of SARS-CoV-2 detection between filters and nasopharyngeal swabs indicated that number of viral particles collected on the face mask filter was below the limit of detection for all patients but those with the highest viral loads. This indicated face masks are unsuitable to replace diagnostic nasopharyngeal swabs in COVID-19 diagnosis. The ability to detect nucleic acids on face mask filters may, however, find other uses worth future investigation.

Evidence of increasing public participation in advance care planning: a comparison of polls in Alberta between 2007 and 2013

BACKGROUND

Advance care planning (ACP) encompasses both verbal and written communications expressing preferences for future health and personal care and helps prepare people for healthcare decision-making in times of medical crisis. Healthcare systems are increasingly promoting ACP as a way to inform medical decision-making, but it is not clear how public engagement in ACP activities is changing over time.

METHODS

Raw data from 3 independently conducted public polls on ACP engagement, in the same Canadian province, were analysed to assess whether participation in ACP activities changed over 6 years.

RESULTS

Statistically significant increases were observed between 2007 and 2013 in: recognising the definition of ACP (54.8% to 80.3%, OR 3.37 (95% CI 2.68 to 4.24)), discussions about healthcare preferences with family (48.4% to 59.8%, OR 1.41 (95% CI 1.17 to 1.69)) and with healthcare providers (9.1% to 17.4%, OR 1.98 (95% CI 1.51 to 2.59)), written ACP plans (21% to 34.6%, OR 1.77 (95% CI 1.45 to 2.17)) and legal documentation (23.4% to 42.7%, OR 2.13 (95% CI 1.75 to 2.59)). These remained significant after adjusting for age, education and self-rated health status.

CONCLUSIONS

ACP engagement increased over time, although the overall frequency remains low in certain elements such as discussing ACP with healthcare providers. We discuss factors that may be responsible for the increase and provide suggestions for healthcare systems or other public bodies seeking to stimulate engagement in ACP.

HER2 positive early breast cancers: tumour demographics and trastuzumab therapy in the real-world

Abstract #3159

Background: Various trials have shown substantial benefits of addition of Trastuzumab (Herceptin®) to adjuvant chemotherapy in Early Breast Cancer (EBC). We analysed our breast cancer population to determine the incidence of HER2 positive Early Breast Cancers, the tumour demographics and the number of patients eligible for and receiving trastuzumab therapy in this group.
 Methods: Data for all patients diagnosed with EBC in 2006 was recorded prospectively in a database. Case notes were consulted where the HER2 positive patients, determined by a combination of IHC and FISH, had not received trastuzumab, to ascertain the reasons.
 Results: A total of 951 patients were diagnosed with Breast Cancer in 2006. 417 (43.9%) of these were screen-detected cancers.
 There were 123 (12.9%) HER2 positive newly diagnosed Breast Cancers of whom 117 were EBCs. The HER2 positivity rate in the screen detected cancers (n=417) was 9% and 17% in the symptomatic cancers (n=433).
 1. Demographics of the HER2 positive Early Breast Cancer Population:
 The median age at diagnosis was 61 yrs (range: 30-92).
 
 2. Fifty nine (50.4%) of the HER2 positive EBCs received trastuzumab therapy.
 
 Conclusions: The HER2 positivity rate is lower than that previously reported suggestive of changing demographics secondary to a high screen detected cancer population. A third of the HER2 positive tumours are screen detected. The percentage of ER positive, node negative and low grade tumours was higher than anticipated.
 Only 50% of HER 2 positive EBC patients received trastuzumab therapy. Of those who did not receive trastuzumab, the commonest reason was low risk status or age and co-morbidities precluded chemotherapy.
 HER 2 positivity alone confers high risk irrespective of pathological stage. Further trials are required to evaluate whether the substantial number of patients who are at present not eligible for trastuzumab therapy might also benefit.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 3159.

Prognostic value of protein tyrosine kinase 6 (PTK6) for long-term survival of breast cancer patients

The cytoplasmic tyrosine kinase PTK6 (BRK) shows elevated expression in approximately two-thirds of primary breast tumours, and is implicated in EGF receptor-dependent signalling and epithelial tumorigenesis. Using immunohistochemistry, we performed a retrospective study on 426 archival breast cancer samples from patients with long-term follow-up and compared the protein expression levels of PTK6, the HER receptors, Sam68 (a substrate of PTK6), and signalling proteins including MAP kinase (MAPK), phosphorylated MAPK (P-MAPK), and PTEN. We show that PTK6 expression is of significant prognostic value in the outcome of breast carcinomas. In multivariate analysis, the disease-free survival of patients of >or=240 months was directly associated with the protein expression level of PTK6 (P<or=0.001), but was also inversely associated with nodal status (P<or=0.001) and tumour size (P<or=0.01). PTK6 expression in tumour tissue significantly correlated (P<or=0.05) with the expression of PTEN, MAPK, P-MAPK, and Sam68. To investigate whether these correlations may be due to molecular interactions between PTK6 and these proteins, we used protein extracts from the T47D cell line for immunoprecipitation and western blot analysis. By this, interactions could be demonstrated between PTK6 and MAPK, P-MAPK, HER2/neu, HER3, HER4, PTEN, and Sam68. On the basis of these results, we suggest that PTK6 may serve as a future target for the development of novel treatments in breast cancer.

Orthotopic ileal neobladder reconstruction after renal transplant

Radical cystectomy and urinary diversion is an effective curative treatment for muscle invasive bladder cancer. The orthotopic ileal neobladder has become a favorable choice of urinary diversion as it offers superior quality of life, cosmetic outcome and the potential for normal voiding. We treated two patients with bladder cancer who previously underwent renal transplant for end-stage renal disease. Radical cystectomy and orthotopic ileal neobladder reconstruction was performed in both patients. One patient had two renal transplants and underwent transplant nephrectomy at the time of cystectomy. In the other patient, the native kidneys were still present and the ureters were anastomosed to the neobladder. There is excellent function of the neobladder. There were no increased complications seen in these patients. Our cases demonstrate that an orthotopic ileal neobladder is safe and feasible after renal transplant and should be offered to these patients.

Rising to the challenges of achieving day surgery targets

Day surgery provides high quality and efficient care for a wide variety of surgical procedures. Patients appreciate the rapid recovery and effective analgesia, while the health service benefits from a streamlined service with lower costs. Despite the numerous advantages, day surgery practices vary enormously and many patients are still denied this excellent form of care. Fundamental to improving this situation is a change in emphasis, with day surgery becoming the default option for many surgical procedures--rather than being applied selectively--with inpatient care being used only where specifically indicated. Appropriate patient preparation is facilitated by consultant-led, nurse-run pre-assessment using modern selection criteria; only conditions which will still cause problems a few hours beyond the end of the operation should be barriers to day surgery. Pre-assessment also provides an excellent opportunity to begin patient education and ensures that pre-existing pathology is optimally treated. Efficient day surgery is best delivered by a specialised, dedicated, multi-disciplinary team, but consultant anaesthetists have a major role to play in co-ordinating policies and providing leadership. Individual anaesthetists should develop techniques that allow their patients to undergo day surgery with minimum stress, maximum comfort and the optimal chance of early discharge. Improving day surgery rates is a win-win situation, with both clinical and financial benefits.

Retrospective analysis of cutaneous T-cell lymphoma (CTCL) biopsy samples for interleukin-2 receptor (IL2-R) subunit expression by immunohistochemistry (IHC) and real-time quantitative PCR (RT-PCR): Correlation to response to denileukin diftitox

20080

Background: Denileukin diftitox, a chimeric diphtheria toxin-IL2 protein, exerts its cytotoxic effect on cells expressing high or intermediate affinity IL2-R. IL2-R is a complex of 3 distinct polypeptide chains: IL2-Rα (CD25), IL2-Rβ (CD122), and IL2-Rγ (CD132). IL2-R α/β/γ heterotrimer binds with high affinity, IL2-R β/γ with intermediate affinity, and IL2-R α/γ with low affinity. Denileukin diftitox is indicated for patients with persistent or recurrent CTCL whose malignant cells express IL2-Rα protein. There is no currently available methodology to measure expression of the high affinity receptor in patient samples. This study was initiated to discover a correlation between expression of IL2-R components (at the mRNA and protein levels) and clinical response to denileukin diftitox. Methods: Of 33 available frozen clinical CTCL biopsy samples, 27 (10 responders) were sufficient for IHC. IL2-Rβ staining intensity was assigned a value of 0 (no staining relative to background), 1+ (weak), 2+ (moderate), or 3+ (strong). 22 samples (8 responders) were sufficient for RT-PCR. mRNA levels of the 3 IL2-R chains were normalized to 36B4 mRNA or 18S rRNA. Correlation between clinical response and IL2-R chain expression was assessed using Spotfire Decision Site. Results: The population of samples tested was representative of the study population. 26 of 27 samples exhibited 2+, all exhibited 1+, and none 3+ IL2-Rβ staining. The percentage of cells stained varied from 20%–90% for 1+ and 10%–80% for 2+ with no correlation to response. Correlation of levels of individual IL2-R subunit mRNA expression with response could not be established. Conclusions: Neither the IL2-Rβ IHC nor the RT-PCR assay, at current sensitivity levels, appear to identify denileukin diftitox responders. Larger sample datasets from current studies, and further assay refinement, are ongoing to define the merits of these approaches.

[Table: see text]

Correlation between immunohistochemistry (HercepTest) and fluorescence in situ hybridization (FISH) for HER-2 in 426 breast carcinomas from 37 centres

Accurate diagnostic assessment of HER-2 is essential for the appropriate application of the humanized anti-HER-2 monoclonal antibody trastuzumab (Herceptin) to the treatment of patients with metastatic breast cancer. The diagnostic test needs to be applicable to archival, fixed tissue removed at excision, in many cases several years earlier. We compared the assessment of HER-2 by immunohistochemistry (IHC; HercepTest) and fluorescence in situ hybridization (FISH) in 426 breast carcinomas from patients being considered for trastuzumab therapy. The tumours were tested in three reference centres having been sent in from 37 hospitals. Only 2/270 (0.7%) IHC 0/1+ tumours were FISH positive. Six of 102 (5.9%) IHC 3+ tumours were FISH negative. Five of the six had between 1.75 and 2.0 HER-2 gene copies per chromosome 17 and the sixth had multiple copies of chromosome 17. Thirteen per cent of tumours were IHC 2+ and overall 48% of these were FISH positive but this proportion varied markedly between the centres. Sixty IHC-stained slides selected to be enriched with 2+ cases were circulated between the three laboratories and scored. There were 20 cases in which there was some discordance in scoring. Consideration of the FISH score in these cases led to concordance in the designation of positivity/negativity in 19 of these 20 cases. These data support an algorithm in which FISH testing is restricted to IHC 2+ tumours in reference centres. The results may not extrapolate to laboratories with less experience or using different methodologies.

A high degree of genetic diversity is revealed in Isatis spp. (dyer's woad) by amplified fragment length polymorphism (AFLP)

Genetic diversity in 38 genotypes, representing 28 individual genotypes from five landraces of Isatis tinctoria (three German: Tubingen, Potsdam and Erfurt, one Swiss and one English), five genotypes of Isatis indigotica (Chinese woad) and five genotypes of Isatis glauca, were investigated using AFLP analysis. Five primer combinations detected a total of 502 fragments of which 436 (86.9%) were polymorphic. The level of polymorphism recorded within each species was 29.8, 86.9 and 35.8% for I. indigotica, I. tinctoria and I. glauca, respectively. Clearly, genetic diversity within I. tinctoria was greater than that observed in I. indigotica or I. glauca. Cluster analyses of the AFLP data using UPGMA and PCO revealed the complete separation of the genotypes of each species into distinct groups. I. indigotica separated as an entirely independent group, whereas I. glauca formed a separate cluster within the I. tinctoria group. Indeed, I. tinctoria and I. glauca are more closely related to each other than either is to I. indigotica. In addition, the genotypes of each landrace, apart from one from the English group, were clearly discriminated. However, the anomalous genotype did associate with the rest of its group when it was linked with the Erfurt group. These results provide new and useful information about the make-up of the Isatis genome, which has not previously been evaluated. They will be useful in the selection of plant material for variety development and conservation of the gene-pool.

HER2 as a prognostic and predictive marker for breast cancer

In recent years investigators have looked at the human epidermal growth factor receptor-2 (HER2), which is overexpressed in 20%-30% of breast cancer patients, with regard to its role as a prognostic and predictive factor. Although many studies have suggested that HER2 overexpression may be associated with a poor clinical outcome, other studies have not fully supported this observation. The inconsistencies between studies may be due in part to discrepancies between different HER2 testing methods. To overcome this problem, a radioimmunohistochemical method was developed to quantitatively measure HER2 overexpression levels in breast tumor samples. The application of this method demonstrated that 85% of all breast tumor samples expressed HER2 at levels greater than normal. Of these, 23% expressed HER2 at levels between 45 and 480 times greater than normal, and this was associated with poor clinical outcome. The investigation of HER2 status as a predictor of response to therapy has also yielded many conflicting results. Overall, it appears that HER2 overexpression may correlate with resistance to hormonal therapy, sensitivity to anthracycline-based chemotherapy and resistance to CMF. With the development of targeted anti-HER2 therapies, assessment of HER2 status will be important in stratifying patients to the most appropriate treatment regimens.

The value of the human epidermal growth factor receptor-2 (HER2) as a prognostic marker

The prognosis for patients with breast cancer is determined by well-established pathological features associated with biological aggressiveness, histological grade, tumour size and nodal involvement. These remain the key determinants, despite the identification of numerous other potential biological markers. The use of prognostic indices, such as the Nottingham Prognostic Index (NPI), which combines and weights these factors, enables clinicians to predict outcome with a certain amount of accuracy. Approximately 20-30% of breast cancers express very high quantities of the human epidermal growth factor receptor-2 (HER2) protein and this is almost always associated with gene amplification. With the use of sensitive techniques, such as the radio-immunohistochemical method (rIHC) described herein, to quantify HER2 protein levels, up to a further 50% of such cancers will be found to express the HER2 receptor at least 4-fold higher than normal breast cells. Adding HER2 expression to the NPI helps to determine more accurately the prognosis for individual patients, particularly those with node-negative disease. Overall, the main value of HER2 measurement is likely to be in the prediction of response to therapies targeting the HER2 gene and protein.

The value of the human epidermal growth factor receptor-2 (HER2) as a prognostic marker

The prognosis for patients with breast cancer is determined by well-established pathological features associated with biological aggressiveness, histological grade, tumour size and nodal involvement. These remain the key determinants, despite the identification of numerous other potential biological markers. The use of prognostic indices, such as the Nottingham Prognostic Index (NPI), which combines and weights these factors, enables clinicians to predict outcome with a certain amount of accuracy. Approximately 20-30% of breast cancers express very high quantities of the human epidermal growth factor receptor-2 (HER2) protein and this is almost always associated with gene amplification. With the use of sensitive techniques, such as the radio-immunohistochemical method (rIHC) described herein, to quantify HER2 protein levels, up to a further 50% of such cancers will be found to express the HER2 receptor at least 4-fold higher than normal breast cells. Adding HER2 expression to the NPI helps to determine more accurately the prognosis for individual patients, particularly those with node-negative disease. Overall, the main value of HER2 measurement is likely to be in the prediction of response to therapies targeting the HER2 gene and protein.

Recommendations for HER2 testing in the UK

Determining the HER2 status of breast carcinomas is a prerequisite for the use of the monoclonal antibody trastuzumab (Herceptin), which has recently been licensed for the treatment of metastatic disease. This necessitates a test based on archival material. The preferred analyses are immunohistochemistry with fluorescent in situ hybridisation (FISH) as a follow up test for ambiguous results. Guidelines have been developed for standardised, well controlled procedures for the provision of reliable results. A group of three reference laboratories has been established to provide advice, quality assurance, and materials, where needed.

Advanced-stage cervix cancer: rapid tumour growth rather than late diagnosis

Either diagnostic delay or tumour biology are possible factors governing the degree of spread at diagnosis of cervical cancer. To try to identify the most important parameter contributing to advanced stage, the duration of symptoms were recorded from patients scheduled for radiotherapy (n = 141) or radical hysterectomy (n = 36). In 146 cases tumour proliferation rates were evaluated following in vivo labelling with the DNA precursor BrdUrd. For symptomatic patients there was no association between duration of symptoms and stage at presentation. There was a significant trend for patients with increasing tumour stage to have more rapidly proliferating tumours with higher mean labelling index (LI) measurements (P = 0.001) and a shorter mean potential doubling time (Tpot) (P = 0.023). Socio economic deprivation may be associated with shorter Tpot values. The conclusion from this data is that stage at diagnosis is more dependent on the biological behaviour of the tumour, as expressed by proliferation rates, than delay in presentation.

Effect of menopause on low-density lipoprotein oxidation: is oestrogen an important determinant?

OBJECTIVES

Significantly increased risk for developing cardiovascular disease in post-menopausal women is linked with the fall of oestrogen. Although supraphysiological levels of oestrogen may inhibit oxygen free radical mediated low-density lipoprotein (LDL) oxidation, the effect of physiological level of oestrogen on LDL oxidation is unknown.

METHODS

The present study compared oxidizability of LDL in healthy pre- and post-menopausal women by using a commonly employed copper ion-dependent method.

RESULTS

Pre-menopausal women (n=20, mean age 27) had significantly higher serum oestradiol level (576+/-109 pmol/l) in comparison to post-menopausal women (n=23, mean age 51, oestradiol 64+/-18 pmol/l, P<0.001). The oxidation of LDL in two groups was not different by measuring either the lag phase of conjugated dienes formation (54+/-12 vs. 55+/-14 min, P0.05) or the generation of thiobarbituric acid reactive substances over 4 h of oxidation. The major lipid soluble antioxidant in LDL, vitamin E (determined as alpha-tocopherol) is similar in two groups (2.34+/-0.48 vs. 2.40+/-0. 56 nmol/mg LDL, pre- and post-menopausal subjects, respectively, P0. 05). Linear regression analysis found a weak but significant correlation between LDL vitamin E level and oxidizability of LDL in both groups but did not show effect of serum oestradiol levels.

CONCLUSION

The results suggest that physiological levels of oestrogen may not be able to affect in vitro LDL oxidation.

What is HER2?

The focus of recent research into the cause of cancer has been the cell systems controlling growth. This has shown that mutations affecting growth factor receptors are involved in oncogenesis. The human epidermal growth factor receptor (HER) family is one of the best characterized systems in breast cancer and has important functions in the control of normal growth regulation. HER2 has a central role in the HER family, interacting with the other members of this receptor family to potentiate intracellular signalling. Although our understanding of how HER2 functions and is regulated is limited, studies have linked HER2 gene amplification/receptor overexpression to cancer development. HER2 gene amplification/receptor overexpression is observed in a significant proportion of various tumour types, occurs relatively early during cancer progression and is associated with poor prognosis in women with breast cancer. Knowing the HER2 status of patients with breast cancer will become increasingly important for making management decisions.

Evaluation of standard haemodynamic tests of autonomic function and HbA1c as predictors of delayed gastric emptying in patients with type 1 diabetes mellitus

We examined the relation between chronic glycaemic control (using glycosylated haemoglobin), haemodynamic autonomic function and rate of gastric emptying in 16 patients with type 1 diabetes mellitus. Gastric emptying was measured using a paracetamol absorption technique. Parameters of gastric emptying include area under the plasma paracetamol concentration time curve. Patients were classified as diabetic autonomic neuropathy positive or negative using five standardized haemodynamic reflex tests. Area under the plasma paracetamol concentration time curve in the neuropathy positive (10.36 (4.5) mmol.-1. min) and negative (9.84 (3.0) mmol.-1. min) groups were similar (.P.=0.42) using unpaired Student's.t. -tests. Glycosylated haemoglobin concentration and area under the plasma paracetamol concentration time curve (.n.=16) demonstrated a Pearson's correlation co-efficient of 0.24. Neither tests of haemodynamic autonomic function, nor concentration of glycosylated haemoglobin, are predictive of diabetic gastroparesis.

Assessment of HER2 status in breast cancer: why, when and how?

Human epidermal growth factor receptor 2 (HER2) is overexpressed, usually as a result of HER2 proto-oncogene amplification, in 20-30% of breast cancers. A HER2-positive status is generally associated with more aggressive disease and a worse prognosis. Furthermore, a positive HER2 status may predict the likelihood of resistance to some conventional therapies, as well as probably being predictive of sensitivity to anthracycline dose intensification. In addition to this prognostic/predictive value, HER2 is a target for specific therapy, with anti-HER2 monoclonal antibody therapy available in the USA. This article reviews the different assays used to determine HER2 status, discussing their relative advantages/disadvantages and the need for their standardisation before integration alongside other pathological indices into the clinical management of breast cancer.

Vitamin E supplementation in hyperlipidaemic patients: effect of increasing doses on in vitro and in vivo low-density lipoprotein oxidation

BACKGROUND

Vitamin E supplementation is associated with a reduced risk of developing atherosclerotic events; probably because it inhibits low-density lipoprotein (LDL) oxidation, an initial step in atherosclerosis. Metal ion-dependent LDL oxidation is a commonly used method to estimate oxidizability of LDL, but the effect of antioxidant supplementation on the levels of autoantibodies to oxidised LDL (ox-LDL), an in vivo indicator of LDL oxidation, is unknown.

DESIGN

This double-blind, placebo-controlled study investigated the susceptibility of LDL to copper induced oxidation and malondialdehyde (MDA) derivatized-LDL (MDA-LDL) in hyperlipidaemic patients on supplements of vitamin E. The vitamin E group (n = 20) took vitamin E 100 IU daily and the dose was doubled at six-weekly intervals to 1600 IU daily. The control group (n = 17) received placebo in the same fashion. Blood samples were obtained at baseline and each subsequent visit to measure vitamin E status and oxidation of LDL.

RESULTS

A significant increase in both alpha-tocopherol levels and the lengths of lag phase was seen in the vitamin E group after first week of supplementation (100 IU day-1). This continued to rise in a dose-dependent fashion with a doubling of the lag phase on 1600 IU daily. However, the titre of antibodies to MDA-LDL was not altered.

CONCLUSIONS

The results suggest that although regarded as an in vivo marker of LDL oxidation, antibodies to MDA-LDL may not be a suitable measure to evaluate the effect of short-term antioxidant supplementation. The failure of autoantibody titres to fall despite reduced oxidizability of LDL may possibly be attributable to a long half-life of the antibody or, once initiated, a continuous immunological response to ox-LDL contained in atherosclerotic lesions of the arterial wall.

4-Chlorobenzyl sulfonamide and sulfamide derivatives of histamine homologues: the design of potent histamine H3 receptor antagonists

4-Chlorophenylmethanesulfonamide and (4-chlorobenzyl)sulfamide derivatives of histamine homologues were prepared and found to be potent and selective histamine H3 receptor antagonists. High receptor affinity and low differences in the data from the bioassays were achieved with the imidazol-4-ylbutyl analogues.

Delayed postoperative gastric emptying following intrathecal morphine and intrathecal bupivacaine

PURPOSE

A decrease in the rate of gastric emptying can delay resumption of enteral feeding, alter bioavailability of orally administered drugs, and result in larger residual gastric volumes, increasing the risk of nausea and vomiting. We compared the effects of 1) intrathecal bupivacaine (17.5 mg) and 2) the combination of intrathecal morphine (0.6 mg) and intrathecal bupivacaine (17.5 mg) on the rate of gastric emptying in patients undergoing elective hip arthroplasty.

METHODS

Twenty four fasting ASA 1-3 patients were randomly assigned, in a double blind manner, to receive intrathecal hyperbaric bupivacaine (17.5 mg), either alone (group 1), or followed by intrathecal morphine (0.6 mg) (group 2). Gastric emptying was measured (using an acetaminophen absorption technique), twice in each patient; preoperatively, and approximately one hour postoperatively. Gastric emptying parameters are: AUC (area under the plasma acetaminophen concentration time curve), maximum plasma acetaminophen concentration (Cmax), and time to Cmax (tCmax), analyzed using paired Student's t tests.

RESULTS

Gastric emptying rates were reduced in both group 1 (AUC = 14.98 (3.8) and 11.05 (4.6) pre- and postoperatively, respectively) and group 2 (AUC = 13.93 (3.59) and 6.4 (3.42) pre- and postoperatively, respectively); the magnitude of the reduction was greater in group 2 [AUC (P = 0.04), Cmax (P = 0.05), tCmax (P = 0.13)].

CONCLUSION

The combination of intrathecal morphine (0.6 mg) and intrathecal bupivacaine (17.5 mg) delays gastric emptying postoperatively.

Combined oestrogen-progestogen replacement therapy does not inhibit low-density lipoprotein oxidation in postmenopausal women

AIMS

The use of oestrogen containing hormone replacement therapy (HRT) is related to a significantly reduced atherosclerotic cardiovascular risk in postmenopausal women. Oestrogen is thought to be antioxidant and may inhibit low-density lipoprotein (LDL) oxidation in vitro. We investigated the effect of combined oestrogen and progestogen HRT on LDL oxidation in postmenopausal women.

METHODS

Eighteen healthy women were given oestrogen/progestogen, and the susceptibility of LDL to oxidation was measured as the level of autoantibody to oxidative modified LDL and the production of conjugated dienes during copper-dependent oxidation after 3 and 6 months HRT. The levels of vitamin E, the major antioxidant in LDL, were also measured.

RESULTS

After HRT, the anti-oxidatively modified LDL antibody level remained unchanged [1.58+/-0.16, 0.10 (-0.10, 0.26), and 0.08 (-0.09, 0.19), mean+/-s.d. at baseline, and mean change with 95% confidence intervals for differences at 3 and 6 months, respectively, P>0.05] as did the production of conjugated dienes when determined as lag phase [51.2+/-7.5, -0.3 (-3.9, 3.3), and 1.5 (-3.4, 6.4) min, P>0.05]. The LDL vitamin E content, measured as alpha-tocopherol, was also not altered [2.34+/-0.54, -0.07 (-0.27, 0.13), and -0.07 (-0.33, 0.16) nmol mg(-1) LDL, P>0.05] by treatment.

CONCLUSIONS

Combined oestrogen and progestogen therapy for 6 months in postmenopausal women does not protect LDL against oxidation.

Effect of anxiety on the rate of gastric emptying of liquids

The efficacy of preoperative fasting is reduced in the presence of any factor which delays gastric emptying. We examined the association between anxiety and gastric emptying in adult patients undergoing elective surgery. Immediately before operation, 21 patients completed both a Spielberger state trait inventory (used to quantify current anxiety state (STAIs) and anxiety predisposition (STAIt)), and the Amsterdam preoperative anxiety and information scale (used to quantify anxiety and need for information). Gastric emptying was measured using the paracetamol absorption technique. Four to 10 weeks later, gastric emptying and STAI were measured again. Patients were more anxious before than after operation (STAIs = mean 35.4 (SD 10.9) and 25 (4.1), respectively; P = 0.0004). Neither anxiety state (P = 0.40) nor measures of anxiety relative to anxiety predisposition (P = 0.86) influenced gastric emptying (as measured by area under the paracetamol absorption-time curve). This contrasts with previous findings that anxiety in patients with low anxiety predisposition scores delays gastric emptying.

Epidemiology of cerebral palsy in England and Scotland, 1984-9

AIMS

To report on the epidemiology of cerebral palsy in England and Scotland, to provide information on the prevalence of cerebral palsy and the severity of the disability or any co-morbidity.

METHODS

Cerebral palsy registers were compiled from multiple sources of ascertainment covering all of Scotland and the counties of Merseyside, Cheshire, Berkshire, Buckinghamshire, Northamptonshire and Oxfordshire in England. All cases of cerebral palsy born in 1984 to 1989, to mothers resident in the area, were included. Denominator number of live births and neonatal deaths for determining birthweight specific prevalence were obtained from birth and death registrations. Learning, manual, and ambulatory disabilities were graded for severity. Any co-existing sensory (hearing or visual) morbidity was also graded for severity.

RESULTS

There were 789,411 live births in 1984-9, with 3651 neonatal deaths (neonatal mortality 4.6 per 1000 live births) and 1649 cases of cerebral palsy--a cerebral palsy prevalence of 2.1 per 1000 neonatal survivors. The birthweight specific cerebral palsy prevalence ranged from 1.1 per 1000 neonatal survivors in infants weighting > or = 2500 g to 78.1 in infants weighing < 1000 g. There was no significant time trend in prevalence of cerebral palsy in any of the birthweight groups, in contrast to the fall in neonatal mortality observed in all birthweight groups. Of the 1649 cases of cerebral palsy, 550 (33.4%) had severe ambulatory disability (no independent walking), 390 (23.7%) had severe manual disability (incapable of feeding or dressing unaided), 381 (23.1%) had severe learning disability (IQ < 50), 146 (8.9%) had severe visual disability (vision < 6/60 in the better eye) and 12 had severe hearing disability (> 70 dB loss).

CONCLUSIONS

Registers fill an important gap left by the lack of routine data on the prevalence of disability in children. The ability to record trends in the prevalence and the severity of the disability should inform those who have responsibility for providing services for children with disabilities.

The effect of pharmacological supplementation with vitamin C on low-density lipoprotein oxidation

AIMS

Vitamin C (ascorbic acid) is a powerful antioxidant but there is limited information on its ability to prevent LDL oxidation and its interaction with other natural antioxidants in vivo. We assessed the effect of 4 weeks pharmacological supplementation with vitamin C 1 g day(-1) on copper induced LDL oxidation and lipid peroxidation.

METHODS

Blood samples were obtained at baseline and at the end of 4 weeks supplementation from 11 healthy non-smokers and also from nine control subjects. Plasma lipid peroxides were measured as malondialdehyde (MDA) by h.p.l.c. The relationship between vitamin C and two other important antioxidants, vitamin E and glutathione, was also studied.

RESULTS

There was no difference in baseline values between the two groups and the oxidizability of LDL, assessed as the lag phase of conjugated dienes production and the formation of thiobarbituric acid reactive substances (TBARS), remained unchanged after 4 weeks. In the vitamin C supplemented group only, there was a 2.2-fold increase in plasma ascorbic acid level and a 28% increase in red cell reduced glutathione (GSH) (P<0.001). Vitamin E, measured as alpha-tocopherol, in red cells increased significantly (P<0.02) and plasma MDA was reduced (P<0.01).

CONCLUSIONS

Vitamin C did not alter LDL oxidation but it may have a protective role against lipid peroxidation as shown by decreased plasma MDA levels and enhanced vitamin E and GSH status.

The changing epidemiology of cerebral palsy

AIM

To determine the prevalence of cerebral palsy in a specific population.

METHODS

Multiple sources of ascertainment were used to create and maintain a register of all cases of cerebral palsy born to mothers resident in the counties of Merseyside and Cheshire in the years 1966 to 1989. Denominator data of infant births and deaths from 1966 to 1981 were obtained from statutory notifications made to health authorities and, for the period 1982-89, from statutory birth and death registrations. Over 1500 cases formed the database for the study.

RESULTS

The prevalence of cerebral palsy has increased among all the low birthweight groups with, most recently, an increase in infants weighing < 1000 g at birth. Low birthweight infants now comprise about 50% of all cases of cerebral palsy; in the early years of the study they comprised about 32% of all cases. The proportion of cerebral palsy by clinical type has changed among low birthweight babies, with relatively fewer cases with diplegia and a concomitant increase in the proportion with hemiplegia. An increase in the severity of functional disability, determined by the proportion of children with severe learning, manual, and ambulatory disabilities, was also found.

CONCLUSIONS

The change in the epidemiology of cerebral palsy has implications for the aetiology of the condition, and for health, educational, and social service provision.

Cerebral palsy and multiple births

AIM

To compare the birthweight specific prevalence of cerebral palsy in singleton and multiple births.

METHODS

Registered births of babies with cerebral palsy born to mothers resident in the counties of Merseyside and Cheshire during the period 1982 to 1989 were ascertained.

RESULTS

The crude prevalence of cerebral palsy was 2.3 per 1000 infant survivors in singletons, 12.6 in twins, and 44.8 in triplets. The prevalence of cerebral palsy rose with decreasing birthweight. The birthweight specific prevalence among those of low birthweight < 2500 g was not significantly different in singleton than in multiple births. Among infants weighing > or = 2500 g, there was a significantly higher risk in multiple than in singleton births. The higher crude cerebral palsy prevalence in multiple births is partly due to the lower birthweight distribution and partly due to the higher risk among normal birthweight infants.

CONCLUSIONS

Multiple birth babies are at increased risk of cerebral palsy. There is also an increased risk of cerebral palsy within a twin pregnancy if the co-twin has died in utero.

Advanced life support: role of the rural registered nurse

This paper provides a human face to advanced life support (ALS) and its assention within rural nursing practice. Over the past 5 years the issue of defibrillation and who performs it has been debated. This paper will add to the discussion. It examines the history surrounding the development of ALS, education within the hospital and isolated rural setting competency testing. It questions the limited role of current nursing practice and makes recommendations for stretching the boundaries of the nursing role in ALS. Emphasis is placed on the rural perspective and its consequent implications for individuals living in a rural environment.

Increasing hepatic arterial flow to hypovascular hepatic tumours using degradable starch microspheres

The effect of degradable starch microspheres (DSM) on the intrahepatic distribution of a low molecular weight marker, 99Tcm-labelled methylene diphosphonate (MDP), was studied in rats with hypovascular HSN liver tumours. MDP was injected regionally, via the hepatic artery, alone or co-administered with DSM, with or without subsequent occlusion of either the hepatic artery or the portal vein. Tumour vascularity was measured with 57Co-labelled microspheres. Co-injection with DSM immediately significantly increased hepatic retention of marker in both tumour (T) (median 22.40 (range 16.82-39.58)% injected dose) and normal liver (N) (9.08 (4.85-12.59) %ID) the greater effect seen in T (P < 0.01). After DSM degradation, very little MDP remained in N (0.61 (0.28-1.40) %ID) but there was significant retention in T (10.01 (6.73-20.28) %ID, P < 0.01). Clamping the hepatic artery had minimal effect on the retention of MDP when administered alone. Regional injection of 16.5 microM 57Co microspheres resulted in a N:T ratio of 2.25:1. Concomitant injection of the 40 microM DSM was 57Co microspheres reversed this ratio to 1:2. The results indicate that DSM selectively enhances the retention of MDP to a hypovascular hepatic tumour, not by causing intra-tumour stasis, but by directing a greater arterial flow to hypovascular areas in the liver.

Growth inhibition of gastric cancer cell lines by the tyrphostin RG13022 and its effects on intracellular signalling

Overexpression of EGFr and c-erbB-2 is related to poor prognosis in a variety of cancers including gastric cancer. Thus: the ability to modulate the functional activity of these receptors is an attractive target for diagnostic intervention. In this study we examined the effect of a well characterised tyrosine kinase inhibitor (RG13022) on the cellular proliferation and EGF activated tyrosine kinase signalling pathway of two primary gastric cell lines: MKN45 and N87. RG13022 has a dose dependent, antiproliferative effect on both gastric cell lines when grown either in serum-free conditions or in the presence of FCS. Western blotting revealed RG13022 caused an inhibition of EGF stimulated tyrosine phosphorylation of EGFr in A431 cells and both EGFr and c-erbB-2 in MKN45 cells. No clear modulation of EGFr or c-erbB-2 phosphorylation was observed in N87 cells. In both A431 cells and N87 cells (which overexpress EGFr and c-erbB-2 respectively) exposed to EGF, MAP2 kinase immunoblot analysis resulted in the detection of a second protein band with reduced migration in SDS-PAGE. In N87 cells, this protein appeared to co-mi,orate with a strongly tyrosine phosphorylated protein, which suggests that it is a hyper-phosphorylated form of MAP2 kinase. However, treatment with RG13022, whilst inhibiting phosphorylation of this protein, did not prevent a shift in gel mobility (suggestive of activation) of MAP2 kinase in response to EGF. These findings demonstrate that the tyrphostin RG13022 inhibits cell proliferation of two primary gastric cancer cell lines. Investigation of intracellular signalling pathways suggests that alterations in intracellular signalling are responsible for the actions of RG 13022 in these cells. The biochemical analysis revealed that in N87 and A431, cells which overexpress c-erbB-2 and EGFr respectively, the tyrphostin affects the MAP2 kinase immunoreactivity and migration on SDS gels but fails to affect this protein in the MKN45 cell line. This data questions the usefulness of MAP2 kinase gel shift assays as markers of activation but supports the further development of tyrosine kinase inhibitors as potential inhibitors of gastric tumour proliferation.

Cholesterol and lipoprotein (a) levels in psoriasis

Psoriasis is a common condition in the western world, but is uncommon in populations with a low prevalence of atherosclerosis such as Japanese, Blacks and indigenous North Americans. Psoriasis appeared to be more prevalent amongst patients attending our lipid clinic compared to the general population. Lipoprotein (a) (Lp(a)) is elevated in conditions such as coronary heart disease and protein loosing nephropathies. Psoriasis is a condition of increased epidermal protein turnover and loss and thus it might be postulated that increased levels of Lp(a) may be found in patients with psoriasis. The aim of this study was to explore an association between psoriasis and Lp(a) and lipid profiles. No association was found between Lp(a) concentrations and psoriasis. Although six of 36 patients were found to have a cholesterol greater than 7.5 mmol L-1, the mean cholesterol for this group was not elevated.

C-erbB-2 gene amplification: a molecular marker in recurrent bladder tumors?

C-erbB-2 gene amplification and protein overexpression have been implicated as prognostic markers for patients with recurrent progressive bladder tumors. This event has been investigated as a potential diagnostic indicator in archival samples of transitional cell carcinoma of the bladder. Two hundred thirty-six bladder tumors from 89 patients with recurrent disease (mean follow-up, 4 years), 20 tumors from patients with no evidence of bladder tumor recurrence (mean follow-up, 7 years) and 10 normal bladder controls (patients with no history of transitional cell carcinoma) were studied. A differential PCR was used to provide a semiquantitative estimate of C-erbB-2 gene amplification. Protein overexpression was assessed immunohistochemically. Sixteen of 89 patients with recurrent disease had evidence of C-erbB-2 gene amplification. No C-erbB-2 gene amplification was seen in the nonrecurrent tumors or normal bladder controls. Of the 89 patients with recurrent bladder tumors, 43 had evidence of progressive disease, and of these, 14 patients exhibited C-erbB-2 gene amplification, indicating a strong association with gene amplification and progressive disease (P < 0.0005). Gene amplification in these patients was seen only after disease progression had occurred. Protein overexpression was seen in 50% of patients with recurrent and 45% of patients with nonrecurrent disease. No protein overexpression was seen in normal controls. Protein overexpression could not be linked to disease progression. C-erbB-2 gene amplification and protein overexpression were of predictive value in multivariate analysis for overall bladder cancer death; however stage and grade remained the most important independent prognostic variables. C-erbB-2 gene amplification and protein overexpression were of no value as independent markers for the prediction of disease recurrence or progression. It appears from these results that the role of C-erbB-2 as a diagnostic marker may far outweigh its usefulness as a prognostic indicator.

Patient acceptance of day surgery

There were 463 patients treated in the initial 12-month period of a general surgical day service. A comprehensive audit was instituted in order to monitor patient acceptability and outcome of the service. There was a high level of patient satisfaction with the service, pain control, anaesthesia, patient information, medical and nursing care and ward privacy. A reduction in the wound complication rate was achieved when operations were performed by senior registrars. A reduction in the wound complication rate and provision of dedicated facilities were responsible for the improved successful discharge and readmission rates. The provision of a safe and acceptable day surgery service has been facilitated by audit.

Life expectancy in children with cerebral palsy

OBJECTIVE

To determine life expectancy of children with cerebral palsy.

DESIGN

Cohort analysis, by means of register compiled from multiple sources of ascertainment, of all children with cerebral palsy born during 1966-84 to mothers resident in Mersey region. Status of children was determined by flagging through NHS central register.

SUBJECTS

1258 subjects with idiopathic cerebral palsy, of whom 1251 were traced and included in analysis.

MAIN OUTCOME MEASURES

Effect of functional ability (ambulation, manual dexterity, and mental ability), sex, birth weight, and gestational age on survival.

RESULTS

20 year survival for whole cohort was 89.3% for females and 86.9% for males. For subjects with no severe functional disabilities 20 year survival was 99% (95% confidence interval 98% to 100%), while subjects severely disabled in all three functional groups had 20 year survival of 50% (42% to 58%). Subjects with birth weight < or = 2500 g had 20 year survival of 92% (89% to 95%), while those with birth weight > 2500 g had survival of 87% (84% to 89%). Subjects with gestational age of > 37 weeks had 20 year survival of 93% (91% to 96%), while those with gestational age > or = 37 weeks had survival of 85% (83% to 88%). Birth weight and gestational age were less predictive of survival than functional disability. Best statistical model used gestational age and number of severe functional disabilities as predictors.

CONCLUSIONS

Life expectancy of this cohort of children with cerebral palsy was greater than has been suggested in some previous studies. This has important implications for social, educational, and health services.

Lipoprotein(a) in restenosis after percutaneous transluminal coronary angioplasty and coronary artery disease

BACKGROUND

The purpose of the study was to investigate the relation of lipoprotein(a) and serum lipid parameters to restenosis after percutaneous transluminal coronary angioplasty (PTCA) and to assess the association of these same biochemical markers to coronary artery disease (CAD) in individuals with angiographically defined normal and diseased coronary arteries.

METHODS AND RESULTS

Sixty-two patients with successful PTCA had follow-up angiography at 35 +/- 10 weeks. Restenosis occurred in 21 male patients (46%) and 6 female patients (38%). Elevated apolipoprotein B (P < .01) and decreased high-density lipoprotein-2 cholesterol (P < .02) were found to be independently associated with restenosis after angioplasty, whereas lipoprotein(a) was not. Eighty-five patients undergoing PTCA were compared with 46 subjects who had no evidence of CAD on angiography. Elevated lipoprotein(a) (P < .001) and reduced apolipoprotein A1 to B ratio (P < .001) were found to be strong independent risk factors for the presence of CAD when adjustment was made for age (P < .005), male sex (P < .01), smoking (P < .005), and hypertension (P = .06).

CONCLUSIONS

Serum lipoprotein(a) levels are not associated with restenosis after PTCA, but elevated levels are strongly associated with CAD. Low-serum, high-density lipoprotein-2 cholesterol concentration and elevated apolipoprotein B concentration were found to be associated with restenosis after PTCA.

Lipoprotein(a) and treatment of chronic renal disease

OBJECTIVES

To compare lipoprotein(a) [Lp(a)] and albumin concentrations in patients with chronic renal disease receiving different forms of treatment and to determine, if any, the relationship between these variables.

DESIGN

A prospective cross-sectional, case-controlled study.

SETTING

A tertiary referral nephrology and dialysis unit.

SUBJECTS

Forty-four consecutive non-diabetic patients with chronic renal failure treated by renal transplantation (n = 18), haemodialysis (n = 18), continuous ambulatory peritoneal dialysis (CAPD; n = 8), and 30 healthy controls from subjects drawn from University personnel were studied.

INTERVENTIONS

Fasting morning venous blood was analysed for Lp(a), albumin, total cholesterol and glucose concentrations.

MAIN OUTCOME MEASURES

Comparison of plasma levels of these variables between the sub-groups.

RESULTS

Concentrations (median; 95% CI) of Lp(a) were significantly (P < 0.05) higher (38.4 mg dl-1; range 15.4-72.0) and of albumin lower (31.6 g l-1; range 28-35.2) in the CAPD group compared with both control subjects and other groups of chronic renal disease patients.

CONCLUSIONS

The elevated Lp(a) concentrations seen only in association with reduced albumin concentrations in CAPD patients suggest a regulatory role for albumin with albumin losses stimulating production of Lp(a).

A comparison of 10 MHz ultrasound and 201-thallium/99m-technetium subtraction scanning in primary hyperparathyroidism

Both high resolution (10 MHz) ultrasound and 201-thallium/99m-technetium subtraction scanning (Tl/Tc) were carried out preoperatively in 25 patients with primary hyperparathyroidism. Operative findings were the standard against which these two imaging methodologies were compared. Tl/Tc scanning showed a sensitivity of 42% and a specificity of 97%. By comparison, sensitivity of ultrasound was 38% and specificity 89%. Both techniques were positive together in nine instances and correctly localized the parathyroid adenoma in eight of these. In 44% of cases, however, both methods together failed to localize any abnormal parathyroid tissue. The ability of these modalities to localize abnormal parathyroid tissue correctly tended to vary with gland size. Where both ultrasound and Tl/Tc scans were negative, median gland size was smaller at 170 mg (range 50-2,500 mg), compared with where Tl/Tc scanning was correct (750 mg, 150-6,820 mg; P < 0.03), ultrasound was correct (960 mg, 100-6,820 mg; P < 0.03) and both techniques together were correct (980 mg, 600-6,820 mg; P = 0.002). These results suggest that neither Tl/Tc scanning or ultrasound has sufficient sensitivity or specificity to be used routinely in the preoperative evaluation of patients with primary hyperparathyroidism.