Mitral Regurgitation Complicated by Cardiogenic Shock: Reassessing Risk Stratification and Therapeutic Strategies

Mitral regurgitation complicated by cardiogenic shock creates a unique and devastating risk profile for patients and poses significant difficulties for physicians who lack a comprehensive range of effective management strategies. Supportive measures such as intravenous vasodilators, intra-aortic balloon pumps, and percutaneous ventricular assist devices are often necessary to stabilize patients prior to definitive treatment with surgical mitral valve replacement or trans-catheter edge-to-edge repair. This review evaluates the evidence for the available supportive and definitive management strategies in patients with mitral regurgitation complicated by cardiogenic shock and presents a framework to aid clinicians in navigating the complex clinical decision-making process. Additionally, the authors review emerging transcatheter mitral valve replacement technologies that hold promise for expanding the therapeutic armamentarium and improving patient outcomes.

Comprehensive Quality of Life Report from a Prospective Clinical Trial of 4DCT-Ventilation Functional Lung Avoidance Radiation Therapy

PURPOSE/OBJECTIVE(S)

Functional imaging has been developed that uses 4DCT images and image processing to generate lung ventilation maps (4DCT-ventilation). 4DCT-ventilation functional avoidance uses 4DCT-images to generate plans that avoid functional regions of the lung with the goal of reducing pulmonary toxicity. A 4DCT-ventilation functional avoidance, phase II, multi-center clinical trial was completed, and patient reported outcomes (PRO) measured. PROs are an essential measure of quality-of-life following radiotherapy. The purpose of this work is to quantify PRO changes for lung cancer patients treated with functional avoidance and to compare PROs against clinical pneumonitis.

MATERIALS/METHODS

Patients with locally advanced lung cancer receiving curative intent radiotherapy (prescriptions of 45-75 Gy) and chemotherapy were accrued. Each patient had a 4DCT-ventilation image generated using 4DCT data. Favorable arc geometry and optimization techniques were used to generate functional avoidance plans. PRO instruments included the Functional Assessment of Cancer Therapy Lung (FACT-L) questionnaire and the Visual Analog Scale (VAS) administered pre-treatment and 3-, 6-, and 12-months post-treatment to gather data on physical, social, emotional, functional, and pulmonary well-being. The percentage of patients with clinically significant decline was calculated using the FACT-TOI (Trial Outcome Index), FACT-LCS (Lung Cancer Subscale), and VAS instruments. To evaluate the correlation between PROs and clinical toxicity, the percentage of clinically significant FACT-LCS decline was compared (Chi-square test) for patients who did or did not experience grade 2+ pneumonitis.

RESULTS

Fifty-nine patients completed baseline PRO surveys. Median age was 65, 83% of patients had non-small-cell lung cancer, with 75% having stage III disease. Clinically significant FACT-TOI decline at, 3, 6, and 12 months was 46.3%, 38.5%, and 26.8%, respectively. The percentage of patients with clinically significant FACT-LCS decline was 33.3%, 33.3%, and 29.3%, at 3 months, 6 months, and 12 months, respectively. The percentage of patients with clinically significant VAS decline at 3, 6, and 12 months was 18.9%, 20.0%, and 18.6%, respectively. Patients who experienced grade 2+ pneumonitis had a greater percentage of clinically significant decline at all time-points with the results reaching significance (p = 0.045) at 6 months.

CONCLUSION

The study presents the first comprehensive evaluation of PROs for patients treated with 4DCT-ventilation functional avoidance. The data show that 20-40% of patients had clinically significant decline and that PROs had a strong correlation with pneumonitis. The PRO data demonstrate that functional avoidance results in low rates of patient reported outcome clinical decline and provide seminal results to be used in phase III studies.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

CCR5 Receptor Occupancy Analysis Reveals Increased Peripheral Blood CCR5+CD4+ T Cells Following Treatment With the Anti-CCR5 Antibody Leronlimab

CCR5 plays a central role in infectious disease, host defense, and cancer progression, thereby making it an ideal target for therapeutic development. Notably, CCR5 is the major HIV entry co-receptor, where its surface density correlates with HIV plasma viremia. The level of CCR5 receptor occupancy (RO) achieved by a CCR5-targeting therapeutic is therefore a critical predictor of its efficacy. However, current methods to measure CCR5 RO lack sensitivity, resulting in high background and overcalculation. Here, we report on two independent, flow cytometric methods of calculating CCR5 RO using the anti-CCR5 antibody, Leronlimab. We show that both methods led to comparable CCR5 RO values, with low background on untreated CCR5+CD4+ T cells and sensitive measurements of occupancy on both blood and tissue-resident CD4+ T cells that correlated longitudinally with plasma concentrations in Leronlimab-treated macaques. Using these assays, we found that Leronlimab stabilized cell surface CCR5, leading to an increase in the levels of circulating and tissue-resident CCR5+CD4+ T cells in vivo in Leronlimab-treated macaques. Weekly Leronlimab treatment in a chronically SIV-infected macaque led to increased CCR5+CD4+ T cells levels and fully suppressed plasma viremia, both concomitant with full CCR5 RO on peripheral blood CD4+ T cells, demonstrating that CCR5+CD4+ T cells were protected from viral replication by Leronlimab binding. Finally, we extended these results to Leronlimab-treated humans and found that weekly 700 mg Leronlimab led to complete CCR5 RO on peripheral blood CD4+ T cells and a statistically significant increase in CCR5+CD4+ T cells in peripheral blood. Collectively, these results establish two RO calculation methods for longitudinal monitoring of anti-CCR5 therapeutic antibody blockade efficacy in both macaques and humans, demonstrate that CCR5+CD4+ T cell levels temporarily increase with Leronlimab treatment, and facilitate future detailed investigations into the immunological impacts of CCR5 inhibition in multiple pathophysiological processes.

EP.FRI.1020 The necessity of colonoscopy to rule out colorectal malignancy after computerised tomography proven diagnosis of acute diverticulitis

Introduction

The current Royal College of Surgeons commissioning guideline on colonic diverticular disease suggests that patients should undergo endoscopic evaluation of the colonic lumen after an episode of computed tomography (CT) proven acute diverticulitis to rule out malignancy. The necessity of routine endoscopic assessment of CT proven diverticulitis remains debatable.

Aim

To establish whether routine endoscopic assessment should be carried out for patients after an episode of acute diverticulitis.

Method

Data was collected retrospectively from all patients diagnosed with acute diverticulitis on CT and who subsequently had follow up endoscopic assessment from January to July 2019.

Results

Total number of patients were 64.Median age of the cohort was 58.Of all patients, 48 had diagnosis of uncomplicated diverticulitis whereas 16 patients had diagnosis of complicated diverticulitis on CT scan. All patients had follow up colonoscopy after an acute attack with following findings: 2 patients had no pathology, 56 patients had diagnosis of only diverticulosis, 4 patients had both diverticulosis and polyps and 2 patients had bowel cancer. All 4 cases of polyps had benign pathology and uncomplicated diverticulitis on CT scan. Two bowel cancer patients, one had complicated diverticulitis with thickening of proximal sigmoid and the other patient had abnormal sigmoid colon suggestive of malignancy on CT scan.

Conclusion

Recent meta-analysis showed no difference between diverticulitis and normal population group in terms of risk of bowel cancer. Routine colonoscopy may not be appropriate in patients with acute uncomplicated diverticulitis but endoscopic assessment after an episode of complicated diverticulitis is necessary.

219 Have New National Guidelines Changed Practice in Referrals with Suspected Ureteric Colic?

Aim

To assess how many patients had a non-contrast CT as first-line investigation for suspected renal colic, and how this was affected by the release of the 2019 NICE guidelines. A secondary aim was to assess the proportion of patients who had CT KUBs that demonstrated a ureteric calculus.

Method

CT KUB scans performed over two separate 3 month periods were identified. These reflected periods of time before and after the new NICE guidelines. Electronic records were used to assess if the patients had an ultrasound performed as the initial diagnostic investigation, instead of a CT scan. The results of the scans were reviewed to identify if a ureteric or renal calculus had been positively identified.

Results

In the period before the new guidelines, 61 patients were scanned. 4 had an ultrasound to assess for a stone prior to a CT. All of these patients were medical inpatients. None of the ultrasounds diagnosed a stone. 22/61 patients had CT-proven stones (36%) In the period after the new guidelines, 79 patients were scanned. 12 had an ultrasound to assess for a stone prior to a CT. 8 were medical patients, 3 were surgical and 1 was gynaecological. 1 ultrasound diagnosed a stone. 28/79 patients had CT-proven stones (35.4%)

Conclusions

The release of new guidelines did not improved compliance with suggested imaging pathways. This clearly demonstrates an area for improvement. It is also worth noting that only 1/3 of referrals with suspected renal colic did actually have a stone, which has implications for specialty referral pathways.

218 The Impact on Minimally Invasive Urological Cancer Surgery During the Covid-19 Pandemic

Aim

Learned bodies recommended restricted use of, or extensive precautions when using, laparoscopic/robotic surgery during the Covid-19 pandemic. We aimed to determine whether minimally invasive surgery (MIS) in uro-oncology patients was safe for patients and staff.

Method

From 16 March to 16 June 2020, patients having MIS in a tertiary referral urology centre were identified from a prospectively collected database. Patient characteristics, operative details and 30-day follow-up for adverse events were recorded including Covid-19 tests and results. Any theatre staff Covid-19 event was traced back 14 days to determine any involvement in these cases.

Results

87 patients were eligible for inclusion (33 robotic prostatectomies, 38 laparoscopic prostatectomies, 11 laparoscopic nephrectomies, 5 robotic nephrectomies). All patients were assessed for symptoms of Covid-19 on the day of theatre. 18(21%) patients had pre-operative screening (all swabs, no CT chest). 46(53%) underwent 14 days pre-operative self-isolation. 38(44%) cases were performed with FFP3 protection. No modification to operating procedure was made for any cases. No patients tested positive for Covid-19 in the 30-day postoperative period. No staff member involved tested positive in the postoperative period. 1 patient tested positive pre-operatively, delaying the operation by 7 weeks. No patients tested positive after the introduction of mandatory screening.

Conclusions

Based on our case-series MIS urological surgery appears to be safe for patients and staff, with no increased risk of Covid-19 complications in patients who are asymptomatic pre-operatively. The introduction of mandatory pre-operative swabs for elective patients, and the use of FFP3 protection, did not significantly alter results.

367 Improving Handover Documentation in Surgical Inpatients Using Weekend Handover Stickers

Introduction

Transfer to the care to the oncoming team is the point at which inpatients are most vulnerable. Effective handover is vital to protect patient safety and clinical governance. The Royal College of Surgery (RCS) Safe Handover guidelines highlight relevant information required for comprehensive handover. This QI project aimed to determine if implementation of weekend handover stickers in surgical patients’ notes improved handover documentation.

Method

A retrospective records-based audit of patients admitted under general surgery over a 4-week period was performed. Standards were set using the RCS guidelines to determine if sufficient weekend handover was documented.

We designed weekend handover stickers to be inserted in notes based on guidelines. A re-audit cycle over a 4-week period was performed to determine if the intervention improved handover documentation.

Results

119 patients were in the initial audit. 125 patients were in the re-audit. Documented handover in the notes improved from 43.7% to 89.6% after intervention.

Documentation of the following clinical information also improved: clinical situation (43.7% to 92.0%); co-morbidities (14.3% to 89.6%); current issues (71.4% to 94.4%); weekend blood tests (32.8% to 92.0%); antibiotic therapy (21.8% to 92.0%).

Conclusions

Weekend handover stickers resulted in a significant improvement in handover documentation improving patient safety.

A Modified AUGIS Delphi Process to Establish Future Research Priorities in Benign Upper Gastrointestinal Surgery

BACKGROUND

The aim of our study was to use a modified Delphi process to determine the research priorities amongst benign upper gastrointestinal (UGI) surgeons in the United Kingdom.

METHODS

Delphi methodology may be utilised to develop consensus opinion amongst a group of experts. Members of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland were invited to submit individual research questions via an online survey (phase I). Two rounds of prioritisation by multidisciplinary expert healthcare professionals (phase II and III) were completed to determine a final list of high-priority research questions.

RESULTS

Four hundred and twenty-seven questions were submitted in phase I, and 51 with a benign UGI focus were taken forward for prioritisation in phase II. Twenty-eight questions were ranked in phase III. A final list of 11 high-priority questions had an emphasis on acute pancreatitis, Barrett's oesophagus and benign biliary disease.

CONCLUSION

A modified Delphi process has produced a list of 11 high-priority research questions in benign UGI surgery. Future studies and awards from funding bodies should reflect this consensus list of prioritised questions in the interest of improving patient care and encouraging collaborative research.

Measurements of the Thermal Resistivity of InAlAs, InGaAs, and InAlAs/InGaAs Superlattices

Thermal management efforts in nanoscale devices must consider both the thermal properties of the constituent materials and the interfaces connecting them. It is currently unclear whether alloy/alloy semiconductor superlattices such as InAlAs/InGaAs have lower thermal conductivities than their constituent alloys. We report measurements of the crossplane thermal resistivity of InAlAs/InGaAs superlattices at room temperature, showing that the superlattice resistivities are larger by a factor of 1.2-1.6 than that of the constituent bulk materials, depending on the strain state and composition. We show that the additional resistance present in these superlattices can be tuned by a factor of 2.5 by altering the lattice mismatch and thereby the phonon-mode mismatch at the interfaces, a principle that is commonly assumed for superlattices but has not been experimentally verified without adding new elements to the layers. We find that the additional resistance in superlattices does not increase significantly when the layer thickness is decreased from 4 to 2 nm. We also report measurements of 250-1000 nm thick films of undoped InGaAs and InAlAs lattice-matched to InP substrates, for there is no published thermal conductivity value for the latter, and we find it to be 2.24 ± 0.09 at 22 °C, which is ∼2.7 times smaller than the widely used estimates.

Evaluation of healing in feline femoral defects filled with cancellous autograft, cancellous allograft or Bioglass

Cancellous bone grafting is a widely accepted technique in human and veterinary orthopaedic surgery. However, the use of autogenous bone graft is limited by the additional surgical time required to harvest the graft, the morbidity associated with the donor site, and the limited availability of cancellous bone, especially in feline patients. Various allografts and bone graft substitutes are available commercially but have not been fully evaluated for efficacy in the cat. The purpose of this study was to compare the incorporation of autogenous and allogenous cancellous bone graft and Bioglass®, a synthetic bone graft substitute, in femoral defects in cats. Four (4.0 mm diameter) defects were created in the lateral diaphyseal cortex of the left femur with an orthopaedic drill. In each femur, one of the cortical defects was filled with autogenous cancellous graft (harvested from the tibia), one was filled with allogenic cancellous graft, and one was filled with Bioglass. The fourth defect remained unfilled. Graft incorporation within the femoral defects was evaluated by radiographic evaluation every two weeks. Six weeks after the grafting procedure, the cats were euthanatized and high detailed radiography, dual energy X-ray absorptiometry (DEXA), histopathology and histomorphometry of the defects were performed. Satisfactory bone healing was observed within all of the defects.

Comfort and performance of power line maintainers' gloves during electrical utility work in the cold

BACKGROUND

Electrical utility workers wear thick rubber gloves and often work in the cold.

OBJECTIVE

To document the challenge of working in the cold and the effectiveness of different glove/liner combinations in keeping workers' hands warm.

METHODS

Ten experienced male electrical utility employees worked in a controlled temperature walk-in chamber at -20 °C for 45 minutes for each of five glove conditions: standard five-finger rubber gloves with cotton liners and gauntlets, mitten style gloves, a prototype wool liner, and two heating options; glove or torso. Dependent measures were maximum grip force, skin temperatures, finger dexterity and sensitivity to touch, ratings of perceived effort and a rating of thermal sensation.

RESULTS

Participants' hand skin temperatures decreased, they perceived their hands to be much colder, their finger sensitivity decreased and their ratings of perceived exertion increased, however their performance did not degrade over the 45 minute trials. The mitten-style gloves showed a smaller drop in skin temperature for the 3rd and 5th digits (p< 0.05) than the other glove conditions.

CONCLUSIONS

Mitten style gloves kept workers' hands warmer than the standard five finger glove.

Evidence based guidelines for the prevention, identification, and management of occupational asthma

BACKGROUND

Occupational asthma is the most frequently reported work related respiratory disease in many countries. This work was commissioned by the British Occupational Health Research Foundation to assist the Health and Safety Executive in achieving its target of reducing the incidence of occupational asthma in Great Britain by 30% by 2010.

AIM

The guidelines aim to improve the prevention, identification, and management of occupational asthma by providing evidence based recommendations on which future practice can be based.

METHODS

The literature was searched systematically using Medline and Embase for articles published in all languages up to the end of June 2004. Evidence based statements and recommendations were graded according to the Royal College of General Practitioner's star system and the revised Scottish Intercollegiate Guidelines Network grading system.

RESULTS

A total of 474 original studies were selected for appraisal from over 2500 abstracts. The systematic review produced 52 graded evidence statements and 22 recommendations based on 223 studies.

DISCUSSION

Evidence based guidelines have become benchmarks for practice in healthcare and the process used to prepare them is well established. This evidence review and its recommendations focus on interventions and outcomes to provide a robust approach to the prevention, identification, and management of occupational asthma, based on and using the best available medical evidence. The most important action to prevent cases of occupational asthma is to reduce exposure at source. Thereafter surveillance should be performed for the early identification of symptoms, including occupational rhinitis, with additional functional and immunological tests where appropriate. Effective management of workers suspected to have occupational asthma involves the identification and investigation of symptoms suggestive of asthma immediately they occur. Those workers who are confirmed to have occupational asthma should be advised to avoid further exposure completely and early in the course of their disease to offer the best chance of recovery.

Evaluation of healing in feline femoral defects filled with cancellous autograft, cancellous allograft or Bioglass

Cancellous bone grafting is a widely accepted technique in human and veterinary orthopaedic surgery. However, the use of autogenous bone graft is limited by the additional surgical time required to harvest the graft, the morbidity associated with the donor site, and the limited availability of cancellous bone, especially in feline patients. Various allografts and bone graft substitutes are available commercially but have not been fully evaluated for efficacy in the cat. The purpose of this study was to compare the incorporation of autogenous and allogenous cancellous bone graft and Bioglass, a synthetic bone graft substitute, in femoral defects in cats. Four (4.0 mm diameter) defects were created in the lateral diaphyseal cortex of the left femur with an orthopaedic drill. In each femur, one of the cortical defects was filled with autogenous cancellous graft (harvested from the tibia), one was filled with allogenic cancellous graft, and one was filled with Bioglass. The fourth defect remained unfilled. Graft incorporation within the femoral defects was evaluated by radiographic evaluation every two weeks. Six weeks after the grafting procedure, the cats were euthanatized and high detailed radiography, dual energy X-ray absorptiometry (DEXA), histopathology and histomorphometry of the defects were performed. Satisfactory bone healing was observed within all of the defects.

Amnesic shellfish poison

Amnesic shellfish poisoning (ASP) is caused by consumption of shellfish that have accumulated domoic acid, a neurotoxin produced by some strains of phytoplankton. The neurotoxic properties of domoic acid result in neuronal degeneration and necrosis in specific regions of the hippocampus. A serious outbreak of ASP occurred in Canada in 1987 and involved 150 reported cases, 19 hospitalisations and 4 deaths after consumption of contaminated mussels. Symptoms ranged from gastrointestinal disturbances, to neurotoxic effects such as hallucinations, memory loss and coma. Monitoring programmes are in place in numerous countries worldwide and closures of shellfish harvesting areas occur when domoic acid concentrations exceed regulatory limits. This paper reviews the chemistry, sources, metabolism and toxicology of domoic acid as well as human case reports of ASP and discusses a possible mechanism of toxicity.

Prevalence of autism in a United States population: the Brick Township, New Jersey, investigation

OBJECTIVE

This study determined the prevalence of autism for a defined community, Brick Township, New Jersey, using current diagnostic and epidemiologic methods.

METHODS

The target population was children who were 3 to 10 years of age in 1998, who were residents of Brick Township at any point during that year, and who had an autism spectrum disorder. Autism spectrum disorder was defined as autistic disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS), and Asperger disorder. The study used 4 sources for active case finding: special education records, records from local clinicians providing diagnosis or treatment for developmental or behavioral disabilities, lists of children from community parent groups, and families who volunteered for participation in the study in response to media attention. The autism diagnosis was verified (or ruled out) for 71% of the children through clinical assessment. The assessment included medical and developmental history, physical and neurologic evaluation, assessment of intellectual and behavioral functioning, and administration of the Autism Diagnostic Observation Schedule-Generic.

RESULTS

The prevalence of all autism spectrum disorders combined was 6.7 cases per 1000 children. The prevalence for children whose condition met full diagnostic criteria for autistic disorder was 4.0 cases per 1000 children, and the prevalence for PDD-NOS and Asperger disorder was 2.7 cases per 1000 children. Characteristics of children with autism in this study were similar to those in previous studies of autism.

CONCLUSIONS

The prevalence of autism in Brick Township seems to be higher than that in other studies, particularly studies conducted in the United States, but within the range of a few recent studies in smaller populations that used more thorough case-finding methods.

Expression of the 67 kDa laminin receptor (67LR) during retinal development: correlations with angiogenesis

Interaction of vascular cells with the laminin component of basement membranes is important for normal cell function. Likewise, abnormal interactions may have a critical role in vascular pathology. It has been previously demonstrated that the 67 kDa laminin receptor (67LR) is expressed at high levels during proliferative retinopathy in a mouse model and in the current study we have examined 67LR in the neonatal mouse to determine if this receptor plays a role in aspects of developmental angiogenesis in the developing murine retina. Groups of C57/BL6 mice were killed at postnatal day P1, P3, P5, P7, P9 and P11 to assess the retinal vasculature. A number of mice were perfused with FITC-dextran and the eyes removed, fixed in 4% paraformaldehyde (PFA) and flat-mounted for confocal scanning laser microscopy. The eyes from the remaining mice were either placed in 4% PFA and embedded in paraffin-wax, or had the neural retina dissected off and total RNA or protein extracted. Immunofluorescence, in situ hybridization, quantitative reverse transcriptase polymerase chain reaction and Western blotting analysis were employed to locate and determine expression levels of 67LR. Both 67LR mRNA and protein expression showed a characteristic bi-phasic expression pattern which correlated with key stages of retinal vascular development in the murine retina. 67LR showed high expression levels at P1 (P < 0.05) (correlating with superficial vascular plexus formation) and at P7 (P < 0.05) (correlating with deep vascular plexus formation). Conversely, 67LR expression was decreased when active angiogenic activity was lowest. Significantly, optical sectioning of retinal flat-mounts revealed high levels of 67LR expression in developing segments of both superficial and deep capillary plexi, a pattern which co-localized strongly with laminin. 67LR is regulated during post-natal development of the retinal vasculature. High levels of 67LR during the two well-defined phases of retinal capillary plexus formation suggests that this receptor may play an important role in retinal angiogenesis.

Effects of reinforcement magnitude and ratio values on behaviour maintained by a cyclic ratio schedule of reinforcement

In Experiments 1 and 2, lever pressing by rats was reinforced on a cyclic ratio schedule of food reinforcement, comprising a repeated sequence of fixed-ratio component schedules. Reinforcement magnitude was varied, on occasional sessions in Experiment 1 and across blocks of sessions in Experiment 2, from one to two or three 45-mg food pellets. In the one-pellet condition, post-reinforcement pauses increased with component schedule value. At higher magnitudes, post-reinforcement pauses increased, and overall response rates declined. Response rate on component schedules was a decreasing linear function of the obtained rate of reinforcement in all conditions. Plotted against component schedule value, response rate increased exponentially to an asymptote that decreased when reinforcement magnitude increased. These findings are consistent with regulatory accounts of food-reinforced behaviour. In Experiment 3, rats were trained under a cyclic ratio schedule comprising fixed-ratio components including higher values, and some inverted U-shaped response functions were obtained. Those rats that did not show this relationship were trained on cyclic ratios with even higher values, and all showed inverted U-shaped response functions. This suggests that behaviour on cyclic ratio schedules can reflect activating of reinforcement as well as the satiating effects seen in Experiments 1 and 2.

Retinal VEGF mRNA measured by SYBR green I fluorescence: A versatile approach to quantitative PCR

PURPOSE

To determine whether continuous monitoring of SYBR Green I fluorescence provides a reliable and flexible method of quantitative RT-PCR. Our aims were (i) to test whether SYBR Green I analysis could quantify a wide range of known VEGF template concentrations, (ii) to apply this method in an experimental model, and (iii) to determine whether 20 existing primer pairs could be used to quantify their cognate mRNAs.

METHODS

Real-time quantitative PCR was performed using a LightCycler rapid thermal cycler (Roche). Retinal VEGF mRNA levels were measured in a murine model of oxygen-induced retinopathy during vaso-obliterative and hypoxic phases.

RESULTS

This technique was able to detect as few as 10 control template copies, with quantitative data available routinely for 1000 or more copies. The levels of retinal VEGF mRNA expression followed the hypoxia-induced pattern determined previously by conventional methods. All gene-specific primer pairs which amplify a specific product by conventional PCR were successfully converted to SYBR Green analysis, including those for housekeeping genes glyceraldehyde phosphate dehydrogenase (GAPDH), cyclophilin, and acidic ribosomal phosphoprotein PO (ARP/36B4) and for 28S rRNA. In each case melting curve analysis and agarose gel electrophoresis confirmed the specificity of the amplification product.

CONCLUSIONS

The sequence-independent detection of DNA with SYBR Green I means that it can be used to quantify the amplification of any cDNA using gene-specific primers. This rapid and flexible method is ideally suited for researchers in vision science wishing to quantify mRNAs from many different genes because it does not require investment in gene-specific hybridization probes.

[Synthesis and transformations of ethyl 1,4-dihydro-4-oxo(1)benzofuro(3,2-b)pyridine-3-carboxylic acid esters: new antibacterial agents]

The title compound 7 was synthesized from potassium 3-amino-[1]benzofuran-2-carboxylate (1) by Gould-Jacobs-reaction. The pyridone 7 reacted with ethyl iodide by N- and O-alkylation to give 9 and 10, while methyl iodide only yielded the N-methylpyridone 11. The 4-chloropyridine 15 was obtained by heating 7 in phosphoryl chloride. Alkaline saponification of the esters 7, 9-11 and 15 afforded the carboxylic acids 8, 12-14 and 16. The carbaldehydes 19 and 22 were prepared from the ethylesters 10 and 15 by boranate reduction to the carbinoles 17 and 20 followed by dehydrogenation with activated manganese dioxide. The aldehyde 22 reacted with beta-aminocrotonic acid esters to yield the 1,4 dihydropyridines (DHP) 23. The pyridines 24 were formed by chemical or electrochemical dehydrogenation of the DHP 23. The tetrazole 27 was accessible from the aldehyde 22 via the aldoxime 25 and the nitrile 26. The pyridone 7 reacted with tosylisocyanate to yield the 4-tosylaminopyridine 28, which after alkylation to form 29 followed by detosylation to give 30 and subsequent alkaline hydrolysis produced the 4-aminonicotinic acid 31. The investigation The N-ethylpyridone-3-carboxylic acid 12 showed antibacterial activity comparable to the reference substance nalidixic acid against Pseudomonas aeruginosa, Escherichia coli and Bacillus megaterium.

Quantitative deficiency of monocyte-specific esterase (MSE) mRNA in monocyte esterase deficiency (MED)

Cytochemical staining of monocyte-specific esterase (MSE) is widely used for identification of the monocytic lineage in leukaemias. Deficiency of this enzymatic activity occurs as a familial trait and the deficiency has been shown to occur with greater frequency in patients with lymphoproliferative or gastrointestinal malignant neoplastic diseases than in normal blood donors. Reverse transcriptase polymerase chain reaction (RT-PCR), sequencing and quantification by Northern blot analysis was conducted on the MSE mRNA of 12 subjects with monocyte esterase deficiency (MED) and seven MSE-positive subjects to examine whether mutations were present or whether the defect was quantitative. Mutations were not found in the mRNA sequences. However, MED subjects had significantly less MSE mRNA than MSE-positive subjects (P = 0.001). These findings show that deficiency of monocyte esterase activity in MED is not as a result of the presence of inactive isoenzymes and may be owing to an abnormality in the regulation of mRNA production.

[Gyrase inhibitors. 3. Synthesis and reactions of 1,4-dihydro-4-oxo-(1)benzothieno(3,2-b)pyridin-3-carboxylic acid esters]

The title compound 4a is synthesized from potassium 3-aminobenzo[b]thiophene-2-carboxylate (1) by Gould-Jacobs reaction. Compound 4a reacts with alkyl halides and sodium hydride in DMF to yield the N-alkylpyridones 5a-c as well as the 4-alkoxypyridines 6a-c; with phosphoryl chloride the 4-chloropyridine 7a is obtained. The carboxylic acids 4b, 5d, 5e, 6d and 7b are received by alkaline saponification of the esters 4a, 5a-c, 6a-c and 7a. The carbinoles 8 and 9, formed by boranate reduction of the esters 6a and 7a, are transformed to the aldehydes 10 and 11 by activated manganese dioxide oxidation. The aldoxime 12 from the carbaldehyde 11 is dehydrated to yield the nitrile 13. The carbaldehyde 11 reacts with methyl beta-aminocrotonate to yield the 1,4-dihydropyridine (DHP) 14, which is dehydrogenated to give the 3,4'-bipyridine 15. The pyridone 4a reacts with tosylisocyanate to yield the 4-tosylaminopyridine 16a. The antibacterial activity of the carboxylic acids 4b, 5d, 5e and 6d is proved. The growth of Escherichia coli and Bacillus megaterium is inhibited by 5d in the same range as nalidixic acid does.

Aetiology of childhood vision impairment, metropolitan Atlanta, 1991-93

Data from the population-based Metropolitan Atlanta Developmental Disabilities Surveillance Program (MADDSP) were used to describe the underlying causes of vision impairment (VI; corrected visual acuity in the better eye of 20/70 or worse) in young children (n = 228) in metropolitan Atlanta in 1991-93. Children with VI were identified through record review at multiple educational and medical sources. Children were categorised as having isolated VI or multiple disabilities (i.e. VI plus one or more of four additional developmental disabilities) and as having low vision (visual acuity 20/70-20/400) or blindness (visual acuity worse than 20/400). Medical conditions abstracted from MADDSP sources were reviewed to determine the probable aetiology of a child's VI. Aetiologies were assigned to one of three developmental time periods: prenatal, perinatal, or postnatal. Prenatal aetiologies were identified in 43% of the children; 38% of the prenatal aetiologies were genetic. Perinatal aetiologies were found in 27% of the children. Postnatal aetiologies were rare. Prenatal aetiologies were more common in children with isolated VI; perinatal and postnatal aetiologies were more common in children with multiple disabilities. Children with prenatal aetiologies tended to have less severe vision loss than did children with perinatal or postnatal aetiologies. The distribution varied by birthweight, but did not differ significantly by sex or race.

Prevalence and phenotype consequence of FRAXA and FRAXE alleles in a large, ethnically diverse, special education-needs population

We conducted a large population-based survey of fragile X (FRAXA) syndrome in ethnically diverse metropolitan Atlanta. The eligible study population consisted of public school children, aged 7-10 years, in special education-needs (SEN) classes. The purpose of the study was to estimate the prevalence among whites and, for the first time, African Americans, among a non-clinically referred population. At present, 5 males with FRAXA syndrome (4 whites and 1 African American), among 1,979 tested males, and no females, among 872 tested females, were identified. All males with FRAXA syndrome were mentally retarded and had been diagnosed previously. The prevalence for FRAXA syndrome was estimated to be 1/3,460 (confidence interval [CI] 1/7,143-1/1,742) for the general white male population and 1/4, 048 (CI 1/16,260-1/1,244) for the general African American male population. We also compared the frequency of intermediate and premutation FRAXA alleles (41-199 repeats) and fragile XE syndrome alleles (31-199 repeats) in the SEN population with that in a control population, to determine if there was a possible phenotype consequence of such high-repeat alleles, as has been reported previously. No difference was observed between our case and control populations, and no difference was observed between populations when the probands were grouped by a rough estimate of IQ based on class placement. These results suggest that there is no phenotype consequence of larger alleles that would cause carriers to be placed in an SEN class.

Perceptions of quality in long-term care: a satisfaction survey

At a 387-bed geriatric hospital in Montreal, Canada, a cross-sectional satisfaction survey was conducted on random samples of patients, families, families of deceased patients, and nursing staff. Using the same pretested structured questionnaire, the subjects were asked to rank (assign importance to) and rate (assign a rate of success to) 15 indicators of quality care. Significant differences both between and within the four groups were found on the perceived importance and rate of success of many of the indicators, supporting the primary hypotheses. Ethnicity and several sociodemographic covariates influenced the importance and rate of success assigned to the key indicators. The article discusses survey methodology issues as well as the integration of a satisfaction survey into an overall quality improvement program.

Chondromyxoid fibroma of the sternum

We report the fourth case of chondromyxoid fibroma of the sternum described in the literature. The clinical, radiographic, pathologic and treatment aspects of this case are presented, and the literature on chondromyxoid fibroma in this unusual location is reviewed.

Ultrasound for detecting osteomyelitis in turkeys

One thousand turkey legs were examined for osteomyelitis (OM) by ultrasonographic, pathologic, and bacteriologic examinations. OM lesions were recognized as hyperechoic (brighter white) disruptions in cortical bone in the growth plate region by ultrasound examination OM was confirmed histologically in 139 of 1000 legs. OM was detected by ultrasound in 109 of 139 OM-positive legs for a sensitivity rate of 78%. OM was not detected by ultrasound in 713 of the 861 OM-negative legs for a specificity rate of 83%. Ultrasonography was superior to current use of green liver discoloration for detection of tibial OM in turkeys at processing. The economic benefit to the turkey industry from the approval and application of this procedure could be considerable.

Reproductive risk factors for epilepsy among ten-year-old children in metropolitan Atlanta

The elements of a woman's reproductive history that may be associated with her risk of having a child who develops epilepsy have not been well described. To examine these possible associations, we used a multiple-source case ascertainment method to identify ten-year-old children with epilepsy who were living in the metropolitan Atlanta area in 1985-87; same-age control children were selected from public schools. To obtain reproductive history and other information, we interviewed 107 mothers of children with epilepsy and 408 mothers of control children. Twenty-nine children with a known intrauterine or postnatal aetiology were excluded from the analysis. We computed adjusted odds ratios for reproductive history characteristics, controlling for the race of the child, maternal education, census block group income, maternal pregnancy history and family history of a developmental disability. Our analyses indicated that mothers of children with epilepsy not only had more previous live births, but more previous adverse reproductive outcomes including spontaneous abortions, very low birthweight infants and infants with birth defects. The risk was especially strong for maternal history of a child with a birth defect. The specific types of birth defects reported in excess include central nervous system defects (specifically spina bifida) and Down's syndrome.

A prospective study of early pregnancy loss

The New York State Early Pregnancy Detection Study was a prospective study of early pregnancy loss, between implantation and menses, in 217 women attempting to become pregnant during 1989-1992. Women collected urine samples on three consecutive mornings during the late luteal phase of their menstrual cycle, for up to 12 cycles, contributing samples for 1253 menstrual cycles. Urinary human chorionic gonadotrophin (HCG), measured using an immunoradiometric assay, was the biomarker for pregnancy. We observed a range of early pregnancy loss (EPL) rates, from a low estimate of 11.0% to a high estimate of 26.9%, depending on the definition used and the subgroup analysed. Based on a definition of 3 days of HCG concentration > or = 4.00 pmol/l, 2 days > or = 5.33 pmol/l or the last day of HCG > or = 6.67 pmol/l, we identified 115 positive cycles; 95 cycles were clinically confirmed pregnancies and 20 cycles were EPL, giving an EPL rate of 17.4% [95% confidence interval (CI) 11.0-25.6]. In addition, we observed an EPL rate of 19.5% (95% CI 11.3-30.1) for samples collected within a 15 day window around menses, and a rate of 20.3% (95% CI 11.3-32.2) for samples limited to the first three menstrual cycles. Because studies use urine collection schemes other than daily sampling, the definition of pregnancy will be crucial in defining EPL.

Patient surveys in general practice: a randomised trial of an instant lottery ticket to increase return rate

BACKGROUND

Patient surveys are becoming increasingly common and already are an obligatory activity to qualify for a Better Practice Program Grant. Strategies to increase return rates remain unevaluated in Australian general practice.

AIM

To evaluate the effectiveness of an instant lottery ticket as a response-aiding technique in patient surveys.

METHOD

A random sample of adult patients was selected from an age-sex-disease register, stratified by sex and randomised to receive an instant lottery ticket with the self-administered questionnaire mailed out in December 1994.

RESULTS

There was no significant difference by group either for women (P = 0.68), men (P = 0.88) or both sexes combined (P = 0.68). However, irrespective of inclusion of the lottery ticket, men were significantly less likely to return questionnaires than women (P = 0.02).

CONCLUSIONS

Instant lottery tickets do not increase return rates to questionnaires and are not recommended. Other strategies need to be tested, particularly to involve male patients in general practice research.