Age- and sex-dependent profiles of APP fragments and key secretases align with changes in despair-like behavior and cognition in young APPSwe/Ind mice

Biological sex exerts distinct influences on brain levels of the β-amyloid (Aβ) peptide in both clinical depression and Alzheimer disease (AD), yet studies in animal models focus primarily on males. We examined behavioral 'despair'/depression (using the tail-suspension test) and memory (using the novel object recognition task) in J20 (hAPP_Swe/Ind) mice. Three month-old male (but not female) J20 mice exhibited less despair-like behavior, but more evidence of cognitive deficits. In young J20 mice, only soluble Aβ peptides -primarily Aβ(1-40)- were detected. There was no evidence of an effect on despair-like behavior in the six month-old J20 mice, although cognitive deficits were now evident in both sexes, and coincided with a greater proportion of the neurotoxic Aβ(1-42) species (in soluble as well as insoluble fractions). This age-dependent shift in Aβ peptide profile coincided with reduced expression of glycosylated species of ADAM-10 (α-secretase) and BACE1 (β-secretase), and an increased co-immunoprecipitation of presenilin-1 with nicastrin (components of the γ-secretase complex). Sex-dependent changes in depression-related monoaminergic, e.g. serotonin and dopamine (but not noradrenaline), systems were evident already in young J20 mice. It is critical to acknowledge that sex-dependent APP-related phenotypes might differentially influence modifiable depression-related monoaminergic signalling at some of the earliest pathological stages of clinical AD.

Development of our TAVI protocol for emergency initiation of cardiopulmonary bypass

All transcatheter aortic valve implantation (TAVI) cases are done in our hybrid operating room with a multidisciplinary team and a primed cardiopulmonary bypass (CPB) circuit on pump stand-by. We decided that we would resuscitate all patients undergoing a TAVI procedure via a transfemoral, transapical or transaortic approach, if required. Perfusion plays an essential role in providing rescue CPB for patient salvage when catastrophic complications occur. To coordinate the multidisciplinary effort, we have developed a written safety checklist that assigns a pre-determined role for team members for the rapid sequence initiation of CPB. Although many TAVI patients are not candidates for conventional aortic valve replacements, we feel strongly that rescue CPB should be offered to all TAVI patients to allow the correction of potentially reversible complications. This protocol is included in every surgical "Time Out" involving a TAVI procedure (Figure 1). The protocol has led to rapid and safe CPB initiation in less than five minutes of cardiac arrest. It has also led to a coordinated and consistent team, with pre-specified roles and improved communication. We discuss a case series of four TAVI patients who required emergent use of CPB. The first few cases did not have a written protocol. The experience from these cases led to the development of our protocol. We identified a lack of coordination, wasted movements, unnecessary delayed resuscitation and overall chaos, each of which was targeted for correction with the protocol. We will discuss the merits of the protocol in two recent TAVI cases which required emergent CPB.

Integration between primary care providers and the cancer system: Gaps and opportunities

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Background: A number of reports suggest that family physicians (FPs) are poorly integrated with the cancer care system. The specific gaps in care integration are poorly understood. In this study we examine specific processes of care associated with integration between FPs and regional cancer programs. Methods: Cross sectional survey of all identified primary care providers within a representative health region in Ontario, Canada. The survey instrument was created specifically for this study with items generated from published literature and expert input and pilot tested in a representative sample. A modified dilman method was used. Results: 500 physicians responded (response rate 60%). Overall 90% of respondants reported confidence in the workup of a new cancer case for the major disease sites but only half (54%) knew the process of referring to the regional cancer program. Only 57% felt investigations necessary could be done in a timely manner and 44% indicated that coordination of care needs to be improved. Most indicated preferance for an active navigation structure for newly diagnosed patients. Despite over 80% of respondents indicating use of the internet only 10% reported accessing cancer program web portals for information on the regional cancer program (such as waiting times). The majority of respondants (75%) indicated ongoing involvement in care during the active treatment phase, mostly for non cancer related medical issues but 20% indicated that they were not properly infomed of patients’ health status by the oncology program and only 57% indicated that they felt their role was valued by the cancer program during this phase in the care trajectory. In the follow up phase, 35% were unclear of their role specific to monitoring and surveillance. 60% felt their current compensation model was inadequate to support care of cancer patients. This did not vary by compensation model reported. Factors associated with better integration included attendance at educational sessions and years in practice. Conclusions: Cancer systems need to be more responsive to the needs of FPs to better integrate them and support optimal quality of care for cancer patients. Policies to clarify and support roles and responsibilites are necessary to ensure that FPs are integrated team members.

No significant financial relationships to disclose.

The association between central venous pressure, pneumoperitoneum, and venous carbon dioxide embolism in laparoscopic hepatectomy

BACKGROUND

Laparoscopic hepatectomy (LH) is increasingly used. However, the safety and outcomes of LH have yet to be elucidated. The risk of venous gas embolism is increased during liver parenchymal transection. This risk may be increased with positive pressure carbon dioxide (CO(2)) pneumoperitoneum (PP). This may be exacerbated further when low central venous pressure (CVP) anesthesia is used to minimize hemorrhage during liver resection.

METHODS

To determine the risk of CO(2) venous embolism, hand-assisted laparoscopic left hepatic lobectomy was performed for 26 domestic pigs. They were divided into three groups involving, respectively, positive gradient (normal-pressure PP of 12-14 mmHg and low CVP of 5-7 mmHg), negative gradient (low-pressure PP of 7-8 mmHg and normal CVP of 10-12 mmHg), and neutral gradient (normal-pressure PP and normal CVP or low-pressure PP and low CVP). Transesophageal echocardiography (TEE) was used intraoperatively to assess the presence of emboli in the suprahepatic vena cava and the right side of the heart. The TEE was recorded and analyzed by blinded observers. Carbon dioxide embolism also was monitored using end-tidal CO(2) and compared with TEE.

RESULTS

Carbon dioxide embolism was demonstrated in 19 of the 26 cases. The majority of gas emboli were small gas bubbles associated with dissection of the major hepatic veins. No statistically significant difference in the occurrence of gas emboli was observed between the groups. Of the 19 animals, 18 experienced no significant hemodynamic changes. One pig in the positive gradient group experienced hypotension in relation to gas embolism. The effects were only transient and did not preclude safe completion of the operation.

CONCLUSIONS

Carbon dioxide embolism during LH occurs frequently. Clinically, this finding appears to be nominal, but care must be taken when dissection around large veins is performed, and awareness by the surgical and anesthesiology teams of potential venous air embolism is essential. Further evaluation of this phenomenon is required.

Educational outreach visits: effects on professional practice and health care outcomes

BACKGROUND

Educational outreach visits (EOVs) have been identified as an intervention that may improve the practice of healthcare professionals. This type of face-to-face visit has been referred to as university-based educational detailing, academic detailing, and educational visiting.

OBJECTIVES

To assess the effects of EOVs on health professional practice or patient outcomes.

SEARCH STRATEGY

For this update, we searched the Cochrane EPOC register to March 2007. In the original review, we searched multiple bibliographic databases including MEDLINE and CINAHL.

SELECTION CRITERIA

Randomised trials of EOVs that reported an objective measure of professional performance or healthcare outcomes. An EOV was defined as a personal visit by a trained person to healthcare professionals in their own settings.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. We used bubble plots and box plots to visually inspect the data. We conducted both quantitative and qualitative analyses. We used meta-regression to examine potential sources of heterogeneity determined a priori. We hypothesised eight factors to explain variation across effect estimates. In our primary visual and statistical analyses, we included only studies with dichotomous outcomes, with baseline data and with low or moderate risk of bias, in which the intervention included an EOV and was compared to no intervention.

MAIN RESULTS

We included 69 studies involving more than 15,000 health professionals. Twenty-eight studies (34 comparisons) contributed to the calculation of the median and interquartile range for the main comparison. The median adjusted risk difference (RD) in compliance with desired practice was 5.6% (interquartile range 3.0% to 9.0%). The adjusted RDs were highly consistent for prescribing (median 4.8%, interquartile range 3.0% to 6.5% for 17 comparisons), but varied for other types of professional performance (median 6.0%, interquartile range 3.6% to 16.0% for 17 comparisons). Meta-regression was limited by the large number of potential explanatory factors (eight) with only 31 comparisons, and did not provide any compelling explanations for the observed variation in adjusted RDs. There were 18 comparisons with continuous outcomes, with a median adjusted relative improvement of 21% (interquartile range 11% to 41%). There were eight trials (12 comparisons) in which the intervention included an EOV and was compared to another type of intervention, usually audit and feedback. Interventions that included EOVs appeared to be slightly superior to audit and feedback. Only six studies evaluated different types of visits in head-to-head comparisons. When individual visits were compared to group visits (three trials), the results were mixed.

AUTHORS' CONCLUSIONS

EOVs alone or when combined with other interventions have effects on prescribing that are relatively consistent and small, but potentially important. Their effects on other types of professional performance vary from small to modest improvements, and it is not possible from this review to explain that variation.

Prospective study of specialist oncology community nursing resulting in improvements in key patient supportive care outcomes

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Background: Cancer patients report ongoing significant gaps in supportive care. To date few interventions have been shown to improve supportive care outcomes in cancer. Research in other areas suggests that specialist nursing interventions in the community may address gaps in unmet need, continuity of care and quality of life. This study prospectively studied a community based nursing intervention for cancer patients. Methods: Patients were followed using a longitudinal cohort design, with assessments at baseline (T1), four (T2) and eight (T3) weeks, upon enrollment in a specialist nursing program. The nursing intervention included a comprehensive supportive care assessment and subsequent care delivery or linkage to appropriate services in the community. Validated patient assessment outcomes included: Supportive Cancer Needs Survey Short Form 34, Quality of Life (EORTC QLC-30(v3)), Continuity and Coordination of Care (CCCQ), and a service utilization instrument. Results: 72 of 109 enrolled patients completed all study measures. The majority had advanced stage disease. Median age was 59 years. Disease categories for participants included: breast (33%), gastrointestinal. (18.1%), lung (13.9%), ovarian (9.7%), and head and neck (8.3%). All participants received a baseline comprehensive assessment and had a mean of 1.7 home visits with a mean of 3.9 telephone contacts. We observed significant reductions in most supportive care need domains ( Table ). There were trends to improvement in domains of quality of life and continuity of care. We also observed reductions in acute care services use and increased community agency use. Conclusions: This is one of the first prospective studies in cancer patients that demonstrates improvements in a number of supportive care outcomes through a community based specialist nursing intervention. A randomized study to confirm these findings is currently underway.

[Table: see text]

No significant financial relationships to disclose.

HLA-G remains a mystery

In this brief summary, we argue that many widely held beliefs about HLA-G are questionable. Recent research has led to a re-evaluation of many of the characteristics that were thought to make HLA-G unusual among the MHC class I molecules. First, contrary to reports suggesting that the gene encoding HLA-G exhibits marked polymorphism in some human populations, recent data have shown that the HLA-G gene has comparatively little polymorphism - a feature that might allow it to be expressed in the placenta without causing rejection by the maternal immune system. Second, although truncated forms of HLA-G are generated in the placenta, most of them are unlikely to have significant biological effects as they do not reach the cell surface. Third, the hypothesis that a major role of HLA-G is to prevent attack of the placenta by maternal natural killer cells is now the subject of renewed scrutiny. Finally, there is little evidence that the induction of expression of HLA-G is a major mechanism by which tumor cells avoid immune attack. HLA-G has once again become as mysterious as when it was discovered: an MHC class I molecule expressed at a challengingly extraordinary site--the immunologically uneasy interface between mother and fetus.

Optimal loading rates and economic analyses for anaerobic digestion of poultry waste

Four combinations of litter and carcasses from broiler chickens were examined utilizing a thermophilic, stirred-tank digester of demonstration size of approximately 10,000 gal. Under computed optimal loading rates, litter with paper bedding had the highest daily production of methane over an 8-day retention period. The greatest methane production per lb of volatile solids was achieved over 10 days with litter and paper bedding combined with carcasses. This research found that sufficient poultry litter is generated within 20 mi (32 km) of Moorefield, WV, to support a commercial-sized digester operation. However, anaerobic digestion of poultry waste cannot be financially supported by methane production alone. To be financially viable, anaerobic digestion requires a disposal fee for poultry waste and/or the sale of the digested solid effluent as an organic fertilizer to retail markets.

Anthropogenic Degradation of the Southern California Desert Ecosystem and Prospects for Natural Recovery and Restoration

/ Large areas of the southern California desert ecosystem have been negatively affected by off-highway vehicle use, overgrazing by domestic livestock, agriculture, urbanization, construction of roads and utility corridors, air pollution, military training exercises, and other activities. Secondary contributions to degradation include the proliferation of exotic plant species and a higher frequency of anthropogenic fire. Effects of these impacts include alteration or destruction of macro- and micro-vegetation elements, establishment of annual plant communities dominated by exotic species, destruction of soil stabilizers, soil compaction, and increased erosion. Published estimates of recovery time are based on return to predisturbance levels of biomass, cover, density, community structure, or soil characteristics. Natural recovery rates depend on the nature and severity of the impact but are generally very slow. Recovery to predisturbance plant cover and biomass may take 50-300 years, while complete ecosystem recovery may require over 3000 years. Restorative intervention can be used to enhance the success and rate of recovery, but the costs are high and the probability for long-term success is low to moderate. Given the sensitivity of desert habitats to disturbance and the slow rate of natural recovery, the best management option is to limit the extent and intensity of impacts as much as possible.KEY WORDS: Mojave Desert; Colorado Desert; California; Human impacts; Recovery; Restorationhttp://link.springer-ny.com/link/service/journals/00267/bibs/24n3p309.html

How to prolong the effects of combination therapy for HIV

Infection with HIV leads to AIDS and death in about 90% of patients within ten years. The first generation of anti-HIV drugs inhibited the viral enzyme reverse transcriptase (RT); but long-term studies have revealed side-effects and a high rate of emergence of drug-resistant HIV mutants. The more recent combination of two anti-RT drugs and a protease inhibitor appears to be more promising: approximately 75% of AIDS patients benefit. However, increasing numbers of treatment failures from toxicity and drug-resistant mutants are emerging. Passive immunotherapy (PIT) is a non-toxic form of treatment based on the neutralization of HIV with antibody-rich plasma from healthy HIV-positive individuals. Studies show it can benefit AIDS patients. Here, we suggest that, in combination with anti-HIV drugs, PIT could reduce some of the toxicity of the latter and limit the emergence of drug-resistant HIV strains. In addition, regular plasma donation seems to be beneficial to the donors.

Variation in expression of MHC class II antigens on horse lymphocytes determined by MHC haplotype

A panel of monoclonal antibodies was used to characterize the expression of equine Major Histocompatibility Complex (MHC) class II antigens on lymphocytes of horses of different MHC types. MHC class II antigen expression was compared between adult horses and foals, and the level of expression of MHC class II antigens on horse T cell subpopulations was also determined. Peripheral blood lymphocytes (PBL) from young and adult healthy horses of different MHC haplotypes were labeled with the antibodies and assayed by single- and two-color immunofluorescence flow cytometry. A variation in the expression of equine MHC class II antigens on PBL was identified that was determined by MHC haplotype. Both young and old animals carrying the MHC class II haplotype D3 expressed lower levels of MHC class II antigens on their PBL than did horses of other MHC class II types. D3 heterozygotes had an intermediate level of expression. Neonates and foals of any MHC haplotype had lower levels of expression of MHC class II antigens than did adults. MHC class II antigens were identified on surface immunoglobulin positive (sIg+) B cells as well as on T cells, with the B cells staining brightest. Dual staining for MHC class II antigens and markers for equine T cell subsets demonstrated that both EqCD4+ and EqCD8+ T cells expressed MHC class II molecules. These results suggest that the relatively low levels of MHC class II antigen expression on foal and neonate lymphocytes may be developmentally regulated, and not determined by environmental factors. The cause of the low expression of MHC class II antigens linked to the MHC class II haplotype D3 is not known, but it appears to reflect a decreased expression by all lymphocyte subpopulations.

Quantitation of solid-phase immunoassays using a fibre-optic reflectance spectrophotometer

A reflectance measuring instrument (fibre-optic spectrometer linked to a personal computer) which will quantitate the results of immunoassays that result in the deposition of a coloured chromophore on a membrane or other similar solid phase (SP) is described and the reflectance spectra of some chromophores which are commonly produced or used in SP immunoassays are presented. The instrument has been used in conjunction with silver-enhanced SP-immunogold capture assays to determine the concentrations in serum of IgG and of IgM rheumatoid factor (RF) and the results have been compared with those obtained by rate nephelometry and latex agglutination assays, respectively. It is concluded that fibre-optic reflectance photometry is an accurate and useful means of quantitating SP immunoassays in which coloured chromophores are produced and that the results obtained from such immunoassays are comparable to those given by established procedures.

Immune status in patients with Menière's disease

Sera of 164 patients with classical Meniere's disease were screened for autoantibodies, immune complexes and HLA status. Increased thyroid microsomal antibodies were significant in those patients in the 40- to 60-year age range. Raised IgM complexes and C1q component of complement were significant in all age groups. Low levels of IgA complexes were a consistent finding and were significantly lower in the HLA Cw7 group. Patients with migraine had no increased incidence of immune disturbances.

Occupational asthma due to methyl methacrylate in an orthopaedic theatre sister

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A double-blind trial of salmefanol, a new bronchodilator

Salmefamol is a new sympathomimetic drug with predominantly β₂ actions. In a double-blind trial in a group of twenty-four patients with airway obstruction, we have compared the effect of 100 μg of salmefamol given by metered aerosol with that of a placebo aerosol. In the same patients we have also compared the aerosols with subcutaneous adrenaline and subcutaneous atropine, the sequence of treatments being determined by a latin square design.

At all times salmefamol had a significantly greater bronchodilator effect than the placebo. Although the effects of atropine and adrenaline were greater at the earlier times of measurement, that of salmefamol was greater at 4 hr.

Some aspects of respiratory function in three siblings with Morquio-Brailsford disease

Morquio-Brailsford disease is a rare genetic disorder of mucopolysaccharide metabolism, and its features include dwarfism and thoracic deformity. A boy aged 15 with this condition developed respiratory failure and later died. This boy and his two affected female siblings were studied and the results are presented. The height of the lungs was less than the anteroposterior diameter on standard chest radiographs. All had small lungs without evidence of airways obstruction. Measurements of dependent airway closure were made in the erect and supine positions. These showed some abnormalities which could cause ventilation-perfusion imbalance. Possible mechanisms leading to the development of respiratory failure in this condition are discussed, including nasopharyngeal obstruction, thoracic deformity, and disturbed ventilation-perfusion relationships. The importance of respiratory failure as a cause of death in Morquio's disease is emphasized.

Goodpasture's syndrome and dialysis

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