2 Pathways to detection of non-infectious childhood uveitis in the UK: findings from the UNICORN cohort study

INTRODUCTION

Prompt detection of childhood uveitis is key to minimising negative impact. From an internationally unique inception cohort, we report pathways to disease detection.UNICORNS is a national childhood non-infectious uveitis study with longitudinal collection of a standardised clinical dataset and patient reported outcomes. Descriptive analysis of baseline characteristics are reported.Amongst 150 recruited children (51% female, 31% non-white ethnicity) age at detection ranged from 2-18yrs (median 10). In 69%, uveitis was diagnosed following onset of symptoms: time from first symptoms to uveitis detection ranged from 0-739days (median 7days), with longer time to detection for those presenting initially to their general practitioner. Non symptomatic children were detected through JIA/other disease surveillance (16%), routine optometry review (5%) or child visual health screening (1%). Commonest underlying diagnoses at uveitis detection were JIA (17%), TINU (9%, higher than pre-pandemic reported UK disease frequency) and sarcoid (1%). 60% had no known systemic disease at uveitis detection. At disease detection, in at least one eye: 34% had structural complications (associated with greater time to detection - 17 days versus 4 days for uncomplicated presentation).The larger relative proportions of children with non-JIA uveitis reported here increase the importance of improving awareness of childhood uveitis amongst the wider clinical communities. There is scope for improvement of pathways to detection. Forthcoming analysis on the full cohort (251 recruited to date across 33 hospitals and 4 nations) will provide nationally representative data on management and the determinants of visual and broader developmental/well-being outcomes.

Diverse Tsunamigenesis Triggered by the Hunga Tonga-Hunga Ha'apai Eruption

On the evening of 15 January 2022, the Hunga Tonga-Hunga Ha’apai volcano¹ unleashed a violent underwater eruption, blanketing the surrounding land masses in ash and debris^2,3. The eruption generated tsunamis observed around the world. An event of this type last occurred in 1883 during the eruption of Krakatau⁴, and thus we have the first observations of a tsunami from a large emergent volcanic eruption captured with modern instrumentation. Here we show that the explosive eruption generated waves through multiple mechanisms, including: (1) air–sea coupling with the initial and powerful shock wave radiating out from the explosion in the immediate vicinity of the eruption; (2) collapse of the water cavity created by the underwater explosion; and (3) air–sea coupling with the air-pressure pulse that circled the Earth several times, leading to a global tsunami. In the near field, tsunami impacts are strongly controlled by the water-cavity source whereas the far-field tsunami, which was unusually persistent, can be largely described by the air-pressure pulse mechanism. Catastrophic damage in some harbours in the far field was averted by just tens of centimetres, implying that a modest sea level rise combined with a future, similar event would lead to a step-function increase in impacts on infrastructure. Piecing together the complexity of this event has broad implications for coastal hazards in similar geophysical settings, suggesting a currently neglected source of global tsunamis.

January 2022 saw the first observations of a tsunami resulting from a large emergent volcanic eruption (Hunga Tonga) captured using modern instrumentation, with broad implications for hazard management in similar geophysical settings.

Differential Effects of Fingolimod and Natalizumab on B Cell Repertoires in Multiple Sclerosis Patients

Natalizumab and fingolimod are effective multiple sclerosis (MS) therapies that disrupt lymphocyte migration but have differential effects on B cell maturation and trafficking. We investigated their effects on peripheral blood (PB) and cerebrospinal fluid (CSF) B cell repertoires using next-generation deep sequencing. Paired CSF and PB B cell subsets (naïve, CD27+ memory, and CD27-IgD- double-negative B cells and plasmablasts) were collected by applying flow cytometry at baseline and after 6 months of treatment and their respective heavy-chain variable region repertoires assessed by Illumina MiSeq. Treatment with fingolimod contracted, whereas natalizumab expanded circulating PB B cells. CSF B cell numbers remained stable following fingolimod treatment but decreased with natalizumab therapy. Clonal overlap between CSF and PB B cells was reduced with natalizumab treatment but remained stable with fingolimod therapy. Lineage analyses of pre- and posttreatment CSF B cell repertoires revealed large, clonally expanded B cell clusters in natalizumab-treated MS patients but no intrathecal clonal expansion following fingolimod therapy. Our findings suggest that natalizumab diminishes the exchange of peripheral and intrathecal B cells without impacting intrathecal clonal expansion. In contrast, fingolimod treatment fails to alter blood-brain barrier B cell exchange but diminishes intrathecal clonal expansion. Sphingosine-1 phosphate receptor inhibition may alter intrathecal B cell biology in MS.

Protocol: Using N-of-1 tests to identify responders to melatonin for sleep disturbance in Parkinson's disease

BACKGROUND

40% of Parkinson's Disease (PD) sufferers experience insomnia, impacting health and quality of life for patients and family members, especially carers. There is little evidence that current treatments are effective.

OBJECTIVES

To determine the effectiveness of melatonin in reducing insomnia in 44 individuals with PD using N-of-1 trials. To aggregate group data to arrive at population estimates of effectiveness (measured by improvements in PDSS-2) and safety (measured by adverse events) of melatonin in improving insomnia in PD. To assess the feasibility of offering N-of-1 trials for insomnia in PD.

METHODOLOGY

Participants will receive either immediate-release melatonin or placebo in random order in 3 paired two-week treatment periods (12 weeks total). Based on their response in a two-week run-in period on 3 mg daily, they will trial either 3 mg or 6 mg. Patients will keep daily sleep diaries and wear a MotionWatch throughout. After the trial patients will discuss their individual report with their doctor, which provides direct feedback about effectiveness and safety of melatonin for them.

STATISTICAL METHODS

We will analyse N-of-1 tests 1) individually: effects of melatonin on PDSS-2 and safety will be reported; and 2) aggregated across individual N-of-1 studies, combined using a Bayesian multilevel random effects model, which will account for repeated measures on individuals over time, and will return posterior estimates of overall treatment effect, and effect in each individual.

CLINICAL TRIAL REGISTRATION NUMBER

ACTRN12617001103358.

Recent Advances in the Etiology and Treatment of Burning Mouth Syndrome

Burning mouth syndrome (BMS) is a debilitating condition that has a striking female predilection. Although the oral mucosa is normal in appearance, patients with BMS experience oral burning that most commonly localizes to the lips and tongue. BMS is a diagnosis of exclusion, and all underlying pathoses associated with allodynia must be ruled out prior to rendering the diagnosis. The etiopathogenesis of BMS remains poorly understood, and thus patient management is challenging. Data indicate that oral and systemic factors both contribute to the development and persistence of the condition. Of particular interest, emerging work identifies structural and functional deficits within the nervous system that may lead to a more mechanistic understanding of BMS pathology. In addition, several novel findings suggest that circadian rhythm dysfunction may be a previously unappreciated yet clinically significant driver of disease. Circadian rhythm controls pain perception, mood, and sleep and plays a key role in the regulation of the hypothalamic-pituitary-adrenal axis. Since these are altered in patients with BMS, this may be reflective of underlying circadian dysfunction. While evidence-based treatment strategies for BMS are lacking, current treatment approaches consist of local and systemic medications, such as clonazepam, alpha lipoic acid, capsaicin, low-level laser therapy, gabapentin, and amitriptylin. In addition, the use of cognitive behavioral therapy is reported. This review provides an overview of the recent literature related to the etiology and treatment of BMS and identifies current challenges facing researchers and clinicians alike.

Patients' preferences for adjuvant sorafenib after resection of renal cell carcinoma in the SORCE trial: what makes it worthwhile?

Background

We sought to determine the survival benefits that patients judged sufficient to warrant adjuvant therapy with sorafenib for 1 year, or for 3 years after resection of renal cell carcinoma in the SORCE trial.

Methods

SORCE participants from all sites in Australia and New Zealand, and selected sites in the UK, completed a validated preferences questionnaire at months 0, 3, 15, and 42 to elicit the minimum survival benefits they judged sufficient to warrant adjuvant sorafenib for 1 year (versus observation), or for 3 years (versus 1 year). The questionnaires used reference survival times of 5 and 15 years; and reference survival rates at 5 years of 65% and 85%.

Results

The 233 participants had a median age of 57 years (range 29-78) and 71% were male. For 1 year of sorafenib versus no adjuvant therapy, the median benefits in survival times judged sufficient to warrant treatment were an extra 9 months beyond 5 years and an extra 1 year beyond 15 years; the median benefit in survival rates were an extra 4% beyond 65% and an extra 3% beyond 85% at 5 years. For 3 years of sorafenib versus 1 year of sorafenib, the median benefit in survival time judged sufficient to warrant extended treatment was an extra 1 year beyond both 5 and 15 years. Participants randomly allocated to treatment with sorafenib judged larger benefits necessary than those allocated to placebo. Participants' preferences were not associated with their baseline characteristics or the interval from randomisation.

Conclusion

Most participants judged an extra year of survival necessary to warrant 1 year of adjuvant sorafenib worthwhile, and an additional year of survival to warrant extending the duration of sorafenib from 1 to 3 years. Patients' preferences are important in shared decision making.

SORCE trial clinical trials number

NCT00492258.

Pregnant Sheep in a Farm Environment Did Not Develop Anaemia

Simple Summary

Anaemia refers to a low red blood cell count and is common during pregnancy in women. Anaemia has been reported in sheep undergoing surgery during pregnancy for biomedical research projects. The incidence and severity of anaemia during pregnancy in sheep is unknown. Three groups of sheep were established: non-pregnant; pregnant with a single lamb; and pregnant with twin lambs. The stage of pregnancy was known as the sheep were mated on a known date and pregnancy was confirmed 50 days later by ultrasound examination. During pregnancy, blood samples were collected to measure red cells in the blood and protein levels. Samples were also collected to ensure that the sheep did not have any risk factors for anaemia, such as nutritional deficiency and internal parasites. Anaemia did not occur in any sheep during the study. Anaemia did not develop during pregnancy and red cell counts and protein levels were similar between each group. All the sheep lambed as expected, except for one that was expecting twins delivered a single lamb.

Abstract

The aim of this study was to document the haematological profile of pregnant ewes throughout gestation. Sheep were divided into three groups (n = 8 per group): non-pregnant, singleton, or twin pregnancy. Blood samples were collected every 14 days from day 55 of gestation for haemoglobin concentration; packed cell volume; total protein; and albumin concentration. On days 55 and 125 of gestation blood was collected for trace element estimation: soluble copper and zinc; glutathione peroxidase (GSHPx); and methylmalonic acid (MMA). Pooled faecal samples were collected on days 55, 97, and 139 of gestation. Pasture cuts were collected on days 97 and 153 of gestation. The haematology and protein concentrations were not different between groups throughout the study. Copper concentration increased in all animals during the study (p < 0.0001). Zinc concentration was lowest in the singleton and twin pregnant sheep on day 55 of gestation (p = 0.04). GSHPx was not different between groups during the study. MMA decreased in all animals during the study (p < 0.0001), but was not different between groups. Faecal samples were consistently negative for strongyle and nematode eggs, and coccidian oocysts. The pasture was good quality. Pregnant sheep in a farm environment with normal trace element status, no parasites, and an adequate diet, did not develop anaemia (PCV < 0.27).

Childhood Sexual Abuse Among New Psychiatric Outpatients in a City in Northern Alberta-prevalence Rate and Demographic/Clinical Predictors

Child sexual abuse (CSA) is a major global health problem with serious adverse effects at later ages. Our paper examines the prevalence rates and the demographic and clinical predictors of CSA among adult psychiatric outpatients. A data assessment tool was used to compile information on the demographic and clinical characteristics of all new patients assessed in four psychiatric outpatient clinics between 1st January 2014 and 31st December 2015. The 12-month prevalence rate for CSA among new psychiatric outpatients in Fort McMurray was 20.7% (10.7% for males and 26.9% in females). With an odds ratio for sex of 3.30 (CI = 2.06–5.29), female patients are about three times more likely to report a history of CSA compared to male patients when controlling for other factors. Similarly patients with at most high school education (OR = 1.8, CI = 1.145–2.871) and those with previous contact with psychiatric services (OR = 1.7, CI = 1.124–2.616) were about two times more likely to report a history of CSA compared to the patients with college/university education or those with no previous contact with psychiatric services respectively. Similarly, patients with histories of substance abuse (OR = 1.5, CI = 1.179–2.642) and patients with family histories of mental illness (OR = 1.8, CI = 1.032–2.308) had higher likelihoods of reporting histories of CSA compared to patients without histories of substance abuse or family histories of mental illness respectively. Our findings suggest that victims of CSA are an at-risk population in need of ongoing mental health and educational support.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Drug-induced liver injury from antituberculous treatment: a retrospective study from a large TB centre in the UK

Background

We describe drug-induced liver injury (DILI) secondary to antituberculous treatment (ATT) in a large tuberculosis (TB) centre in London; we identify the proportion who had risk factors for DILI and the timing and outcome of DILI.

Methods

We identified consecutive patients who developed DILI whilst on treatment for active TB; patients with active TB without DILI were selected as controls. Comprehensive demographic and clinical data, management and outcome were recorded.

Results

There were 105 (6.9%) cases of ATT-associated DILI amongst 1529 patients diagnosed with active TB between April 2010 and May 2014. Risk factors for DILI were: low patient weight, HIV-1 co-infection, higher baseline ALP, and alcohol intake. Only 25.7% of patients had British or American Thoracic Society defined criteria for liver test (LT) monitoring. Half (53%) of the cases occurred within 2 weeks of starting ATT and 87.6% occurred within 8 weeks. Five (4.8%) of seven deaths were attributable to DILI.

Conclusions

Only a quarter of patients who developed DILI had British or American Thoracic Society defined criteria for pre-emptive LT monitoring, suggesting that all patients on ATT should be considered for universal liver monitoring particularly during the first 8 weeks of treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2330-z) contains supplementary material, which is available to authorized users.

Species Delimitation and Phylogenetic Relationships in Ectobiid Cockroaches (Dictyoptera, Blattodea) from China

We collected Ectobiidae cockroach specimens from 44 locations in the south of the Yangtze valley. We obtained 297 COI sequences specimens and carried out phylogenetic and divergence dating analyses, as well as species delimitation analysis using a General Mixed Yule Coalescent (GMYC) framework. The intraspecific and interspecific sequence divergence in Ectobiidae cockroaches ranged from 0.0 to 7.0% and 4.6 to 30.8%, respectively. GMYC analysis resulted in 53 (confidence interval: 37-65) entities (likelihood ratio = 103.63) including 14 downloaded species. The COI GMYC groups partly corresponded to the ectobiid species and 52 ectobiid species were delimited successfully based on the combination of GMYC result with morphological information. We used the molecular data and 6 cockroach fossil calibrations to obtain a preliminary estimate of the timescale of ectobiid evolution. The major subfamilies in the group were found to have diverged between ~125-110 Ma, and morphospecies pairs were found to have diverged ~10 or more Ma.

Factors which influence treatment initiation for pulmonary non-tuberculous mycobacterium infection in HIV negative patients; a multicentre observational study

BACKGROUND

Clinical, radiological and microbiological criteria inform diagnosis of pulmonary Non-Tuberculous Mycobacteria (NTM) disease and treatment decisions. This multicentre, review aims to characterise NTM disease meeting ATS/IDSA criteria and define factors associated with initiation of treatment.

METHODS

Sputum samples growing NTM from 5 London hospitals between 2010 and 2014 were identified. Data for HIV-negative individuals meeting ATS/IDSA guidelines for pulmonary NTM disease were extracted. Associations between clinical variables and treatment decision were investigated using Chi-squared, Fishers-exact or Mann Whitney tests. Factors associated with treatment in univariate analysis (p < 0.150) were included in a multivariate logistic regression model.

RESULTS

NTM were identified from 817 individuals' sputum samples. 108 met ATS/IDSA criteria. 42/108 (39%) were initiated on treatment. Median age was 68 (56-78) in the cohort. On multivariate analysis, factors significantly associated with treatment of pulmonary NTM infection were: Cavitation on HRCT (OR: 6.49; 95% CI: 2.36-17.81), presenting with night sweats (OR 4.18; 95% CI: 1.08-16.13), and presenting with weight loss (OR 3.02; 95% CI: 1.15-7.93). Of those treated, 18(43%) have completed treatment, 9(21%) remain on treatment, 10(24%) stopped due to side effects, 5(12%) died during treatment. Mortality was 31% (n = 13) in treated versus 21% (n = 14) in the non-treated cohort. Subgroup analysis of individual NTM species did not observe any differences in treatment initiation or outcomes between groups.

DISCUSSION

Decision to treat pulmonary NTM infection requires clinical judgement when interpreting clinical guidelines. Factors independently associated with decision to treat in this HIV-negative cohort include cavitation on HRCT and presenting with night sweats or weight loss.

Design and Synthesis of a Quenched Fluorogenic Peptide Substrate for Human Cytomegalovirus Proteinase

A fluorogenic peptide substrate for HCMV proteinase was synthesized by solid-phase peptide synthesis. The amino acid sequence of this substrate is derived from the maturation cleavage site (M site) of the natural substrate, the assembly protein precursor. The minimum sequence for efficient cleavage requires at least seven residues (P4-P3′). A systematic modification of the peptide substrate was carried out to identify positions suitable for the introduction of the fluorescent donor and the quencher acceptor groups.

The role of viral infections in exacerbations of chronic obstructive pulmonary disease and asthma

Asthma and chronic obstructive pulmonary disease (COPD) are major causes of global morbidity and mortality worldwide. The clinical course of both asthma and COPD are punctuated by the occurrence of exacerbations, acute events characterized by increased symptoms and airflow obstruction. Exacerbations contribute most of the morbidity, mortality and excess healthcare costs associated with both asthma and COPD. COPD and asthma exacerbations are frequently associated with respiratory virus infections and this has led to an intense research focus into the mechanisms of virus-induced exacerbations over the past decade. Current therapies are effective in reducing chronic symptoms but are less effective in preventing exacerbations, particularly in COPD. Understanding the mechanisms of virus-induced exacerbation will lead to the development of new targeted therapies that can reduce the burden of virus-induced exacerbations. In this review we discuss current knowledge of virus-induced exacerbations of asthma and COPD with a particular focus on mechanisms, human studies, virus-bacteria interactions and therapeutic advances.

Lower airway colonization and inflammatory response in COPD: a focus on Haemophilus influenzae

Bacterial infection of the lower respiratory tract in chronic obstructive pulmonary disease (COPD) patients is common both in stable patients and during acute exacerbations. The most frequent bacteria detected in COPD patients is Haemophilus influenzae, and it appears this organism is uniquely adapted to exploit immune deficiencies associated with COPD and to establish persistent infection in the lower respiratory tract. The presence of bacteria in the lower respiratory tract in stable COPD is termed colonization; however, there is increasing evidence that this is not an innocuous phenomenon but is associated with airway inflammation, increased symptoms, and increased risk for exacerbations. In this review, we discuss host immunity that offers protection against H. influenzae and how disturbance of these mechanisms, combined with pathogen mechanisms of immune evasion, promote persistence of H. influenzae in the lower airways in COPD. In addition, we examine the role of H. influenzae in COPD exacerbations, as well as interactions between H. influenzae and respiratory virus infections, and review the role of treatments and their effect on COPD outcomes. This review focuses predominantly on data derived from human studies but will refer to animal studies where they contribute to understanding the disease in humans.

Kidney function after off-pump or on-pump coronary artery bypass graft surgery: a randomized clinical trial

IMPORTANCE

Most acute kidney injury observed in the hospital is defined by sudden mild or moderate increases in the serum creatinine concentration, which may persist for several days. Such acute kidney injury is associated with lower long-term kidney function. However, it has not been demonstrated that an intervention that reduces the risk of such acute kidney injury better preserves long-term kidney function.

OBJECTIVES

To characterize the risk of acute kidney injury with an intervention in a randomized clinical trial and to determine if there is a difference between the 2 treatment groups in kidney function 1 year later.

DESIGN, SETTING, AND PARTICIPANTS

The Coronary Artery Bypass Grafting Surgery Off- or On-pump Revascularisation Study (CORONARY) enrolled 4752 patients undergoing first isolated coronary artery bypass graft (CABG) surgery at 79 sites in 19 countries. Patients were randomized to receive CABG surgery either with a beating-heart technique (off-pump) or with cardiopulmonary bypass (on-pump). From January 2010 to November 2011, 2932 patients (from 63 sites in 16 countries) from CORONARY were enrolled into a kidney function substudy to record serum creatinine concentrations during the postoperative period and at 1 year. The last 1-year serum creatinine concentration was recorded on January 18, 2013.

MAIN OUTCOMES AND MEASURES

Acute kidney injury within 30 days of surgery (≥50% increase in serum creatinine concentration from prerandomization concentration) and loss of kidney function at 1 year (≥20% loss in estimated glomerular filtration rate from prerandomization level).

RESULTS

Off-pump (n = 1472) vs on-pump (n = 1460) CABG surgery reduced the risk of acute kidney injury (17.5% vs 20.8%, respectively; relative risk, 0.83 [95% CI, 0.72-0.97], P = .01); however, there was no significant difference between the 2 groups in the loss of kidney function at 1 year (17.1% vs 15.3%, respectively; relative risk, 1.10 [95% CI, 0.95-1.29], P = .23). Results were consistent with multiple alternate continuous and categorical definitions of acute kidney injury or kidney function loss, and in the subgroup with baseline chronic kidney disease.

CONCLUSIONS AND RELEVANCE

Use of off-pump compared with on-pump CABG surgery reduced the risk of postoperative acute kidney injury, without evidence of better preserved kidney function with off-pump CABG surgery at 1 year. In this setting, an intervention that reduced the risk of mild to moderate acute kidney injury did not alter longer-term kidney function.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00463294.

An evaluation of the growth, carcass and meat quality characteristics of Omani goat breeds

Body weight, growth, carcass and meat quality characteristics were evaluated in three breeds of goats (Batina, Dhofari and Jabal Akdhar) in Oman. Fourteen intact male goats from each breed were used. Jabal Akdhar goats had significantly heavier slaughter, empty body, and carcass weights and higher growth rates than Dhofari and Batina goats. Jabal Akdhar goats had significantly heavier internal organs than the other two breeds. Dressing-out percent (based on empty body weight) of goats ranged between 53 and 57%, with the Dhofari goats having the highest value. Longissimus muscle dimensions varied between the three breeds, with Jabal Akdhar having a significantly larger area than Batina with Dhofari in between. Dhofari goats produced significantly shorter and wider carcasses than Batina and Jabal Akhdar goats. Carcass cuts were significantly heavier in Jabal Akdhar than the other two breeds. Four muscles (Mm. longissimus dorsi, biceps femoris, semitendinosus, and semimembranosus) from both sides of each carcass were subjected to two different ageing periods (1 day vs. 6 day) and evaluated for ultimate pH, expressed juice, percent cooking loss, colour (L*, a* and b*), and Warner-Bratzler shear force. Breed had a significant influence on pH and percent cooking loss but not on expressed juice, shear force value and colour (CIE L*,a*, b* values). Muscles from the Batina goats had significantly higher ultimate pH values and lower percent cooking loss than Dhofari and Jabal Akdhar goats. Ageing from 1 to 6 days increased tenderness significantly (27%), but decreased cooking loss by 5%.

Idiopathic retroperitoneal hematoma

Idiopathic retroperitoneal hematoma is a rare, but potentially life threatening cause of an acute surgical abdomen. Initially diagnosis may be overlooked, leading to unnecessary exploration, which may have implications for prognosis of the patient. An enhanced Computer Tomography (CT) scan of the abdomen is the principle method of diagnosis. However, as in our case, laparoscopic management of the acute abdomen can play a vital role in this group of patients. Importantly, early diagnosis and vigilant conservative management can improve the outcome in idiopathic retroperitoneal hematoma.

Endothelin and effects of endothelin‐receptor activation in the mammary and radial artery

OBJECTIVE

To determine the tissue content and endothelin-receptor characteristics of endothelin-1 in the radial artery in relation to the internal mammary artery.

DESIGN

Endothelin-1 content was quantified in the radial artery and the internal mammary artery. Both arteries were exposed to endothelin-1 and agonists of the endothelin A and B receptors.

RESULTS

The highest level of endothelin-1 was found in the radial artery. Endothelin-1 contracted both arteries. The contraction was sensitive to endothelinA-receptor agonism and enhanced in both arteries by inhibition of prostacyclin and nitric oxide formation. In the internal mammary artery the endothelinB-receptor agonist caused an endothelinA-receptor sensitive contraction augmented by inhibition of nitric oxide and prostacyclin. However, in the radial artery this contraction was only observed in the presence of inhibition of nitric oxide and prostaglandin.

CONCLUSION

The highest endothelin-1 content was found in the radial artery. The functional effects of endothelin-1 in the radial artery were similar to that in the internal mammary artery, mediated by predominantly endothelinA-receptor activation causing vasoconstriction. Selective endothelinA-receptor blockade may prove beneficial in preventing graft spasm in the radial as well as the internal mammary artery.

PAR bZIP-bik is a novel transcriptional pathway that mediates oxidative stress-induced apoptosis in fibroblasts

PAR bZIP (cells knockout for PAR bZIP transcription factors) proteins, thyrotroph embryonic factor (TEF), albumin D-site-binding protein (DBP), and hepatic leukemia factor (HLF), are a family of transcription factors that have been shown to contribute to the expression of genes involved in detoxification and drug metabolism. Recently, we showed that PAR bZIP proteins were able to regulate the BH3-only gene bcl-gS in tumor cells. Here, we have extended the role of these transcription factors in the control of apoptosis executors by analyzing the expression of BH3-only genes in PAR bZIP triple knockout mouse fibroblasts. We found that bik was the only BH3-only gene downregulated in knockout cells. Consistently, transfection of TEF or DBP induces the expression of endogenous bik, regardless of the presence of active p53. Moreover, both promoter-reporter and chromatin immunoprecipitation assays indicate that PAR bZIP proteins activate the bik promoter directly. Treatment with different stress stimuli reveals a higher survival of knockout fibroblasts compared with that of wild-type cells, especially after incubation with H(2)O(2), which suggest that PAR bZIP proteins participate in oxidative stress-induced apoptosis. Furthermore, the apoptotic cell death promoted by treatment with H(2)O(2) can be impaired by reducing the expression of Bik in wild-type fibroblasts or enhanced by the overexpression of Bik in knockout cells. These findings reveal a novel transcriptional pathway relevant in transducing the apoptotic response to oxidative stress.

The phospholipase A inhibitor, aristolochic acid, disrupts cortical microtubule arrays and root growth in Arabidopsis

The role of phospholipase A(2) in Arabidopsis root growth and microtubule organisation was investigated using a specific inhibitor, aristolochic acid. At 0.5-1.5 microm concentrations, this inhibitor reduced root elongation and caused radial swelling of the root tip. The normally transverse cortical microtubules in root tip cells became progressively more disorganised with increasing concentrations of the inhibitor. Microtubule disorganisation also occurred in leaf epidermal cells of Allium porrum. We propose that phospholipase A(2) is involved in microtubule organisation and anisotropic growth in a manner similar to that reported previously for phospholipase D, thus broadening the significance of phospholipid signalling in microtubule organisation in plants.

The management of deep sternal wound infections using vacuum assisted closure (V.A.C.) therapy

A group of international experts met in May 2006 to develop clinical guidelines on the practical application of vacuum assisted closure (V.A.C.)+ therapy in deep sternal wound infections. Group discussion and an anonymous interactive voting system were used to develop content. The recommendations are based on current evidence or, where this was not available, the majority consensus of the international group. The principles of treatment for deep sternal wound infections include early recognition and treatment of infection. V.A.C. therapy should be instigated early, following thorough wound irrigation and surgical debridement. V.A.C. therapy in deep sternal wound infections requires specialist surgical supervision and should only be undertaken by clinicians with adequate experience and training in the use of the technique.

Vascular Smooth Muscle Cells Undergo Telomere-Based Senescence in Human Atherosclerosis

Although human atherosclerosis is associated with aging, direct evidence of cellular senescence and the mechanism of senescence in vascular smooth muscle cells (VSMCs) in atherosclerotic plaques is lacking. We examined normal vessels and plaques by histochemistry, Southern blotting, and fluorescence in situ hybridization for telomere signals. VSMCs in fibrous caps expressed markers of senescence (senescence-associated β-galactosidase [SAβG] and the cyclin-dependent kinase inhibitors [cdkis] p16 and p21) not seen in normal vessels. In matched samples from the same individual, plaques demonstrated markedly shorter telomeres than normal vessels. Fibrous cap VSMCs exhibited markedly shorter telomeres compared with normal medial VSMCs. Telomere shortening was closely associated with increasing severity of atherosclerosis. In vitro, plaque VSMCs demonstrated morphological features of senescence, increased SAβG expression, reduced proliferation, and premature senescence. VSMC senescence was mediated by changes in cyclins D/E, p16, p21, and pRB, and plaque VSMCs could reenter the cell cycle by hyperphosphorylating pRB. Both plaque and normal VSMCs expressed low levels of telomerase. However, telomerase expression alone rescued plaque VSMC senescence despite short telomeres, normalizing the cdki/pRB changes. In vivo, plaque VSMCs exhibited oxidative DNA damage, suggesting that telomere damage may be induced by oxidant stress. Furthermore, oxidants induced premature senescence in vitro, with accelerated telomere shortening and reduced telomerase activity. We conclude that human atherosclerosis is characterized by senescence of VSMCs, accelerated by oxidative stress-induced DNA damage, inhibition of telomerase and marked telomere shortening. Prevention of cellular senescence may be a novel therapeutic target in atherosclerosis.

Use of community genetic screening to prevent HFE-associated hereditary haemochromatosis

HFE-associated hereditary haemochromatosis is a recessive, iron-overload disorder that affects about one in 200 north Europeans and that can be easily prevented. However, genetic screening for this disease is controversial, and so we assessed whether such screening was suitable for communities. Cheek-brush screening for the Cys282Tyr HFE mutation was offered to individuals in the workplace. Outcomes were assessed by questionnaires before and after testing. 11,307 individuals were screened. We recorded no increase in anxiety in individuals who were homozygous for the Cys282Tyr mutation or non-homozygous. Self-reported tiredness before testing was significantly higher in homozygous participants than in non-homozygous participants (chi2 test, p=0.029). Of the 47 homozygous individuals identified, 46 have taken steps to treat or prevent iron accumulation. Population genetic screening for HFE-associated hereditary haemochromatosis can be practicable and acceptable.

Is treatment with interferon-alpha effective in all patients with metastatic renal carcinoma? A new approach to the investigation of interactions

The first analysis of the MRC RE01 trial in metastatic renal carcinoma identified a 28% reduction in the hazard of death for patients treated with interferon-α compared with medroxyprogesterone acetate (MPA). No subgroup was identified in which treatment with interferon-α was more or less effective than MPA. We used a new approach based on fractional polynomials to investigate the updated data from this trial for the possible interaction of treatment with prognostic factors. In the spirit of hypothesis generation, we considered 10 possible prognostic variables, of which white cell count (WCC) was found to influence the effectiveness of interferon treatment. In patients treated with MPA, there was no prognostic effect of WCC, whereas, in patients treated with interferon, the risk of dying increased significantly with WCC level. We defined subgroups of patients based on WCC levels and estimated a hazard ratio of 0.53 in favour of interferon in patients with WCC <6.5 × 10⁹, whereas for patients with WCC >10 × 10⁹ the risk appears to be similar between the treatment groups, or even slightly raised in the interferon group. Since our results are derived from flexible statistical models, they may be interpreted as a new hypothesis and require validation in independent data.

Rupture of the atherosclerotic plaque: does a good animal model exist?

By its very nature, rupture of the atherosclerotic plaque is difficult to study directly in humans. A good animal model would help us not only to understand how rupture occurs but also to design and test treatments to prevent it from happening. However, several difficulties surround existing models of plaque rupture, including the need for radical interventions to produce the rupture, lack of direct evidence of rupture per se, and absence of convincing evidence of platelet- and fibrin-rich thrombus at the rupture site. At the present time, attention should therefore focus on the processes of plaque breakdown and thrombus formation in humans, whereas the use of animal models should probably be reserved for studying the function of particular genes and for investigating isolated features of plaques, such as the relationship between cap thickness and plaque stability.