Care navigation increases initiation of hepatitis C treatment following release from prison in a prospective randomised controlled trial: The C-LINK Study

Background

Prison-based hepatitis C treatment is safe and effective; however, many individuals are released untreated due to time or resource constraints. On community re-entry, individuals face a number of immediate competing priorities, and in this context, linkage to hepatitis C care is low. Interventions targeted at improving healthcare continuity after prison release have yielded positive outcomes for other health diagnoses; however, data regarding hepatitis C transitional care are limited.

Methods

We conducted a prospective randomized controlled trial comparing a hepatitis C care navigator intervention with standard of care for individuals released from prison with untreated hepatitis C infection. The primary outcome was prescription of hepatitis C direct-acting antivirals (DAA) within 6 months of release.

Results

Forty-six participants were randomized. The median age was 36 years and 59% were male. Ninety percent (n = 36 of 40) had injected drugs within 6 months before incarceration. Twenty-two were randomized to care navigation and 24 were randomized to standard of care. Individuals randomized to the intervention were more likely to commence hepatitis C DAAs within 6 months of release (73%, n = 16 of 22 vs 33% n = 8 of 24, P < .01), and the median time between re-entry and DAA prescription was significantly shorter (21 days [interquartile range {IQR}, 11–42] vs 82 days [IQR, 44–99], P = .049).

Conclusions

Care navigation increased hepatitis C treatment uptake among untreated individuals released from prison. Public policy should support similar models of care to promote treatment in this high-risk population. Such an approach will help achieve hepatitis C elimination as a public health threat.

O-249 The impact of semen parameters on ICSI and pregnancy outcomes in egg recipient cycles with PGT-A

Study question

To assess the effect of male factor on ICSI and pregnancy outcomes in egg recipient cycles combined with preimplantation aneuploidy testing

Summary answer

In egg donor cycles where sperm was obtained from azoospermic men there was a significant effect on ART and clinical outcomes.

What is known already

The increased incidence of chromosomal problems in men with azoospermia and its correlation with chromosomally abnormal embryos and with adverse pregnancy outcomes has been shown by multiple studies. Nevertheless, few studies in the literature outline the impact of non-obstructive azoospermia in the subgroup of couples who opt to use donated eggs.

The egg donation model offers an opportunity to isolate the male factor and evaluate its impact on IVF-ICSI and pregnancy outcomes.

The aim of our study was to study the effect of non-obstructive azoospermia(NOA) on ICSI outcomes compared with oligoasthenozoospermia(OATS) and moderate male factor(MMF) infertility, from ART parameters to clinical outcomes.

Study design, size, duration

This is a retrospective longitudinal cohort study involving 1,594 ICSI cycles using donor eggs performed between January 2016 and May 2020.

The cohort was divided into three groups according to the male partner’s sperm parameters: couples with NOA accounting for 479 cycles (30%); couples with OAT-S (sperm number &lt;5 x 106/ml), accounting for 442 cycles (27.8%); couples with moderate male factor, with sperm number &gt;_5 x 106/ml and &lt;15 x 106/ml, accounting for 673 cycles (42.2%).

Participants/materials, setting, methods

Participants:

Subfertile couples who opted to use donor eggs. Donor eggs were utilized, due to history of severe female infertility, including low ovarian reserve, poor response to ovarian stimulation, repeated IVF failures or premature ovarian failure.

Setting:

Private IVF Unit

Intervention:

ICSI with ejaculated/surgically retrieved sperm, blastocyst culture, PGT-A and frozen-thawed euploid embryo transfer.

Outcomes:

The primary outcomes were live birth, fertilization, blastocyst development and euploidy rates; the secondary outcomes were clinical pregnancy, miscarriage rates, preterm labour and SGA.

Main results and the role of chance

The fertilization rate was significantly reduced in the NOA group as compared to the OATS and the MMF group: 30.3% versus 63% and 77.3%. Logistic regression analysis adjusted for confounders highlighted NOA as a negative predictor of obtaining an euploid blastocyst per inseminated oocyte. When the analysis was performed per obtained blastocyst, no correlation between male factor and euploidy rate was observed.

The clinical pregnancy rates were similar in the MMF and OATS group, but significantly lower in the NOA group (38.2% versus 36.3% and 29.5% respectively). The miscarriage rate in the NOA group was 11.8%; higher than the OATS and MMF group (7% and 2.7%). The live birth rate per ET was significantly lower in the NOA group compared to the OATS and the MMF group (20.4% vs 30.3% and 35.4%,p&lt;0.05). The live birth rate was significantly lower in the OATS group compared to the MMF group(p &lt; 0.05).

The risk of preterm labour was significantly higher in the NOA group, compared to the OATS and MMF group (55.1% versus 46.8 and 16.1%,p&lt;0.001) and a higher number of babies born with a birth weight &lt;2.5kg came from the NOA group, compared to the OATS and MMF group (34% versus 19.8% and 12.2%, p &lt; 0.001).

Limitations, reasons for caution

The present study is limited by its retrospective design and the fact that the confounding factors of advanced maternal age, endometrial ageing and uterine factors cannot be fully evaluated. However, the study was controlled for female and male partner's age. Neonatal outcomes were not available.

Wider implications of the findings

Non-obstructive azoospermia can impair early embryonic potential and reduce live birth rates. Our study also shows an association between NOA and preterm birth. Future research should focus on prospective collection of data and long-term follow up of babies born by fathers with non-obstructive azoospermia.

Trial registration number

Not applicable

Wolf Rock lighthouse: past developments and future survivability under wave loading

Lighthouses situated on exposed rocky outcrops warn mariners of the dangers that lurk beneath the waves. They were first constructed when approaches to wave loading and structural response were relatively unsophisticated, essentially learning from previous failures. Here, we chart the evolution of lighthouses on the Wolf Rock, situated between Land's End and the Isles of Scilly in the UK. The first empirical approaches are described, followed by design aspects of the present tower, informed by innovations developed on other rocky outcrops. We focus on a particular development associated with the automation of lighthouses: the helideck platform. The design concept is described and the structure then scrutinized for future survivability, using the latest structural modelling techniques of the entire lighthouse and helideck. Model validation data were obtained through a complex logistical field operation and experimental modal analysis. Extreme wave loading for the model required the identification of the 250-year return period wave using a Bayesian method with informative prior distributions, for two different scenarios (2017 and 2067). The structural models predict responses of the helideck to wave loading which is characterized by differential displacements of 0.093 m (2017) and 0.115 m (2067) with associated high tension forces and plastic strain. This article is part of the theme issue 'Environmental loading of heritage structures'.

Robot-assisted resection of ectopic kidney in children: An anatomical illustration

INTRODUCTION

Failure of kidney migration during embryonic life results in an ectopic kidney, with an incidence varying from 1 in 500 to 1 in 1200. Pelvic kidney can be a rare cause of recurrent urinary tract infection (UTI), warranting nephrectomy in some cases.

MATERIAL AND METHODS

A 7-year-old girl with a history of recurrent UTIs and vaginal discharge was diagnosed with a dysplastic afunctional ectopic kidney located in the pelvis, with ureter draining into the cervix or vaginal wall.

RESULTS

A robot-assisted approach was chosen, with side docking of the robot to allow concurrent vaginoscopic/hysteroscopic exploration. A uterus bicornis was found. The ectopic ureter was dissected toward its drainage in the vaginal wall, where it was sutured and resected. The dysplastic kidney and ureter were removed. Compared to pure laparoscopic approach, dissection deep into the pelvis toward the vaginal wall is aided by the robotic dexterity and facilitates complete resection of the structure, which avoids leaving a ureteric stump into the vaginal wall.

CONCLUSIONS

Robot-assisted surgery is a safe and effective option for resection of ectopic kidneys with ectopic ureter in children. Dissection up until the vaginal wall in children is aided by robotic dexterity, making this kind of surgery the ideal indication for robotic-assisted surgery.

Avoiding hypoglycemia: the use of insulin pump combined with continuous glucose monitor in type 1 diabetes crossing a Rocky Gorge

BACKGROUND

Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring systems (CGMS) have been proven very effective in diabetes management.

AIM

This study evaluated the usefulness of these devices during prolonged, intense physical activity in an uncontrolled natural environment away from the clinical research center.

DESIGN

Non-randomized, prospective and observational study.

METHODS

During the summer, 38 participants with type 1 diabetes crossed the Samaria gorge, the second largest gorge in Europe (17 km). Twenty subjects on CSII combined with real-time CGMS and 18 on multiple daily injections (MDI) combined with professional (retrospective) CGMS participated in the program. All participants were unsupervised during the event.

RESULTS

All 38 participants managed to reach the destination point safely. There were no episodes of severe hypoglycemia. The duration of the exercise (mean ±SD) was 6.4 ± 1.3 h. The CSII group exhibited significantly lower hypoglycemic episodes during exercise (0.1 ± 0.3 vs. 0.4 ± 0.6; P = 0.047) as well as lower AUC below 70 mg/dl compared with the MDI, during the 24 h (0.61 ± 0.78 vs. 1.84 ± 1.55; P = 0.007). Individuals on CSII were significantly less likely to develop a hypoglycemic episode during exercise (P = 0.038). Exercise induced nocturnal hypoglycemia was not prevented effectively in neither group.

CONCLUSIONS

CSII combined with CGMS is effective in controlling blood glucose levels in type 1 diabetics who perform prolonged strenuous exercise. The use of insulin pump technology in regions with hot Mediterranean climates is safe and can provide protection against exercise-induced hypoglycemia. Development of precise instructions for T1DM who occasionally get involved in exercise activities, requires further studies.

Prospective research on infants with mild encephalopathy: the PRIME study

OBJECTIVE

To determine short-term outcomes of infants with evidence of hypoxia-ischemia at birth and classified as mild neonatal encephalopathy (NE) at <6 h of age.

STUDY DESIGN

Prospective multicenter study. Mild NE was defined as ⩾1 abnormal category in modified Sarnat score. Primary outcome was any abnormality on early amplitude integrated electroencephalogram (aEEG) or seizures, abnormal brain magnetic resonance imaging (MRI) or neurological exam at discharge.

RESULTS

A total of 54/63 (86%) of enrolled infants had data on components of the primary outcome, which was abnormal in 28/54 (52%): discontinuous aEEG (n=4), MRI (n=9) and discharge exam (n=22). Abnormal tone and/or incomplete Moro were the most common findings. MRI abnormalities were confined to cerebral cortex but two infants had basal ganglia and/or thalamus involvement. The 18 to 24 months follow-up is ongoing.

CONCLUSIONS

A larger than expected proportion of mild NE infants with abnormal outcomes was observed. Future research should evaluate safety and efficacy of neuroprotection for mild NE.

Role of lymphatic vessel density in colorectal cancer: prognostic significance and clinicopathologic correlations

BACKGROUNDS AND AIMS

Over the past decades the identification of several molecules that are expressed specifically in the lymphatic endothelial cells has resulted in marked advances in the field of lymphangiogenesis. We aimed to measure LVD in colorectal cancer patients and to compare it with microvascular density (MVD) - a marker of angiogenesis - and patients' clinicopathological parameters and survival, as the measurement of lymphatic vessel density (LVD) has been documented in various tumor types, including colorectal cancer.

PATIENTS AND METHODS

Fifty one patients who had undergone surgical resection for stage I-III colorectal cancer entered this study. LVD and MVD were determined immunohistochemically with the use of D2-40 and CD34 antibody respectively. The evaluation of LVD was performed by both visual and computer-aided image analysis.

RESULTS

The majority of lymphatic vessels were located in the peritumoral areas rather than within the tumor. The results obtained from the image analyzer correlated significantly with the data obtained using visual counting with light microscopy. Both visual and image analysis LVD failed to correlate with patients' age and gender and tumor location, stage, grade, MVD count and survival.

CONCLUSIONS

The biologic role of the lymphatic vasculature in tumor progression remains controversial. The present study failed to associate LVD with outcome markers and prognosis and further studies would be required to verify our results.

Assessing personality traits by questionnaire: psychometric properties of the Greek version of the Zuckerman-Kuhlman personality questionnaire and correlations with psychopathology and hostility

BACKGROUND

The Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) was developed in an attempt to define the basic factors of personality or temperament. We aimed to assess the factor structure and the psychometric properties of its Greek version and to explore its relation to psychopathological symptoms and hostility features.

METHODS

ZKPQ was translated into Greek using back-translation and was administered to 1,462 participants (475 healthy participants, 619 medical patients, 177 psychiatric patients and 191 opiate addicts). Confirmatory and exploratory factor analyses were performed. Symptoms Distress Check-List (SCL-90R) and Hostility and Direction of Hostility Questionnaire (HDHQ) were administered to test criterion validity.

RESULTS

Five factors were identified, largely corresponding to the original version's respective factors. Retest reliabilities were acceptable (rli's: 0.79-0.89) and internal consistency was adequate for Neuroticism-Anxiety (0.87), Impulsive Sensation Seeking (0.80), Aggression-Hostility (0.77) and Activity (0.72), and lower for Sociability (0.64). Most components were able to discriminate psychiatric patients and opiate addicts from healthy participants. Opiate addicts exhibited higher rates on Impulsive Sensation Seeking compared to healthy participants. Neuroticism-Anxiety (p<0.001) and Impulsive Sensation Seeking (p<0.001) were significantly associated with psychological distress and Aggression-Hostility was the most powerful correlate of Total Hostility (p<0.001), and Neuroticism-Anxiety was the stronger correlate of introverted hostility (p<0.001), further supporting the instrument's concurrent validity.

CONCLUSIONS

Present findings support the applicability of the Greek version of ZKPQ within the Greek population. Future studies could improve its psychometric properties by finding new items, especially for the Sociability scale.

Procalcitonin in patients with colorectal cancer

PURPOSE

Bacterial translocation (BT) is common in colon cancer patients and may be associated with increased occurrence of septic complications as well as with adverse oncologic outcomes. The aim of the present study was to correlate the BT detectable through peritoneal lavage culture or identified by abnormal inflammatory parameters with the clinicopathologic parameters and the short-term prognosis in a prospective series of patients.

METHODS

Fifty-four consecutive patients with histologically proven colorectal cancer were included in this prospective study. White blood cells (WBC), erythrocyte sedimentation rate (ESR) and serum levels of procalcitonin (PCT) and C-reactive protein (CRP) were determined and cultures from peritoneal lavage were collected immediately after laparotomy.

RESULTS

Positive PCT was detected in 31 (55.3%) patients while positive cultures were obtained in 6 (11%) patients. Significant positive correlation of PCT with inflammation markers was noticed. Patients with distant metastases had higher serum PCT levels than patients without distant metastases (p=0.01). Borderline statistical significance was found between PCT and tumor grade (p=0.09). PCT was not correlated with the cultures of the lavage or the outcome.

CONCLUSION

PCT is an adequate inflammatory marker, able to preoperatively discriminate patients with bacterial systemic inflammatory reaction due to BT. However, the clinical consequence of BT may be minimal as is shown by the lack of association of PCT or positive peritoneal lavage cultures with time to discharge, complications and short-term survival.

Clinical role of HER-2/neu expression in colorectal cancer

PURPOSE

To evaluate the HER-2/neu expression and its relationship with clinicopathological parameters and prognosis in colorectal cancer patients.

METHODS

A total of 51 colorectal cancer patients who underwent resection with curative intent from January 2005 to March 2006 were included in this study. Patients were regularly followed up and survival data were obtained as of as April 2011. HER-2/neu protein expression was evaluated from tissue samples from the primary tumor using a semiquantitative standardized immunohistochemical staining kit. Staining intensity was scored as faint (1+), weak to moderate (2+) and moderate to strong (3+).

RESULTS

Forty-nine (96.1%) patients showed 1+ staining, 2 (3.9%) 2+, while no case was strongly positive (3+) for HER-2/neu. No apparent association was noted between HER-2/neu expression and patients' age, gender, tumor location, tumor grade, stage and survival.

CONCLUSION

Moderate (2+) overexpression of HER-2/neu was detected in a small proportion of colorectal cancer patients. Considering the low rate of HER-2/neu overexpression in colorectal cancer, studies with larger sample sizes using standardized tests are essential to understanding the biologic role of HER-2/neu in this disease.

Liquid based cytology and HPV DNA testing in a Greek population compared to colposcopy and histology

Screening for cervical cancer in Greece is still unorganised and based on self- motivation. The purpose of this study was to evaluate the accuracy of cytological findings from a large observational population sample, originating from Western Athens, in association with reflex DNA test, colposcopic estimation, and final histologic diagnosis. The rate of invasive carcinoma, both squamous cell and adenocarcinoma, is indicative of a largely unscreened population. In this study, the estimated overall prevalence of human papilloma virus (HPV) was 41.1%, with HPV positivity at 37.4% of cytologically normal women. HPV testing did not seem to improve sensitivity of cytology for atypical squamous cells of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LGSIL) cases in identifying CIN 2+ lesions, but outperformed cytology in detecting CIN3+ for cytological high-grade squamous intraepithelial lesion (HGSIL) cases. For HGSIL cases sensitivity of colposcopy for detecting CIN3+ was comparable to cytology.

Impact of 'targeted' fluconazole prophylaxis for preterm neonates: efficacy of a highly selective approach?

OBJECTIVE

The objective of this study was to evaluate the efficacy of targeted intermittent fluconazole prophylaxis (FP) to high-risk preterm (PT) infants.

STUDY DESIGN

Observational pre-post cohort study (n=524). Targeted FP (3  mg  kg(-1)) was administered to PT infants (birth weights <1500  g and <6 weeks of age) who received broad-spectrum antibiotics for more than 2 days and had at least one additional risk factor for invasive candidiasis during the antibiotic administration period.

RESULT

Invasive candidiasis decreased significantly from 15.3 to 6.2% during the FP period. Duration of parenteral nutrition (15.5 vs 19.2 days), central line (12.7 vs 15.8 days) and necrotizing enterocolitis rates (7 vs 9.5%) were significantly higher in the FP period. FP was administered to 89 (31.3%) infants; the median (range) number of doses was four (1 to 24) and duration was 7 (1 to 38) days.

CONCLUSION

In the current study, targeted intermittent FP to a selected population of PT infants was efficacious in reducing the rate of invasive candidiasis, compared with historical controls.

Constipation-predominant irritable bowel syndrome associated to hyperprolactinemia

Irritable bowel syndrome (IBS) is considered to be a physical disorder that mainly affects the bowel and is clinically characterized by lower abdominal pain or discomfort, diarrhea, constipation (or alternating diarrhea/constipation), gas, bloating, and nausea. According to recent studies, it appears that there is an association with increased prolactin levels in patients suffering from IBS. We report a rare case of regression of IBS symptoms (constipation type) in a 16-year-old female adolescent after receiving cabergoline for treating hyperprolactinemia due to pituitary macroadenoma. Our hypothesis is that increased prolactin levels, for instance due to a pituitary adenoma, may suppress prolactin-releasing peptide release and lead to a reverse feedback interaction, consequently resulting in oversecretion of cholecystokinin, inducing the development of IBS.

The value of TOP2A, EZH2 and paxillin expression as markers of aggressive breast cancer: relationship with other prognostic factors

INTRODUCTION

The immunocytochemical expression of topoisomerase II alpha (TOP2A), enhancer of zeste homologue 2 (EZH2) and paxillin has recently gained increasing attention. Although previous studies have commented on the clinical usefulness of these markers, their role remains controversial.

AIM

The purpose of the study was to investigate the expression of TOP2A, EZH2 and paxillin in relation to classic prognostic parameters and their significance as prognostic markers in imprints of resected breast carcinomas.

METHODS

Imprint smears from 55 patients who underwent surgical treatment for primary carcinoma in our department between 2005 and 2006 were studied immunocytochemically with the use of TOP2A, EZH2 and paxillin antibodies.

RESULTS

The expression of TOP2A correlated with higher histologic grade, tumor size and negative PR expression. High intensity staining for EZH2 expression was associated with higher histologic grade, negative ER and PR expression and positive Ki-67 expression. The expression of paxillin showed no correlation with estrogen/progesterone and HER2 expression nor with tumor grade and stage.

CONCLUSION

Our data indicate that TOP2A and EZH2 expression are related to a more aggressive tumor phenotype. The expression of paxillin failed to correlate with any of the studied clinicopathologic factors. Further studies are needed to verify these results.

Analysis of clinical and molecular associations of triple negative breast cancers in node-negative patients

INTRODUCTION

Therapeutic modalities in node-negative breast cancer patients remain a matter of controversy. Various prognostic factors have been proposed to help select those patients that would most likely benefit from adjuvant therapy. In view of this notion the triple negative phenotype (hormone receptors and HER2 negative tumors) has gained increasing attention.

AIM

To evaluate the clinicopathologic characteristics of triple negative (TN) tumors in node-negative invasive breast carcinomas.

METHODS

We retrospectively analyzed the archival pathology tissues of 160 patients with node-negative invasive carcinomas, diagnosed and treated in two surgical departments in Greece from 1999 to 2006. Statistical analysis was used to examine the association between TN tumors and other clinicopathological factors.

RESULTS

Triple negative breast cancers correlated with higher histologic grade, mitotic activation index and Ki-67 expression (p < 0.05). Moreover TN tumors were correlated with negative staining for bcl-2 (p < 0.05).

CONCLUSION

In node-negative breast cancer patients, triple negativity is associated with aggressive biologic behavior. Further studies are required to better understand the clinical implications of these findings.

The value of proliferation indexes in breast cancer

INTRODUCTION

During the past several years, the Ki-67 antigen has gathered great interest in its role as a prognostic marker. Nevertheless, despite the large number of published papers, the role of Ki-67 in clinical practice remains controversial.

AIM

To evaluate the association between Ki-67 immunoreactivity and other clinicohistopathological parameters.

METHODS

We retrospectively analyzed the archival pathology tissues of 356 patients, diagnosed and treated in our department, from 2002 to 2006. Statistical analysis was used to examine the association between Ki-67 expression and other clinicopathological factors.

RESULTS

The expression of Ki-67 was correlated with the mitotic count, tumor grade and size and p53, HER2 and EGFR expression. Furthermore Ki-67 expression was significantly related with nodal status and inversely associated with hormonal expression. Moreover, invasive carcinomas appeared to have greater proliferation values than in situ carcinomas, while invasive ductal carcinomas were correlated with higher Ki-67 expression compared to lobular cancers.

CONCLUSION

The expression of Ki-67 appears to be a valuable method of proliferation measurement that could prove helpful in clinical practice. Further research is warranted in order to standardize the methodology and to reach uniformity in regard with the optimal cut-off value.

Gastrointestinal stromal tumors of the rectum: report of five cases

We report on five patients (three males and two females), with a median age of 66.2 years (range, 58-73 years) who were admitted in our department from April 1998 until January 2004 with the diagnosis of rectal gastrointestinal stromal tumor (GIST). Their main symptoms were rectal bleeding, constipation and abdominal discomfort. Two patients were treated by an abdominoperineal resection of the rectum. One patient received palliative surgical treatment and adjuvant therapy with imatinib for metastatic disease. Another patient presented with complete rectal prolapse, and was treated with Delorme's procedure. The subsequent pathological examination of the resected specimen showed positive resection margins and was given adjuvant therapy with imatinib. Finally, one case was considered inoperable. However, after nine months of treatment with imatinib, the magnetic resonance imaging (MRI) scan revealed a significant reduction in the tumor size, and the patient was treated with abdominoperineal excision of the rectum. All cases have been proved to be immunohistochemically positive for the CD117 and the CD34 stain. During the follow-up period (mean duration 3.7 years), one patient died of progressive disease while the other four had no sign of recurrence.

The effect of eccentric exercise on position sense and joint reaction angle of the lower limbs

Impaired position sense and impaired joint reaction angle of the lower limbs after muscle-damaging activities is a serious functional limitation that may lead to an increased risk of injury, particularly in older populations. The purpose of the present study was to examine whether position sense and joint reaction angle to release can be affected by eccentric exercise-induced muscle damage. Twelve women underwent an isokinetic exercise session of the lower limb. Isometric peak torque, delayed-onset muscle soreness, serum creatine kinase, position sense, and knee joint reaction angle to release were examined before, immediately after, and 24, 48, and 72 h post-exercise. Due to the effect of eccentric exercise, subjects persistently placed their lower limb at a more extended position, representing a shorter knee extensor muscle. Eccentric exercise increased the knee reaction angle of the lower limb after release from 0 degrees and 15 degrees but not from 30 degrees and 45 degrees . Position sense and joint reaction to release were similarly affected by eccentric exercise and independently of visual feedback. Position sense was impaired only immediately post-exercise (probably due to muscle fatigue), whereas impairment of the reaction angle to release persisted up to 3 days post-exercise (probably due to muscle damage). Attenuation of position sense and joint reaction angle of the lower limbs after damaging activities is a serious functional limitation that may lead to an increase risk of injury, particularly in older populations.

Scintigraphy with [111In]octreotide and 201Tl in a Hürthle cell thyroid carcinoma without detectable radio-iodine uptake. Report of a case and review of the literature

AIM

To describe the visualization of recurrent disease by [111In]octreotide and 201Tl scintigraphy in a patient with Hürthle cell thyroid carcinoma, increased thyroglobulin levels, and a negative radio-iodine total-body scan.

METHODS

Scintigraphy with [111In]octreotide and 201Tl was performed, and a local recurrence in the thyroid bed was detected which was excised by surgery.

RESULTS

On histology, the tumour proved to be a Hürthle cell carcinoma, and within the tumour somatostatin receptors were detected by RT-PCR.

CONCLUSION

Scintigraphy with [111In]octreotide and 201Tl is an alternative imaging method for the detection of residual disease in patients with a differentiated thyroid carcinoma having increased thyroglobulin levels and a negative radio-iodine total-body scan.

Dynamic pedobarography (DPB) in operative management of cavovarus foot deformity

Dynamic pedobarography (DPB) was performed in 21 patients, 9 male and 12 female with cavovarus foot deformity mostly of Charcot-Marie-Tooth origin. Age ranged from 14 to 52 years (mean 30 y). Twenty-six feet were examined pre- and postoperatively clinically, radiologically and by dynamic pedobarography with a follow-up time from 9 to 49 months (mean 22.5 mo). The EMED SF system was used for data collection during walking. Gait line, contact areas (CA), peak pressures (PP) and pressure time integral (PTI) were determined. According to the contact pattern the examined feet could be divided into three groups with antegrade, retrograde and inversion contact pattern. Data analysis showed postoperatively considerable increase in CA and decrease in PP and PTI. Clinical results such as plantar callosities and "roll over avoidance gait" did not always correlate with pedobarographic data. DPB adds a dynamic component in the diagnosis and management of cavovarus feet but certain limitations exist.

Relative frequencies of DRB1*11 alleles and their DRB3 associations in five major population groups in a United States bone marrow registry

One hundred sixty-one individuals from each of five US population groups, Caucasians (CAU), African Americans (AFA), Asians/Pacific Islanders (API), Hispanics (HIS), and Native Americans (NAT), were randomly selected from a volunteer bone marrow registry database consisting of 14,452 HLA-DRB1*11 positive individuals. This sampling provided at least an 80% probability of detecting a rare allele that occurred at 1% in the DRB1*11 positive population. Samples were typed for DRB1*11 alleles by polymerase chain reaction-sequence specific oligonucleotide probe typing (PCR-SSOP). A total of 10 DRB1*11 alleles out of 27 possible alleles were detected. The distribution and diversity of DRB1*11 alleles varied among populations although DRB1*1101 was the predominant DRB1*11 allele in all populations. Caucasians were the least diversified; only four common alleles (DRB1*1101-*1104) were observed. As well as the four common alleles, other groups also carried one or two other less frequent alleles including DRB1*1105 (API), *1106 (API), *1110 (AFA), *1114 (HIS), *1115 (NAT), and *1117 (AFA). A subset (418) of these individuals were also typed for DRB3 alleles. Most (97.6%) showed a strong association of DRB1*11 with DRB3*0202.

Characterization of a novel dUTP-dependent activity of CTP synthetase from Saccharomyces cerevisiae

CTP synthetase [EC 6.3.4.2, UTP:ammonia ligase (ADP-forming)] from the yeast Saccharomyces cerevisiae catalyzes the ATP-dependent transfer of the amide nitrogen from glutamine to the C-4 position of UTP to form CTP. In this work, we demonstrated that CTP synthetase utilized dUTP as a substrate to synthesize dCTP. The dUTP-dependent activity was linear with time and with enzyme concentration. Maximum dUTP-dependent activity was dependent on MgCl(2) (4 mM) and GTP (K(a) = 14 microM) at a pH optimum of 8.0. The apparent K(m) values for dUTP, ATP, and glutamine were 0.18, 0.25, and 0.41 mM, respectively. dUTP promoted the tetramerization of CTP synthetase, and the extent of enzyme tetramerization correlated with dUTP-dependent activity. dCTP was a poor inhibitor of dUTP-dependent activity, whereas CTP was a potent inhibitor of this activity. The enzyme catalyzed the synthesis of dCTP and CTP when dUTP and UTP were used as substrates together. CTP was the major product synthesized when dUTP and UTP were present at saturating concentrations. When dUTP and UTP were present at concentrations near their K(m) values, the synthesis of dCTP increased relative to that of CTP. The synthesis of dCTP was favored over the synthesis of CTP when UTP was present at a concentration near its K(m) value and dUTP was varied from subsaturating to saturating concentrations. These data suggested that the dUTP-dependent synthesis of dCTP by CTP synthetase activity may be physiologically relevant.

Identification of Ser424 as the protein kinase A phosphorylation site in CTP synthetase from Saccharomyces cerevisiae

The URA7-encoded CTP synthetase [EC 6.3.4.2, UTP:ammonia ligase (ADP-forming)] in the yeast Saccharomyces cerevisiae is phosphorylated on a serine residue and stimulated by cAMP-dependent protein kinase (protein kinase A) in vitro. In vivo, the phosphorylation of CTP synthetase is mediated by the RAS/cAMP pathway. In this work, we examined the hypothesis that amino acid residue Ser424 contained in a protein kinase A sequence motif in the URA7-encoded CTP synthetase is the target site for protein kinase A. A CTP synthetase synthetic peptide (SLGRKDSHSA) containing the protein kinase A motif was a substrate (Km = 30 microM) for protein kinase A. This peptide also inhibited (IC50 = 45 microM) the phosphorylation of purified wild-type CTP synthetase by protein kinase A. CTP synthetase with a Ser424 --> Ala (S424A) mutation was constructed by site-directed mutagenesis. The mutated enzyme was not phosphorylated in response to the activation of protein kinase A activity in vivo. Purified S424A mutant CTP synthetase was not phosphorylated and stimulated by protein kinase A. The S424A mutant CTP synthetase had reduced Vmax and elevated Km values for ATP and UTP when compared with the protein kinase A-phosphorylated wild-type enzyme. The specificity constants for ATP and UTP for the S424A mutant CTP synthetase were 4.2- and 2.9-fold lower, respectively, when compared with that of the phosphorylated enzyme. In addition, the S424A mutant enzyme was 2.7-fold more sensitive to CTP product inhibition when compared with the phosphorylated wild-type enzyme. These data indicated that the protein kinase A target site in CTP synthetase was Ser424 and that the phosphorylation of this site played a role in the regulation of CTP synthetase activity.

Enhancing math competency of baccalaureate students

The result of a 4-year effort to study and institute changes in Baylor University School of Nursing's baccalaureate (BSN) students' math competencies was successful. The evolution of the current math competency process is detailed. By identifying at-risk, entry-level students through math examination in the junior I semester and each semester in the program, individual clinical faculty can customize the teaching-learning experience for students. Students who need more help than a clinical instructor has available, which is documented by semester examination failure, benefit from taking a 1-hour medication administration course before graduating from the BSN program. Insights and suggestions are offered for other schools encountering this problem.

Beyond labeling: the role of maternal input in the acquisition of richly structured categories

Recent research shows that preschool children are skilled classifiers, using categories both to organize information efficiently and to extend knowledge beyond what is already known. Moreover, by 2 1/2 years of age, children are sensitive to nonobvious properties of categories and assume that category members share underlying similarities. Why do children expect categories to have this rich structure, and how do children appropriately limit this expectation to certain domains (i.e., animals vs. artifacts)? The present studies explore the role of maternal input, providing one of the first detailed looks at how mothers convey information about category structure during naturalistic interactions. Forty-six mothers and their 20- or 35-month-old children read picture books together. Sessions were videotaped, and the resulting transcripts were coded for explicit and implicit discussion of animal and artifact categories. Sequences of gestures toward pictures were also examined in order to reveal the focus of attention and implicit links. drawn between items. Results indicate that mothers provided a rich array of information beyond simple labeling routines. Taxonomic categories were stressed in subtle and indirect ways, in both speech and gesture, especially for animals. Statements and gestures that linked two pictures were more frequent for taxonomically related animal pictures than for other picture pairs. Mothers also generalized category information using generic noun phrases, again more for animals than for artifacts. However, mothers provided little explicit discussion of nonobvious similarities, underlying properties, or inductive potential among category members. These data suggest possible mechanisms by which a notion of kind is conveyed in the absence of detailed information about category essences.

Nucleotide-dependent tetramerization of CTP synthetase from Saccharomyces cerevisiae

The nucleotide-dependent tetramerization of purified native URA7-encoded CTP synthetase (EC 6.3.4.2, UTP: ammonia ligase (ADP-forming)) from the yeast Saccharomyces cerevisiae was characterized. CTP synthetase existed as a dimer in the absence of ATP and UTP. In the presence of saturating concentrations of ATP and UTP, the CTP synthetase protein existed as a tetramer. Increasing concentrations of ATP and UTP caused a dose-dependent conversion of the dimeric species to a tetramer. The kinetics of enzyme tetramerization correlates with the kinetics of enzyme activity. The tetramerization of CTP synthetase was dependent on UTP and Mg2+ ions. ATP facilitated the UTP-dependent tetramerization of CTP synthetase by a mechanism that involved the ATP-dependent phosphorylation of UTP catalyzed by the enzyme. The glutaminase reaction that is catalyzed by the enzyme was not required for enzyme tetramerization. CTP, a potent inhibitor of CTP synthetase activity, did not inhibit the ATP/UTP-dependent tetramerization of the enzyme. Phosphorylation of the purified native CTP synthetase with protein kinase A and protein kinase C facilitated the nucleotide-dependent tetramerization. Dephosphorylation of native CTP synthetase with alkaline phosphatase prevented the nucleotide-dependent tetramerization of the enzyme. This correlated with the inactivation of CTP synthetase activity. Rephosphorylation of the dephosphorylated enzyme with protein kinase A and protein kinase C resulted in a partial restoration of the nucleotide-dependent tetramerization of the enzyme. This tetramerization correlated with the partial restoration of CTP synthetase activity. Taken together, these results indicated that enzyme tetramerization was required for CTP synthetase activity and that enzyme phosphorylation played an important role in the tetramerization and regulation of the enzyme.

Genetic uncoupling of the dsRNA-binding and RNA cleavage activities of the Escherichia coli endoribonuclease RNase III--the effect of dsRNA binding on gene expression

RNase III, a double-stranded RNA-specific endonuclease, is proposed to be one of Escherichia coli's global regulators because of its ability to affect the expression of a large number of unrelated genes by influencing post-transcriptional control of mRNA stability or mRNA translational efficiency. Here, we describe the phenotypes of bacteria carrying point mutations in rnc, the gene encoding RNase III. The substrate recognition and RNA-processing properties of mutant proteins were analysed in vivo by measuring expression from known RNase III-modulated genes and in vitro from the proteins' binding and cleavage activities on known double-stranded RNA substrates. Our results show that although the point mutation rnc70 exhibited all the usual rnc null-like phenotypes, unlike other mutations, it was dominant over the wild-type allele. Multicopy expression of rnc70 could suppress a lethal phenotype of the wild-type rnc allele in a certain genetic background; it could also inhibit the RNase III-mediated activation of lambdaN gene translation by competing for the RNA-binding site of the wild-type endonuclease. The mutant protein failed to cleave the standard RNase III substrates in vitro but exhibited an affinity for double-stranded RNA when passed through poly(rI):poly(rC) columns. Filter binding and gel-shift assays with purified Rnc70 showed that the mutant protein binds to known RNase III mRNA substrates in a site-specific manner. In vitro processing reactions with purified enzyme and labelled RNA showed that the in vivo dominant effect of the mutant enzyme over the wild-type was not necessarily caused by formation of mixed dimers. Thus, the rnc70 mutation generates a mutant RNase III with impaired endonucleolytic activity but without blocking its ability to recognize and bind double-stranded RNA substrates.

Generic noun phrases in mother-child conversations

Generic noun phrases (e.g. Tigers are fierce) are of interest for their semantic properties: they capture 'essential' properties, are timeless, and are context-free. The present study examines use of generic noun phrases by preschool children and their mothers. Mother-child pairs were videotaped while looking through a book of animal pictures. Each page depicted either a single instance of a particular category (e.g. one crab) or multiple instances of a particular category (e.g. many crabs). The results indicated a striking difference in how generics vs. non-generics were distributed, both in the speech of mothers and in the speech of preschool children. Whereas the form of non-generic noun phrases was closely linked to the structure of the page (i.e. singular noun phrases were used more often when a single instance was presented; plural noun phrases were used more often when multiple instances were presented), the form of generic noun phrases was independent of the information depicted (e.g. plural noun phrases were as frequent when only one instance was presented as when multiple instances were presented). We interpret the data as providing evidence that generic noun phrases differ in their semantics and conceptual organization from non-generic noun phrases, both in the input to young children and in children's own speech. Thus, this simple linguistic device may provide input to, and a reflection of, children's early developing notion of 'kinds'.

An erbium:YAG laser to obtain capillary blood samples without a needle for point-of-care laboratory testing

BACKGROUND

Needlestick injury poses an occupational hazard to health care workers that will increase with the increasing availability of point-of-care testing using capillary blood obtained with a lancet.

OBJECTIVES

To demonstrate the safety and efficacy of a portable pulsed erbium:yttrium-aluminum-garnet (Er:YAG) laser in obtaining a blood sample from patients in a clinical setting and to determine whether the laser radiant energy alters the level of various components of blood, resulting in misleading laboratory results.

DESIGN

Comparison of laboratory values of blood samples obtained with the laser and conventional lancet and comparison of patient and user preferences by questionnaire.

PATIENTS AND METHODS

One hundred patients with diabetes mellitus attending a diabetes clinic were randomized to have capillary blood sampling from the fingertip performed either by the laser or a conventional lancet first, then with the other device.

MAIN OUTCOME MEASURES

A comparison of pain, healing, hematocrit, and glycosylated hemoglobin (HbAlc), blood urea nitrogen, sodium, potassium, bicarbonate, and glucose levels.

RESULTS

Adequate blood was obtained with both devices 97% of the time. Blood flow was greater with the laser perforation, resulting in higher operator preference. Although patients felt greater pain and experienced slower healing with the laser, these were not serious problems. Modification of the laser energy output led to a reduction in pain. Possibly owing to hemolysis, the potassium level in the blood obtained with the laser was significantly elevated and unsuitable for clinical decision making in many cases. None of the other measurements were similarly affected.

CONCLUSIONS

We conclude that the laser device has the potential to obtain a blood sample for routine tests without a needle. This needle-free method will decrease the risk of bloodborne infections caused by needlestick injuries and thus lead to considerable cost savings and public health advantages. Further work is needed to alter the laser energy so that hemolysis can be decreased, thus enabling a more reliable potassium estimation.

Retooling faculty orientation

Are nursing faculty gradually becoming extinct? The answer is yes if we rely on National League for Nursing statistics indicating that 13 per cent of the nurses pursuing advanced education are directing their studies toward a teaching career and the United States Department of Health and Human Services Division of Nursing statistics indicating a total decline of 30 per cent in employed nurse educators during a 4-year period. New faculty are currently being recruited from the ranks of clinicians or from those with an administration specialization. The scarcity of faculty with adequate preparation to teach will affect quality education unless mechanisms to recruit, nurture, and retain qualified faculty are developed. This article addresses the use of a formalized orientation program to develop and socialize new faculty members into the academic setting in an expeditious manner. A general and specific orientation program was developed that began 6 weeks before employment and spanned one semester. Examples of the tools that were developed and used for orientation are included. Three new faculty have participated in the orientation process and have become valued team members. The results indicate that they benefited from a modular approach, which includes ongoing support meetings and the use of a mentor.

Circulating gonadotrophin surge-attenuating factor from superovulated women suppresses in vitro gonadotrophin-releasing hormone self-priming

A perifusion system based on ovine pituitary tissue explants was used to investigate the effects of follicular fluid (hFF) and serum from superovulated women on pituitary responsiveness to gonadotrophin-releasing hormone (GnRH). The specific aims of the study were to determine both if gonadotrophin surge-attenuating factor (GnSAF) bioactivity is present in the peripheral circulation as well as in the follicles of superovulated women and if GnSAF suppresses GnRH self-priming in vitro. Two pulses of GnRH, 1 h apart, produced marked peaks in LH secreted from control chambers, with GnRH self-priming evident in the significant difference between the first (134.4 +/- 1.7 - 232.1 +/- 24.0% of basal secretion) and second (183.9 +/- 15.8 - 313.9 +/- 14.0% of basal secretion) LH peaks. Both follicular fluid and serum pooled from two different groups of women produced marked suppression of the first (unprimed) and second (primed) LH peaks. The hFF reduced the first LH peak to 69.6 +/- 7.8 and 60.2 +/- 9.7% and the second LH peak to 57.4 +/- 6.7 and 42.6 +/- 6.5% of control LH secretion. Overall, the serum reduced the first and second LH peaks to 76.8 +/- 4.2 and 62.9 +/- 3.6% of control respectively. These results demonstrated that GnSAF bioactivity suppresses GnRH self-priming, and is present in both the peripheral circulation and hFF. The same material administered to dispersed ovine pituitary monolayers produced similar marked suppression of GnRH-induced LH secretion, with approximately 50-fold less GnSAF bioactivity in serum compared with hFF. Combined doses of oestradiol and progesterone, or hFF from large follicles containing little GnSAF, produced stimulation of GnRH-induced LH secretion and GnRH self-priming (second peaks 78.1 +/- 38.9 and 27.4 +/- 15.7% respectively higher than first peaks). Thus, in conclusion, GnSAF in hFF and serum markedly attenuated both unprimed and primed pituitary response to GnRH, virtually abolishing the GnRH self-priming effect.

Nuclear magnetic resonance in pathology: I. Principles and general aspects

Nuclear magnetic resonance (NMR) has become established as a powerful diagnostic imaging technique in medicine. The power of NMR as a tool for characterizing molecular structure and for quantitative analysis of complex mixtures in the clinical laboratory or even in vivo is beginning to be exploited. In the clinical laboratory, NMR can analyze the complex mixtures of bodily fluids, intact cells, tissues, and their extracts. Phosphorus-31 or 1H NMR spectroscopy in vivo can provide a noninvasive probe of high-energy compounds, amino acids, and compounds of phospholipid metabolism. The basic principles of NMR spectroscopy are presented here, with emphasis on the various NMR parameters and the information they provide. A companion article presents a survey of applications in pathology.

The acute urethral syndrome in routine practice

Midstream samples of urine from 185 acutely dysuric women and 89 symptom-free controls were screened according to the modified criteria of Kass by both conventional and microaerophilic culture. Among the 185 symptomatic women, coliform bacilli were isolated from 125 (67.5%) and in 45 (36%) of the latter the concentration of these organisms in the urine was less than 10(8)/l. Fastidious organisms were isolated in pure and mixed cultures from 25 (13.4%) of the 185 patients and from 4 (4.5%) of 89 controls. Staphylococcus species were isolated from 10.8% (9.7% S. saprophyticus; 1.1% S. epidermidis) and Ureaplasma urealyticum from 2.7%. All patients infected with conventional organisms but only 30.4% of those yielding fastidious organisms had pyuria. The isolation rate of fastidious organisms tended to be higher (P = 0.055) in symptomatic women that in symptom-free controls.

A Comprehensive Preseason Fitness Evaluation for Professional Baseball Players

In brief: Preseason health and fitness evaluations were performed on 40 professional baseball players to assess level of conditioning, potential for injury, and health-related lifestyle habits. Group means for coronary risk profile, muscular endurance, flexibility, and maximum aerobic capacity were normal, but screening identified many players with problems or potential problems. Test findings resulted in at least one training or life-style recommendation in every player tested. This information provides a comprehensive physiological profile of one professional baseball team. Further research is needed to define sport-specific testing for the professional baseball player.

Comparison of ftorafur with 5-fluorouracil in combination chemotherapy of advanced gastrointestinal carcinoma

The aim of the study was to compare the combination 5-FU-carmustine with ftorafur-carmustine in the treatment of advanced gastrointestinal cancer. To this end, a prospective, multicenter, randomized trial was initiated. Part I of this trial showed that similar response rates can be obtained with 5-FU-carmustine and ftorafur-carmustine in 109 patients (32.7% versus 26.3%). However, median survival was better in patients treated with 5-FU-carmustine (307 days versus 163 days). Part II of the trial revealed that neither a higher dosage of ftorafur (2 g/m2/day X 5 days) nor the addition of vincristine to both regimens changed the previously obtained results significantly. Again, median survival was found to be better in patients treated with 5-FU combination chemotherapy (304 days versus 144 days). Both the 5-FU and the ftorafur combination were tolerated reasonably well. The results suggest that combination chemotherapy including 5-FU is superior to ftorafur at the applied dosages in terms of survival.

[Tumor-specific immune response of hypernephroid renal carcinoma after in vitro irradiation (author's transl)]

It is possible to reproduce in vitro the induction in the leucocyte migration test of an immune response specific to hypernephroid carcinoma by preoperative radiation treatment of this neoplasm. The leucocyte migration is inhibited by soluble extracts of the tumor, prepared from hypernephroma-tissues (of 11 patients nontreated preoperatively) after in vitro irradiation either with electrons or with 60Co. This effect depends on the dose. The radiation dose producing a maximal inhibition following in vitro irradiation is nearly equal to that delivered by us before surgical treatment.