A Multicenter Study of the Clinical Utility of Nontargeted Systematic Transperineal Prostate Biopsies in Patients Undergoing Pre-Biopsy Multiparametric Magnetic Resonance Imaging

PURPOSE

The added value of nontargeted systematic prostate biopsies when performed alongside magnetic resonance imaging targeted biopsies in men referred with a suspicion of prostate cancer is unclear. We aimed to determine the clinical utility of transperineal nontargeted systematic prostate biopsies, when performed alongside targeted systematic prostate biopsies, using pre-biopsy multiparametric magnetic resonance imaging.

MATERIALS AND METHODS

Consecutive patients referred with a suspicion of prostate cancer (April 2017 to October 2019) underwent pre-biopsy multiparametric magnetic resonance imaging. A transperineal biopsy was advised if multiparametric magnetic resonance imaging PI-RADS® (v.2.0) score was 4 or 5, and score 3 required a prostate specific antigen density 0.12 ng/ml or greater. Primary threshold for clinically significant prostate cancer was defined as any Gleason 3+4 or greater. Multivariable logistic regression analysis identified pre-biopsy predictors of clinically significant prostate cancer in nontargeted systematic prostate biopsies, regardless of targeted pathology (p <0.05, R, version 3.5.1).

RESULTS

A total of 1,719 men underwent a pre-biopsy multiparametric magnetic resonance imaging, with 679 (39.5%) proceeding to combined targeted systematic prostate biopsies and nontargeted systematic prostate biopsies. In these men clinically significant prostate cancer was detected in 333 (49%) and 139 (20.5%) with targeted systematic prostate biopsies and nontargeted systematic prostate biopsies, respectively. In those men with clinically significant prostate cancer in targeted systematic prostate biopsies, clinically significant prostate cancer was also present in nontargeted systematic prostate biopsies in 117 (17.2%); Gleason 3+3 was present in 50 (7.4%). In 287 men without any cancer in the targeted systematic prostate biopsies, 13 (1.9%) had clinically significant prostate cancer in nontargeted systematic prostate biopsies. In addition 18/679 (2.7%) had Gleason 3+3 disease and no Gleason greater than 4+3 was detected. Predictors associated with clinically significant prostate cancer in nontargeted systematic prostate biopsies were prostate specific antigen 5 ng/ml or greater (OR 2.05, 95% CI 1.13-3.73, p=0.02), PI-RADS score 5 (OR 2.26, 95% CI 1.51-3.38, p <0.001) and prostate volume less than 50 cc (OR 2.47, 95% CI 1.57-3.87, p <0.001).

CONCLUSIONS

Detection of clinically significant prostate cancer in exclusively nontargeted transperineal systematic biopsies in a pre-biopsy multiparametric magnetic resonance imaging pathway was low (1.9%).

Prognostic Accuracy of Fetal MRI in Predicting Postnatal Neurodevelopmental Outcome

BACKGROUND AND PURPOSE

The superior diagnostic accuracy of fetal MR imaging in detecting fetal brain abnormalities has been previously demonstrated; however, the ability of fetal MR imaging to prognosticate postnatal outcome is not well-studied. We performed a retrospective analysis to determine the prognostic accuracy of fetal MR imaging in predicting postnatal neurodevelopmental outcome.

MATERIALS AND METHODS

We identified all fetal MR imaging performed at the Children's Hospital of Eastern Ontario during a 10-year period and assessed agreement between prenatal prognosis and postnatal outcome. Prenatal prognosis was determined by a pediatric neurologist who reviewed the fetal MR imaging report and categorized each pregnancy as having a favorable, indeterminate, or poor prognosis. Assessment of postnatal neurodevelopmental outcome was made solely on the basis of the child's Gross Motor Function Classification System score and whether the child developed epilepsy. Postnatal outcome was categorized as favorable, intermediate, or poor. We also assessed the diagnostic accuracy of fetal MR imaging by comparing prenatal and postnatal imaging diagnoses.

RESULTS

We reviewed 145 fetal MR images: 114 were included in the assessment of diagnostic accuracy, and 104 were included in the assessment of prognostic accuracy. There was 93.0% agreement between prenatal and postnatal imaging diagnoses. Prognosis was favorable in 44.2%, indeterminate in 50.0%, and poor in 5.8% of pregnancies. There was 93.5% agreement between a favorable prenatal prognosis and a favorable postnatal outcome.

CONCLUSIONS

A favorable prenatal prognosis is highly predictive of a favorable postnatal outcome. Further studies are required to better understand the role of fetal MR imaging in prognosticating postnatal development, particularly in pregnancies with indeterminate and poor prognoses.

MRI features of the placenta in fetuses with and without CNS abnormalities

AIM

To investigate if magnetic resonance imaging (MRI) features of the placenta are different in fetuses with and without central nervous system (CNS) abnormalities.

MATERIAL AND METHODS

Institutional research ethics board approval was obtained. Fetal MRI of 97 singleton pregnancies were analysed retrospectively (19-25 weeks gestation), 65 with CNS morphological abnormalities and 32 controls. Placental T2 signal intensity, placental and fetal volumes, placental-to-fetal volume ratio, and placental apparent diffusion coefficient (ADC) values were assessed. Measurements were compared with the presence or absence of CNS fetal abnormalities using the Mann-Whitney test. Separate slopes models and intercept models were used to check for significant differences in the slopes and intercepts, respectively, among the groups.

RESULTS

Placental ADC values were significantly lower in placentas of fetuses with CNS abnormalities compared to controls (p=0.04). Placental T2 signal intensity, fetal and placental volumes did not differ between the two groups. The rate of increase in fetal-to-placental volume ratio with gestational age (GA) was greater among the controls.

CONCLUSION

The presence of fetal CNS abnormalities is associated with reduced ADC values of the placenta. Moreover, placentas of fetuses with CNS abnormalities show a less rapid increase in fetal to placental volume ratio with GA. Therefore, ADC mapping, as well as different growth kinetics of the placenta relative to the fetus, may potentially serve as early markers of pathological neurodevelopment.

Factors affecting high-density lipoprotein cholesterol in HIV-infected patients on nevirapine-based antiretroviral therapy

Background & objectives:

Cardiovascular disease (CVD) risk with low high-density lipoprotein cholesterol (HDL-C) and high triglycerides is common in the general population in India. As nevirapine (NVP)-based antiretroviral therapy (ART) tends to increase HDL-C, gene polymorphisms associated with HDL-C metabolism in HIV-infected adults on stable NVP-based ART were studied.

Methods:

A cross-sectional study was conducted between January 2013 and July 2014 among adults receiving NVP-based ART for 12-15 months. Blood lipids were estimated and gene polymorphisms in apolipoprotein C3 (APOC3), cholesteryl ester transfer protein (CETP) and lipoprotein lipase (LPL) genes were analyzed by real-time polymerase chain reaction. Framingham's 10-yr CVD risk score was estimated. Logistic regression was done to show factors related to low HDL-C levels.

Results:

Of the 300 patients included (mean age: 38.6±8.7 yr; mean CD4 count 449±210 cell/μl), total cholesterol (TC) >200 mg/dl was observed in 116 (39%) patients. Thirty nine per cent males and 47 per cent females had HDL-C levels below normal while 32 per cent males and 37 per cent females had TC/HDL ratio of 4.5 and 4.0, respectively. Body mass index [adjusted odds ratio (aOR)=1.70, 95% confidence interval (CI) 1.01-2.84, P=0.04] and viral load (aOR=3.39, 95% CI: 1.52-7.52, P=0.003) were negatively associated with serum HDL-C levels. The 10-yr risk score of developing CVD was 11-20 per cent in 3 per cent patients. Allelic variants of APOC3 showed a trend towards low HDL-C.

Interpretation & conclusions:

High-risk lipid profiles for atherosclerosis and cardiovascular disease were common among HIV-infected individuals, even after 12 months of NVP-based ART. Targeted interventions to address these factors should be recommended in the national ART programmes.

Combined modalities in the prevention of venous thromboembolism: A review of the literature

Objective

Despite recent advances in the field of venous thromboembolism (VTE) prophylaxis and adherence to guideline recommendations, VTE remains a serious problem, especially in high-risk groups. The aim of the present review was to summarize the evidence supporting the use of combined modalities, both physical and pharmacological, in VTE prevention.

Methods

Using Medline, original studies on the value of combined modalities in VTE prevention were identified. Keywords used for physical methods included elastic stockings and intermittent pneumatic compression, and for pharmacological methods included unfractionated and low molecular weight heparin. Relevant articles from their bibliography were also retrieved.

Results

Combined pharmacological and physical modalities were more effective than each modality alone in a variety of specialties, including orthopaedic, general and cardiac surgery, as shown by 14 of the 18 randomized or case-control studies retrieved. Mean reduction in VTE incidence was 69% (range 16–100%).

Conclusion

Combined modalities are more effective than single modalities in VTE prophylaxis. These results endorse their use, especially in high-risk patients, and support this otherwise typical recommendation of the consensus documents on VTE prophylaxis.

Attitudes of undergraduates towards mental illness: A comparison between nursing and business management students in India

<p><strong>Background.</strong> Mental illness is an important public health issue worldwide; stigmatisation and negative attitudes towards people with mental illness are widespread among the general public. However, little is known about the attitudes of undergraduates to mental illness. </p><p><strong>Purpose.</strong> To compare the attitudes towards mental illness among undergraduates enrolled in nursing courses v. those enrolled in Bachelor of Business Management (BBM) courses. </p><p><strong>Methods.</strong> A cross-sectional descriptive design was adopted for the present study. A total of 268 undergraduates were selected to complete the<em> </em>Attitude Scale for Mental Illness (ASMI) and the Opinions about Mental Illness in the Chinese Community (OMICC) questionnaires. </p><p><span><strong>Results. </strong>We found significant differences between the number of nursing and BBM students who agreed with statements posed by the questionnaires, e.g., that they would move out of their community if a mental health facility was established there (χ²=16.503, <em>p</em>&lt;0.002), that they were not afraid of treated mentally ill people (χ²=15.279, <em>p</em>&lt;0.004), and that people with mental illness tend to be violent (χ²=14.215, <em>p</em>&lt;0.007) and dangerous (χ²=17.808, <em>p</em>&lt;0.001). Nursing students disagreed that people with mental illness are easily identified (χ²=30.094, <em>p</em>&lt;0.000), have a lower IQ (χ²=70.689, <em>p</em>&lt;0.000) and should not have children (χ²=24.531, <em>p</em>&lt;0.000). Nursing students were more benevolent than BBM students, as they agreed that people with mental illness can hold a job (χ²=49.992, <em>p</em>&lt;0.000) and can return to their former position (χ²=11.596, p&lt;0.021), that everyone faces the possibility of becoming mentally ill (χ²=38.726, <em>p</em>&lt;0.000), and that one should not laugh at the mentally ill (χ²=17.407, <em>p</em>&lt;0.002). Nursing students held less pessimistic attitudes, as they felt that the mentally ill should receive the same pay for the same job (χ²=10.669, <em>p</em>&lt;0.031) and that the public are prejudiced towards people with mental illness (χ²=17.604, <em>p</em>&lt;0.001).</span></p><p><strong>Conclusion.</strong> College students’ attitudes towards people with mental illness vary based on the course that they are enrolled in. Attitudes may be positively improved by revising curriculum design to incorporate educational sessions about mental illness. These are essential steps to combat discrimination, and potentially enhance the promotion of human rights for the mentally ill.</p>

Combined staged endoscopic and microsurgical approach of a third ventricular choroid plexus papilloma in an infant

BACKGROUND

Choroid plexus papillomas of the third ventricle in newborn infants are quite rare and present a significant surgical challenge. This case report illustrates the utility of endoscopy in facilitating tumor resection.

PATIENT

A 6-week-old boy, born prematurely at a gestational age of 35 weeks, presented with hydrocephalus secondary to a choroid plexus papilloma in the third ventricle, extending to the aqueduct of Sylvius and into the fourth ventricle. On admission, he was found to have clinical signs of raised intracranial pressure. MRI revealed a homogeneously enhancing mass primarily in the third ventricle. The initial surgical procedure was insertion of a ventriculo-peritoneal shunt, followed by an endoscopic biopsy, which allowed the surgeons to mobilize the tumor into the right lateral ventricle. This facilitated a subsequent transcortical approach to completely remove the tumour.

RESULT AND CONCLUSION

The authors present a case of choroid plexus papilloma in an uncommon location with a unique surgical approach and a successful outcome with no neurological deficits. We detail our surgical approach and the complexity of approaching a tumor located in the third ventricle of an infant.

Treatment effects produced by preorthodontic trainer appliance in patients with class II division I malocclusion

The aim of the present study was to evaluate cephalometrically the treatment effects of preorthodontic trainer on dentoskeletal components in individuals showing class II division I malocclusion. This study comprised of 50 class II div. I patients (20 test patients and 30 controls) in the age group of 8-12 years. The test group was treated with a preorthodontic trainer for a period of 15 months. Standardized lateral cephalograms of both groups were taken before and after the treatment period. The cephalograms were then evaluated to determine the skeletal and dental changes in the course of treatment and then compared with the normative growth data to eliminate the possible growth effects. The readings were tabulated and subjected to statistical analysis. The results of the study after excluding the changes due to growth showed reduction in ANB and OP-SN values, indicating a significant reduction in the skeletal class II relationship. An upward cant of the occlusal plane in the treatment group was noted, probably due to the forward rotation of mandible. A significant increase in the vertical dimensions of the face in general and the mandible in particular was observed with the use of preorthodontic trainer. A significant reduction in the overjet and an increase in the inclination of mandibular incisor (L1-NB deg) were noted in the treatment group when compared with control group. It can be concluded that class II corrections can be achieved with the preorthodontic trainer appliance, which appears to have mostly dentoalveolar effects with smaller but significant skeletal effects.

Ankylosis of temporomandibular joint in children

BACKGROUND

Temporomandibular joint (TMJ) ankylosis or hypomobility involves fusion of the mandibular condyle to the base of the skull. It is a major clinical problem that affects many patients suffering from facial trauma, infection, or systemic disease. The treatment of TMJ ankylosis poses a significant challenge because of technical difficulties and a high incidence of recurrence.

CASE REPORT

This report describes a case of a 4-year-old boy with inability to open mouth, diagnosed with unilateral right bony TMJ ankylosis. The surgical approach consisted of gap arthroplasty followed by vigorous physiotherapy.

CONCLUSION

A detailed history, clinical and functional examination, radiographic examination facilitating correct diagnosis followed by immediate surgical intervention, and physiotherapy can help us to restore physical, psychological, and emotional health of the child patient.

In vitro biological activity and essential oil composition of four indigenous South African Helichrysum species

Helichrysum species are used widely to treat various medical conditions. In this study, the anti-microbial, anti-oxidant (DPPH assay) and anti-inflammatory activity (5-lipoxygenase assay) of Helichrysum dasyanthum, Helichrysum felinum, Helichrysum excisum and Helichrysum petiolare were investigated. The essential oil compositions of these species were determined. The acetone and methanol extracts as well as the essential oils exhibited activity against Gram-positive bacteria, while both the methanol and acetone extracts of all four species were active in the anti-oxidant assay. The essential oils, on the other hand, displayed activity in the 5-lipoxygenase assay, which was used as an indication of anti-inflammatory activity. Two extracts exhibited promising activity in the anti-microbial assay, the acetone extract of Helichrysum dasyanthum with a MIC value of 15.63 microg/ml and the methanol extract of Helichrysum excisum with a MIC value of 62.5 microg/ml. The acetone extract of Helichrysum dasyanthum was the most active free radical scavenger in the DPPH assay (IC(50) of 9.53 microg/ml) while values for the anti-inflammatory activity of the essential oils ranged between 25 and 32 microg/ml. The essential oil compositions of three species (Helichrysum dasyanthum, Helichrysum excisum and Helichrysum petiolare) were dominated by the presence of monoterpenes such as alpha-pinene, 1,8-cineole and p-cymene. In the oil of Helichrysum felinum, monoterpenes were largely absent. Its profile consisted of a variety of sesquiterpenes in low concentrations with beta-caryophyllene dominating.

Role of chelate substituents and cis σ-effect on the rate of ligand substitution at Pt(N–N–N) and Pt(N–N–C) centres

Four complexes of the type [Pt(N-N-X)Cl](X = N or C) were tailor synthesized for mechanistic studies in methanol. The terdentate ligands included terpy, 4'-Ph-terpy, 4'-(2"-CF(3)-Ph)-terpy, and 4'-(2"'-CF(3)-Ph)-6-Ph-2,2'-bipy. The rate of substitution of the chloro ligand by thiourea, N,N'-dimethylthiourea, and N,N,N',N'-tetramethylthiourea was studied as a function of nucleophile concentration, temperature and pressure by using a stopped-flow technique. The observed pseudo-first-order rate constants for the substitution reactions obeyed the simple rate law k(obs) = k(2)[Nu]. Second-order kinetics and negative activation entropies and volumes support an associative substitution mechanism. At 298 K, the values of the second-order rate constant show a slight dependence on the nature of the moiety attached to the terpy ligand. Changing from a nitrogen sigma-donor to a carbon sigma-donor in the cis position, results in a deceleration of the substitution rate. The results suggest that the Pt-C bond in the cis position activates the metal centre in a different way than in the trans position.

The Sambungmacan 3 Homo erectus calvaria: a comparative morphometric and morphological analysis

The Sambungmacan (Sm) 3 calvaria, discovered on Java in 1977, was illegally removed from Indonesia in 1998 and appeared in New York City in early 1999 at the Maxilla & Mandible, Ltd. natural history shop. Here we undertake an analysis of its phylogenetic and systematic position using geometric morphometrics and comparative morphology. The coordinates of points in the sagittal plane from glabella to opisthion were resampled to yield "lines" of 50 semi-landmarks. Coordinates of glabella, bregma, lambda, inion, and opisthion were also collected and analyzed separately. Casts of Homo erectus fossils from Indonesia, China, and Kenya and of "archaic H. sapiens" from Kabwe and Petralona, as well as 10 modern human crania, were used as the primary comparative sample. The modern humans were well separated from the fossils in a graphical superimposition of Procrustes-aligned semi-landmarks as well as in principal component and canonical discriminant analyses. In all of these, Sm 3 falls intermediate between the fossil and modern groups. Morphological comparisons of Sm 3 with a selection of Homo erectus fossils revealed its greatest similarity to specimens from Ngandong and the Sm 1 calvaria. Compared to all other H. erectus, Sm 3 was distinctive in its more vertical supratoral plane, less anteriorly projecting glabella and less sharply angled occiput. In these features it was somewhat similar to modern humans. It is not yet possible to determine if this similarity implies an evolutionary relationship or (more likely) individual or local populational variation. Several features of Sm 3 (small size, gracile supraorbital torus and lack of angular torus, and position in principal component analysis) suggest that it was a female. The use of geometric morphometrics provides a means to statistically test the shapes of such fossils in a manner not easily duplicated by other methods. The intermediate position of Sm 3 between fossil and modern samples in several different subanalyses exemplifies the value of this approach.

A comparison of the short and long forms of the Multiple Affect Adjective Check List-Revised (MAACL-R)

Brief, reliable, and valid assessment instruments are very important for clinical psychology research and practice. The possible equivalency of a short form and the long form of the Multiple Affect Adjective Check List-Revised (MAACL-R; Zuckerman & Lubin,1985) was studied by correlating both forms of the MAACL-R with the State Trait Personality Inventory (Spielberger,1995); the Affect Balance Scale (Bradburn,1969); and the Sensation Seeking Scale (Zuckerman,1978). Reliability and validity of the two forms were equivalent.

Outcome following heart transplantation in Maori and Polynesian patients: a comparison with European New Zealanders

AIM

To compare demographic, clinical and outcome data of Maori and Polynesian with New Zealand European heart transplant patients.

METHODS

A retrospective analysis was made of data from the 104 patients who underwent heart transplantation at Green Lane Hospital over a period of twelve years, of whom 79 were European, 23 Maori/Polynesian, and two Asian. Clinical characteristics, blood group, HLA matching and outcomes of recipients were compared.

RESULTS

There was no significant difference in age and gender between the two groups. Maori and Polynesian patients were heavier, had a greater body mass index and were more likely to have rheumatic heart disease than their European counterparts. Maori/Polynesian patients were predominantly blood group A, whilst European patients were mainly group O. The waiting time for a donor heart was similar in both groups. There was no significant difference in number of rejection episodes and survival.

CONCLUSIONS

Green Lane Hospital has the largest international experience of heart transplantation in Maori and Polynesian patients. Although there are some differences in clinical profile, outcome in terms of rejection episodes and survival is similar in the two groups.

Variants of trophic factors and expression of cardiac hypertrophy in patients with hypertrophic cardiomyopathy

Patients with hypertrophic cardiomyopathy (HCM) exhibit variable expression of left ventricular hypertrophy (LVH), a major determinant of mortality and morbidity, which is partly due to the diversity of causal mutations, genetic background (modifier genes), and probably environmental factors. We determined association of functional variants of tumor necrosis factor (TNF)- alpha, interleukin-6 (IL6), insulin-like growth factor-2 (IGF2), transforming growth factor- beta 1 (TGFB1), and aldosterone synthase (CYP11B2) genes, all previously implicated in cardiac hypertrophy, with the severity of LVH in patients with HCM. Two-dimensional echocardiography was performed and demographic variables were recorded in 142 genetically independent patients. Indices of LVH including interventricular septal thickness (IVST), left ventricular mass index (LVMI), and LVH score were measured/calculated. TNF-alpha-308G/A, IL6-174G/C, IGF2 820G/A, TGFB1-509C/T, and CYP11B2-344T/C genotypes were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). Genotypes were identified by the presence of specific electrophoretic patterns and their distributions were according to the Hardy-Weinberg equilibrium. Demographic variables were not significantly different among the genotypes. Subjects with the AA genotype of TNF-alpha (n=8) were approximately 13 years younger at the time of clinical diagnosis. Despite a younger age, they had a greater mean LVMI than those with the GG (n=94) or GA (n=33) genotypes (191.8+/-59.5 v 139.1+/-47.3 v 132.1+/-34.3, respectively, P=0.004). TNF-alpha-308G/A genotypes accounted for 6.0% of variability of LVMI (P=0.002). Mean IVST, LVEDD, and LVH score were not significantly different. Variants of IL6, IGF2, TGFB1, and CYP11B2 were not associated with indices of LVH. The uncommon allele of TNF-alpha-308G/A polymorphism, known to produce more TNF- alpha, was associated with greater LVMI and clinical diagnosis at a younger age in patients with HCM. Functional variants of other trophic factors, previously implicated in cardiac hypertrophy, were not associated with the indices of LVH. These results suggest that TNF-alpha is a modifier gene for HCM.

Cascara sagrada-induced intrahepatic cholestasis causing portal hypertension: case report and review of herbal hepatotoxicity

Herbal medicines are gaining widespread popularity. Much of the public believes that botanical herbs are both harmless and useful for the treatment of a variety of symptoms. This belief stands in contrast with the fact that many herbal therapies have been shown to be toxic. In the present case report, cascara sagrada (CS) has been associated with the development of cholestatic hepatitis, complicated by portal hypertension. CS is a mixture of ingredients, among which is anthracene glycoside--an herbal agent that previously has been associated with chronic hepatitis. The liver injury in the case herein reported is believed to be related to either anthracene glycoside or one of the other constituents of CS.

Cascara sagrada-induced intrahepatic cholestasis causing portal hypertension: case report and review of herbal hepatotoxicity

Herbal medicines are gaining widespread popularity. Much of the public believes that botanical herbs are both harmless and useful for the treatment of a variety of symptoms. This belief stands in contrast with the fact that many herbal therapies have been shown to be toxic. In the present case report, cascara sagrada (CS) has been associated with the development of cholestatic hepatitis, complicated by portal hypertension. CS is a mixture of ingredients, among which is anthracene glycoside--an herbal agent that previously has been associated with chronic hepatitis. The liver injury in the case herein reported is believed to be related to either anthracene glycoside or one of the other constituents of CS.

Improved production of adenovirus vectors expressing apoptotic transgenes

Adenovirus vectors expressing gene products that can induce apoptosis have potential utility in gene therapy applications ranging from the treatment of proliferative diseases to transplantation. However, adenovirus vectors carrying proapoptotic gene products are difficult to produce, as the apoptotic environment is not conducive to adenovirus gene expression and replication. Production of AdFasL/G, an adenovirus vector that expresses high levels of Fas ligand, was severely reduced in the 293 packaging cell line. Increased yields of AdFasL/G were achieved by inclusion of peptide-based caspase inhibitors in the growth medium. However, use of these inhibitors for large-scale production would be difficult and expensive. A screen for gene products that increase the yield of AdFasL/G in 293 cells revealed that the poxvirus serpin CrmA and the adenovirus 14.7K product were able to increase virus yields significantly. Apoptosis induced by AdFasL/G was attenuated in 293CrmA cell lines and virus titers were increased dramatically. However, serial passage of AdFasL/G on 293CrmA cells resulted in the generation of replication-competent adenovirus. To resolve this problem, the CrmA gene was introduced into AE25 cells, an E1-complementing cell line that has limited sequence identity with the vectors. AdFasL/G titers were increased 100-fold on AE25CrmA cells relative to the AE25 cells and RCA contamination was not detectable. In addition, adenovirus vectors that express FADD, caspase 8, and Fas/APO1 were produced efficiently in AE25CrmA and 293CrmA.

Modulation of platinum-induced toxicities and therapeutic index: mechanistic insights and first- and second-generation protecting agents

Platinum-type drugs have proven to be valuable in the treatment of a variety of solid tumors, beginning with the commercial approval of cisplatin 18 years ago. There are several clinically important toxicities commonly associated with the administration of these drugs. Despite the extensive use of cisplatin and carboplatin, the fundamental chemical transformations and mechanisms that underlie their antitumor and toxic effects have not been fully characterized. Several first-generation protective thiols have been clinically studied in an attempt to reduce the toxicity of platinum-type drugs; while some of these agents appear to protect against certain toxicities, nearly all platinum-protecting drugs have their own intrinsic toxicities, which can be additive to the toxicity of platinum-type drugs. Tumor protection by platinum-protecting drugs is an additional untoward effect that is associated with certain types of agents and must be addressed with care. Recent advances in theoretical and laboratory methods and the use of supercomputers have extended our understanding of the possible major mechanisms underlying platinum drug antitumor activity and toxicity; we present strong evidence that there are two classes of chemical species of platinum drug. One class appears to predominantly account for the antitumor activity, and the other class of chemical species produces many of the toxic effects of platinum drugs. We have discovered a new nontoxic, second-generation platinum-protecting agent, known as BNP7787, which appears to selectively inactivate and eliminate toxic platinum species. BNP7787 has recently entered phase I clinical testing in cancer patients.

Central opiate mu-receptor-mediated suppression of tissue protein synthesis

We determined the dose-dependent effects of central mu-opioid receptor stimulation on rates of tissue protein synthesis. Chronically catheterized conscious rats received an intracerebroventricular injection of [D-Ala2, N-Me-Phe4,Gly5-ol]enkephalin (DAGO, 0.5, 2, or 8 nmol/rat) or water (5 microliters) 45 min before determination of protein synthesis by the flooding dose technique. DAGO produced a significant decrease in tissue protein synthesis in liver (57%), spleen (54%), gut mucosa (36%), gut serosa (23%), kidney (48%), gastrocnemius (33%), and plantaris muscle (27%), but it did not alter rates of protein synthesis in the brain, heart, and soleus muscle. DAGO produced an acute dose-dependent respiratory depression 30 min after intracerebroventricular injection; this depression resulted in acidosis, hypoxia, and hypercapnia (pH 7.19 +/- 0.04, arterial partial O2, pressure 44.2 +/- 3.4 Torr, arterial O2 saturation 65.3 +/- 5.5%, and PCO2 66.3 +/- 4.4 Torr). Intracerebroventricular DAGO increased circulating levels of catecholamines, corticosterone, and growth hormone but did not alter those of insulin and insulin-like growth factor I. Significant positive correlations between protein synthesis and pH were observed in the tissues studied (i.e., liver protein synthesis vs. pH, P < 0.0001, r = 0.902; gastrocnemius protein synthesis vs. pH, P < 0.0001, r = 0.830). Our results indicate that mu-receptor stimulation inhibits tissue protein synthesis, and this effect appears to be secondary to respiratory depression and the resulting acidosis and/or hypoxia. Furthermore, our findings suggest differential sensitivity in tissue response to alterations in pH, hypoxia, and stress hormone elevation.

Transfection and overexpression of the calcium binding protein calbindin-D28k results in a stimulatory effect on insulin synthesis in a rat beta cell line (RIN 1046-38)

Calbindin-D28k, a calcium binding protein that is thought to act as a facilitator of calcium diffusion in intestine and kidney, is known to be regulated by vitamin D in these tissues. Calbindin-D28k is also present in pancreatic beta cells, but its function in these cells is not known. To determine a role for calbindin-D28k in the beta cell, rat calbindin-D28k was overexpressed in the pancreatic beta cell line RIN 1046-38 by transfection of calbindin in expression vector, and changes in insulin mRNA were examined. Five transfected RIN cell clones were found to overexpress calbindin 6- to 35-fold as determined by radioimmunoassay. Northern blot analysis revealed increases in abundance in calbindin mRNA (>20-fold for most clones). Overexpressed calbindin was functional because it was capable of buffering calcium in response to a rapid calcium influx induced by 1 and 5 microM calcium ionophore. In cells transfected with calbindin, there was a marked increase in the expression of insulin mRNA (>20-fold for most clones compared with vector transfected cells). Besides an increase in insulin mRNA, calbindin overexpression was also associated with an increase in insulin content and release (a 5.8-fold increase in insulin release was noted for clone C10, and a 54-fold increase was noted for clone C2). To begin to address the mechanism whereby overexpression of calbindin results in increased insulin gene expression, calbindin-overexpressing clones were transiently transfected with plasmids incorporating various regions of the rat insulin I (rInsI) promoter linked to the chloramphenicol acetyltransferase coding sequence. Transient transfection with reporter plasmids bearing the regulatory sequences of the rInsI promoter (-345/+1) or five copies of the Far-FLAT minienhancer (-247/-198) from the rInsI promoter suggests that increased insulin mRNA in calbindin transfected cells is due, at least in part, to enhanced insulin gene transcription. These studies provide the first direct evidence (to our knowledge) for a role for calbindin in beta cell function.

Detection of bony metastases of androgen-independent prostate cancer by PET-FDG

Fourteen F-18 fluorodeoxyglucose (FDG) studies were carried out in 13 patients known to have bony metastases from carcinoma of the prostate. One patient was newly diagnosed. The remaining patients had various types of therapy and were considered hormonally resistant. The average age was 67. All patients had extensive bony metastases shown on the conventional Tc99m-MDP bone scans. Only about 18% of bony lesions apparent on the conventional bone scans showed corresponding increase of FDG uptake. Anatomical correlation was performed by using co-registered images of SPECT and PET in the same area. The positive FDG uptake was not related to the duration of illness, level of PSA, previous therapy, and magnitude of disease involvement. It appears that only a small percentage of bony metastases is associated with increased glycolysis. It is possible that other metabolic processes are more important than glycolysis for providing prostate cancer with a source of energy and nutrients.

Attitudes towards parental presence at induction of anaesthesia

OBJECTIVE

To determine the attitudes of South African anaesthetists with regard to allowing parents to be present during the induction of anaesthesia in children, and to determine the source and extent of resistance to this controversial practice.

DESIGN

Questionnaire survey consisting of three parts and based on a previous study.

SETTING

Southern Africa.

PARTICIPANTS

All practising anaesthetists, specialist and non-specialist, on the mailing list of a major pharmaceutical company.

RESULTS

Responses were obtained from 222 anaesthetists from 80 different localities in southern Africa. The majority of the respondents were specialist anaesthetists in private practice with between 5 and 15 years' experience. Of the respondents 55% agreed that it was acceptable to allow parents to be present at induction and that this did not compromise the child's safety; 117 claimed that there was resistance to the practice, perceiving the matron and nursing staff as the major source of resistance, both currently and in the past. Lack of facilities and loss of operating theatre sterility were cited as the main reasons for resistance.

CONCLUSION

Although the practice is still controversial, the majority of anaesthetists who responded to the survey would be happy to allow parents to accompany children at induction. It should be catered for and encouraged according to certain guidelines.

Physician decision-making in antiretroviral use

The results of a survey of physicians treating HIV are reported. The survey aimed to determine physicians' attitudes to and practices in antiretroviral prescribing and to assess the factors they use for decision-making regarding initiation and change of therapy.

Expression of the carcinoma-associated le(a)-le(x) oligosaccharide in vertebrate endoderm and its fetal derivatives

The extended Le(a)-Le(x) oligosaccharide, expressed as a cell surface antigen by human squamous lung carcinomas marks cancer cells of tumors having poor prognosis. In order to see if the extended Le(a)-Le(x) also has a precisely controlled pattern of expression during embryogenesis, a survey of representative vertebrate embryos and fetuses in various stages was undertaken. Embryonic and fetal cells which express the epitope are derived from embryonic endoderm. No. epitope expression was demonstrated in tissues of ectodermal or mesodermal origin. Vertebrate conservation of this endodermal cell surface carbohydrate suggests function necessary for normal growth and development with inappropriate re-expression during carcinogenesis.

Identification of a novel microtubule-binding domain in microtubule-associated protein 1A (MAP1A)

Several microtubule-associated proteins (MAPs) have been shown to bind to microtubules via short sequences with repeated amino acids motifs. A microtubule-binding domain has hitherto not been defined for the adult brain microtubule-associated protein 1A (MAP1A). We have searched for a microtubule-binding domain by expressing different protein regions of MAP1A in cultured cell lines using cDNA constructs. One construct included an area with homology to the microtubule-binding domain of MAP1B (Noble et al. (1989) J. Cell Biol. 109, 437–448), but this did not bind to microtubules in transfected cells. Further investigation of other areas of MAP1A revealed a protein domain, capable of autonomously binding to microtubules, which bears no homology to any previously described microtubule-binding sequence. This MAP1A domain is rich in charged amino acids, as are other mammalian microtubule-binding domains, but unlike them has no identifiable sequence repeats. Whereas all previously described mammalian microtubule-binding domains are basic, this novel microtubule-binding domain of MAP1A is acidic. The expression of this polypeptide in cultured cell lines led to a rearrangement of the microtubules in a pattern distinct from that produced by MAP2 or tau, and increased their resistance to treatment with the microtubule depolymerising agent nocodazole. When the MAP1A microtubule-binding domain was co-expressed in cultured cell lines together with MAP2c, the MAP1A microtubule-binding domain was able to bind to the MAP2c-induced microtubule bundles. These results suggest that different microtubule-binding sequences have a common ability to stabilise microtubules but differ in their influence on microtubule arrangement in the cell. This may be significant in neurons, where microtubule-associated proteins with different microtubule-binding sequences are expressed in different cell compartments and at different times during development.

Parathyroid hormone-related protein as a prohormone: posttranslational processing and receptor interactions

Since the elucidation of the structures of the three human PRHrP isoforms in 1987, information has rapidly accured which indicates that the role of PTHrP in normal physiology will prove to be crucial as well as exceedingly complex. The importance of the role of PTHrP in normal physiology is underscored by its broad tissue expression, by its intense evolutionary conservation, by its extremely early expression after fertilization of the ovum, and by the lethal consequences of PTHrP gene disruption. The complexity of the role of PTHrP in normal physiology increases almost monthly. This complexity is reflected in the broad tissue distribution of the peptide, its complex transcriptional regulation and mRNA instability motifs, and its multiple transcripts and isoforms. It is now clear that additional complexity exists at the level of posttranslational processing. Expression of the PTHrP gene leads to the tissue-specific processing and secretion of an increasingly complex family of derivative peptides, each with its own repertoire of cognate receptors, signal transduction pathways, and physiological consequences. Further elucidation of the posttranslational processing pathways and mechanisms can be anticipated in the coming years, coupled with a corresponding elucidation of multiple PTHrP receptors, their specific signal transduction pathways, and their unique physiological roles. The role of PTHrP in causing HHM is now clearly established. Work in the coming decade will focus on the normal physiological roles played by PTHrP.

A reevaluation of the role of crystalloid preload in the prevention of hypotension associated with spinal anesthesia for elective cesarean section

BACKGROUND

Hypotension after spinal anesthesia for cesarean section remains a common and serious complication despite the use of uterine displacement and volume preloading. The current study revaluated the role of crystalloid volume preloading in this context.

METHODS

In a two-stage open sequential design, patients presenting for elective repeat cesarean section were allocated to receive either no preload or 20 ml/kg crystalloid administered over 15-20 min before spinal anesthesia. Hypotension was defined as a decrease in systolic pressure to less than 100 mmHg and to less than 80% of baseline value, and the study was designed to detect a 20% difference in the incidence of hypotension between the groups, with statistical significance at the 10% (alpha = 0.1) level, one-tailed.

RESULTS

One hundred forty patients were studied. Hypotension occurred in 43 (55%, 95% CI 43.4-66.4) preloaded and 44 (71%, 95% CI 58-81.8) unpreloaded subjects, a difference in incidence of 16% (95% CI 0.04-31.6), which was statistically significant. There were no significant differences in the severity, timing, or duration of hypotension; the dose requirement for ephedrine; or the clinical and biochemical status of neonates between the groups. The only difference seen was a lower mean base excess (-3.4, SD 2.81 mM-1) in the neonates of hypotensive mothers compared to neonates of nonhypotensive mothers (-2.4, SD 1.99 mM-1).

CONCLUSIONS

The study confirms that hypotension associated with spinal anesthesia for cesarean section cannot be eliminated by volume preloading in the supine wedged patient. The relatively small reduction in incidence of hypotension challenges our perception of the value of crystalloid preload. Though volume preload in the elective cesarean section is advocated, the requirement for a mandatory administration of a fixed volume before spinal anesthesia for urgent cases has been abandoned.