The use of simulation in liver transplantation anesthesiology fellowship training: A survey of fellowship program directors in the United States

INTRODUCTION

Liver transplantation surgeries are challenging cases for anesthesiologists. While intra-operative teaching is paramount, simulation has emerged as an educational tool to augment clinical training. A variety of simulation modalities have been described in the literature, but no study has aimed to assess the use of simulation in liver transplantation fellowship training.

METHODS

A 20-question survey detailing the use of simulation, including simulation modalities used and barriers to simulation use, was developed and distributed to 22 program directors for liver transplantation anesthesiology fellowships. An exploratory analysis was performed on multiple-choice and free-text responses.

RESULTS

Thirteen program directors completed the survey and were included in our analysis. Most programs (61.5%) did not report the use of simulation for liver transplantation fellow training. Of the programs that did use simulation, four required it as a mandatory component of their curriculum. Task trainers and screen-based simulators were more commonly used by these programs. Faculty availability and interest, as well as a lack of an established curriculum, were cited as major limitations to simulation use.

CONCLUSIONS

Simulation is an important component of anesthesiology trainee education, as evidenced by the requirement for simulation during residency by the American Council for Graduate Medical Education. Our findings suggest that simulation is an underutilized educational tool that we believe could greatly augment the training of liver transplantation anesthesiology fellows by providing exposure to a wide range of clinical challenges.

GENECHOC study: genetic markers of arrhythmic risk in heart failure

Background

Ventricular arrhythmic events are responsible for 50% of death in heart failure but no reliable predictive marker is known to discriminate patients at risk of fatal arrhythmia. Interestingly, familial predisposition has been reported suggesting a role of genetic factors.

Purpose

Identify genetic markers increasing the arrhythmic risk in heart failure population.

Method

We prospectively included heart failure patients with left ventricular ejection fraction (LVEF) under 35% and a cardioverter defibrillator in primary prevention in 22 French centres between 2009 and 2017. Patients were followed for 72 months and divided into two groups: cases with an arrhythmic event during follow-up and controls. A Genome Wide Association Study (GWAS) was done. Single Nucleotide Polymorphisms (SNPs) genotyping was performed on Affymetrix Axiom Precision Medicine Research Array plates. To complement the directly genotyped SNPs we performed large-scale imputation based on the Haplotype Reference Consortium European ancestry panel leading to a dataset of 7,5 million of SNPs.

Results

332 cases and 567 controls were included (86% men, mean age at implantation 52±11 years). 78% of patients had ischaemic cardiopathy, 20% had dilated cardiomyopathy. Mean LVEF was 27±5%. No statistical difference was found between cases and controls on clinical parameters, biological results, electrocardiographic measures. No locus shows genome-wide significant association (p<5.10–8) on the GWAS analysis. However, 16 signals with a p-value between 5.10–8 and 5.10–5 were investigated. eQTL and chromatin conformation point to 35 genes with cardiac expression previously associated with heart failure, cardiomyopathies, cardiogenesis, arrhythmias and inflammation. Variants identified point to regulatory regions of the genome and may then propose a molecular mechanism predisposing patients to arrhythmias.

Conclusion

No locus raises genome-wide significance, but several signals with a nominal p-value point to relevant genes and pathways. Replication of the GWAS is ongoing on a cohort of 156 new patients with a less severe cardiopathy implanted with a cardioverter defibrillator in secondary prevention.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Nantes University Hospital

P2864A novel mechanism of sinus node dysfunction: intergenic deletion between PITX2 and ANK2 disrupts chromatin structure in pacemaker cell differentiation

Background

Genetics of sinus node dysfunction (SND) remains poorly understood with few genes identified (HCN4, SCN5A, GJA5, KCNQ1, MYH6 and ANK2) and further genetic heterogeneity.

Purpose

We report two families with SND segregating with an intergenic deletion associated with long-range cis-regulatory elements (CREs) of PITX2.

Methods

We applied 30x whole genome sequencing (WGS) to two French families in which exome sequencing did not allow to detect the causing genes of SND and analyzed them bioinformatically.

Results

We first applied WGS to a 4-generation family presenting 16 patients with SND, atrial fibrillation and/or repolarization abnormalities and identified a 15-Kb deletion within a 16.5-cM linkage interval (Zmax = 5.9, θ = 0) on chromosome 4q25. We also applied WGS on a second family presenting 5 patients with SND and identified a 91-Kb deletion overlapping the initial deletion. This intergenic deletion, which was located between PITX2 and ANK2 and contained a binding motif of CCCTC-binding factor (CTCF), was segregating in all patients and was not found in 855 French control genomes. CTCF functions as a genome organizer mediating genomic interactions between genes and CREs. To clarify a possible regulatory function of the 1.5-Mb intergenic region containing the deletion, we interrogated 3 epigenetic databases. High-throughput chromosome conformation capture (Hi-C) (1) revealed that this intergenic region was placed in a topologically associating domain (TAD) containing PITX2. Chromatin interaction analysis by paired-end tag (ChIA-PET) of CTCF (2) suggested several possible functional chromatin loops in the TAD. Of them, a CTCF-mediated chromatin loop corresponding to a 300-Kb genomic region was clarified as a possible CRE using histone modification data from Roadmap. The region ranging between the intra-deletion CTCF motif and another distal motif was repressed in H3K27me3 profiles of fetal heart, while the region was activated in H3K27ac profiles of H1 ESC-derived mesendoderm.

Conclusion

This CRE may regulate expression of PITX2 and/or ANK2 in pacemaker cell differentiation. Ongoing experiments on patient's iPSC and transgenic mouse will further characterize the disease mechanism.

P4653A natural history of carcinoid heart disease in the modern management era

Background

The development of carcinoid heart disease (CaHD) is still relatively unknown at present. It is difficult to define an optimal follow-up for patients initially free from cardiac involvement. The aim of this study was to assess the prevalence and the evolution of CaHD using annual echocardiographic follow-up.

Methods

We reviewed from our database 137 patients (61±12 years, 53% men) with histologically proven neuroendocrine tumor between 1997 and 2017. All patients underwent serial conventional transthoracic echocardiographic studies. Right-sided and left-sided CaHD were systematically assessed. We used a previous validated echocardiographic scoring system of severity for the assessment of CHD. An increase of 25% of the score was considered as significant.

Results

Mean follow-up was 2.6±3.5 years [0; 16]. Prevalence of CaHD was 27% (37 pts) at baseline and 36% (49 pts) at the end of follow-up. Among patients with initial CaHD followed for more than one year, disease progression was observed in 28% of cases. Among the patients free from initial cardiac involvement, an onset of the disease was observed during follow-up in 21% of cases. The onset of CHD could be very late, more than 5 years from the initial echocardiographic examination in 42% of our cases (Figure). This late occurrence of CaHD was only observed in patients presenting with new resumption of neuroendocrine tumor (symptoms, increased of 5-HIAA, occurrence of new metastasis).

Conclusion

Our study demonstrated that in patients without initial CaHD, cardiac involvement may occur tardily after a normal initial assessment. Our data suggest the need for prolonged echocardiographic follow-up in patients presenting with a resumption of tumor process.

Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal

BACKGROUND

Evidence shows benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services.AimEvaluating the clinical value of adding psychological treatments, delivered by community-based counsellors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the Mental Health Gap Action Programme (mhGAP).

METHOD

Two randomised controlled trials, separately for depression and AUD, were carried out. Participants were randomly allocated (1:1) to mental healthcare delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity, measured using the Patient Health Questionnaire - 9 item (PHQ-9) for depression and the Alcohol Use Disorder Identification Test for AUD, and functional impairment, measured using the World Health Organization Disability Assessment Schedule (WHODAS), at 12 months post-enrolment.

RESULTS

Participants with depression in the intervention arm (n = 60) had greater reduction in PHQ-9 and WHODAS scores compared with participants in the control (n = 60) (PHQ-9: M = -5.90, 95% CI -7.55 to -4.25, β = -3.68, 95% CI -5.68 to -1.67, P < 0.001, Cohen's d = 0.66; WHODAS: M = -12.21, 95% CI -19.58 to -4.84, β = -10.74, 95% CI -19.96 to -1.53, P= 0.022, Cohen's d = 0.42). For the AUD trial, no significant effect was found when comparing control (n = 80) and intervention participants (n = 82).

CONCLUSION

Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared with only mhGAP-based services by primary health workers 12 months post-treatment.Declaration of interestNone.

Cortical regions supporting reading comprehension skill for single words and discourse

A substantial amount of variation in reading comprehension skill is explained by listening comprehension skill, suggesting tight links between printed and spoken discourse processing. In addition, both word level (e.g., vocabulary) and discourse-level sub-skills (e.g., inference-making) support overall comprehension. However, while these contributions to variation in comprehension skill have been well-studied behaviorally, the underlying neurobiological basis of these relationships is less well understood. In order to examine the neural bases of individual differences in reading comprehension as a function of input modality and processing level, we examined functional neural activation to both spoken and printed single words and passages in adolescents with a range of comprehension skill. Data driven Partial Least Squares Correlation (PLSC) analyses revealed that comprehension skill was positively related to activation in a number of regions associated with discourse comprehension and negatively related to activation in regions associated with executive function and memory across processing levels and input modalities.

Patterns of intimate partner violence among perinatal women with depression symptoms in Khayelitsha, South Africa: a longitudinal analysis

BACKGROUND

A combination of intimate partner violence (IPV) and depression is a common feature of the perinatal period globally. Understanding this association can provide indications of how IPV can be addressed or prevented during pregnancy. This paper aims to determine the prevalence and correlates of IPV among pregnant low-income women with depressive symptoms in Khayelitsha, South Africa, and changes in IPV reports during the course of the perinatal period.

METHODS

This study is a secondary analysis of data collected as part of a randomised controlled trial testing a psychosocial intervention for antenatal depression. IPV, socio-demographic measures, depression and other mental health measures were collected at recruitment (first antenatal visit), 8 months gestation, and 3 and 12 months postpartum. IPV was defined as a sexual or physical violence perpetrated by the participant's partner in the past 3 months. Descriptive statistics are reported.

RESULTS

Of 425 recruited depressed participants, 59 (13.9%) reported IPV at baseline, with physical IPV being the most frequently reported (69.5%). Reported IPV was associated with greater emotional distress, potentially higher food insecurity and higher rates of alcohol abuse. There were clear longitudinal trends in reported IPV with the majority of women no longer reporting IPV postpartum. However, some women reported IPV at later assessment points after not reporting IPV at baseline.

CONCLUSIONS

There is a strong association between IPV and depression in pregnancy. IPV reports remit over time for the women in this study, although the reason for this reduction is not clear and requires further investigation.

Carateres de seleção do Toiro de Lide para a tourada à corda dos Açores

Com o objetivo de identificar caraterísticas com interesse na seleção do toiro de lide para as touradas à corda, foi elaborado um inquérito, incluindo 38 questões, tendo sido inquiridos, no período de janeiro a março de 2013, todos os ganadeiros (n=18) inscritos na Associação Regional de Criadores de Toiros da Tourada à Corda. Os resultados foram submetidos a análise estatística com um teste não paramétrico de qui-quadrado por simulação Monte Carlo (MMC–10 000 bootstraps) (p≤0,05). Os resultados obtidos evidenciaram que todos os ganadeiros definiram elevada mobilidade para os toiros das touradas à corda (pontuações ≥3), e 88,89 % (p≤0,05) destacaram esta caraterística como uma das mais importantes para a seleção. Para os ganadeiros os toiros têm de responder rapidamente aos estímulos de investida e com temperamento altamente agressivo e combativo. Esta caraterística foi apontada como uma das mais importantes na seleção do toiro de lide para a tourada à corda (94,44 % - p≤0,05). Os toiros devem estar atentos ao que ocorre à sua volta, (94,44 %; p≤0,05). Os resultados ainda aferiram que todos os ganadeiros destacaram a resistência como um caracter a selecionar nos animais. Ficou demonstrado que os ganadeiros valorizam a melhoria do desempenho dos toiros ao longo de uma tourada à corda. Através da avaliação dos itens REG34, REG36, REG35 e REG37, ficou evidenciado que a regularidade dos desempenhos dos toiros nas várias touradas é um caráter muito levado em consideração pelos ganadeiros. No final foram identificados e definidos sete caracteres: mobilidade; capacidade de arremeter; capacidade de fixar; codícia; resistência; crescer e regularidade. Os caracteres foram organizados numa escala de avaliação para o seu uso na seleção do toiro de lide para a as touradas à corda.

Similar response patterns to topical minoxidil foam 5% in frontal and vertex scalp of men with androgenetic alopecia: a microarray analysis

BACKGROUND

There are regional variations in the scalp hair miniaturization seen in androgenetic alopecia (AGA). Use of topical minoxidil can lead to reversal of miniaturization in the vertex scalp. However, its effects on other scalp regions have been less well studied.

OBJECTIVES

To determine whether scalp biopsies from men with AGA show variable gene expression before and after 8 weeks of treatment with minoxidil topical foam 5% (MTF) vs. placebo.

METHODS

A placebo-controlled double-blinded prospective pilot study of MTF vs. placebo was conducted in 16 healthy men aged 18-49 years with Hamilton-Norwood type IV-V thinning. The subjects were asked to apply the treatment (active drug or placebo) to the scalp twice daily for 8 weeks. Stereotactic scalp photographs were taken at the baseline and final visits, to monitor global hair growth. Scalp biopsies were taken at the leading edge of hair loss from the frontal and vertex scalp before and after treatment with MTF and placebo, and microarray analysis was performed using the Affymetrix GeneChip HG U133 Plus 2.0.

RESULTS

Global stereotactic photographs showed that MTF induced hair growth in both the frontal and vertex scalp of patients with AGA. Regional differences in gene expression profiles were observed before treatment. However, MTF treatment induced the expression of hair keratin-associated genes and decreased the expression of epidermal differentiation complex and inflammatory genes in both scalp regions.

CONCLUSIONS

These data suggest that MTF is effective in the treatment of both the frontal and vertex scalp of patients with AGA.

Advanced UV/H₂O₂ oxidation of deca-bromo diphenyl ether in sediments

Removal of BDE-209 from contaminated sediments by UV/H2O2 treatment was investigated under different reaction conditions (different UV irradiance and H2O2 concentrations). After 10h of UV/H2O2 treatment, 90% of BDE-209 was removed with a half-life time (t1/2) of 3.5h and a kinetic constant (k) of 0.22 h(-1). Possible formation of OH-PBDEs and debrominated polybromodiphenyl ethers was investigated by GC-MS and LC-MS/MS. None of the abovementioned BDE-209 by-products was found after 2.5, 5.5 and 10h of UV/H2O2 treatment. Toxicity experiments carried out with zebrafish embryos exposed to the sediment before and after the UV/H2O2 treatment did not show any morphological or behavioural alterations, suggesting that no putative debrominated or oxidation products were originated by the treatment in concentrations high enough to elicit significant toxic effects in zebrafish embryos.

Genetic relationships of the Portuguese Lidia bovine populations

To clarify the genetic relationships among the Lidia breed lineages and two main Portuguese Lidia bovine populations, Casta Portuguesa and Brava dos Açores, 24 autosomal microsatellites were analyzed in 120 samples. Brava dos Açores showed the highest observed and expected heterozygosity (0.73 and 0.70, respectively) while Casta Portuguesa showed the lowest observed and expected heterozygosity (0.51 and 0.50, respectively). The results of this study were compared with the previous microsatellites data from the main Lidia bovine lineages. Casta Portuguesa was the most genetically isolated Lidia bovine population as revealed by the average FST genetic distance value with respect to the other lineages (32%). All the populations of Portuguese Lidia had negative FIS values. The Neighbour-joining dendrogram grouped Casta Portuguesa in the same branch with Miura, which was supported by the STRUCTURE software. The results evidenced low levels of genetic diversity and high levels of genetic differentiation in Casta Portuguesa and high levels of genetic diversity in Brava dos Açores populations, probably due to the crossbreeding of different bovine lineages at origin, and genetic flow among herds.

Screening and pathways to maternal mental health care in a South African antenatal setting

In low-resource settings, a stepped care approach is necessary to screen and provide care for pregnant women with mental health problems. This study sought to identify screening items that were most robust at differentiating women experiencing psychological distress and requiring counselling [assessed by screening with the Edinburgh Postnatal Depression Scale (EPDS) and a Risk Factor Assessment (RFA)] from those with a psychiatric disorder as diagnosed by a psychiatrist. Case records of women in an antenatal mental health service in Cape Town were reviewed. Composite scores and individual items on screening scales (EPDS, RFA) of participants who qualified for counselling (n = 308) were compared to those of participants who were diagnosed with a psychiatric disorder (n = 58). All participants with a psychiatric disorder were diagnosed with either depression or anxiety disorders. These participants had higher mean scores on the EPDS and RFA than those who qualified for counselling (p < 0.01). Logistic regression and ROC analyses suggested that the best items to distinguish women with depression or anxiety from those qualifying for counselling were 'I have felt sad and miserable', 'I am not pleased about being pregnant' and 'I have had serious depression, panic attacks or problems with anxiety before' (sensitivity 0.655, specificity 0.750 for this combination of three items). A small number of items may be useful in screening for mental illness in pregnancy which requires higher levels of care. Such screening may contribute to a more efficient stepped care approach.

Effect of bovine ovarian tissue vitrification on the structural preservation of antral follicles

This study was performed to evaluate the structural preservation of antral follicles after bovine ovarian tissue vitrification using histological analysis. Ovaries (n = 30) of slaughtered cows were cut into small fragments using a scalpel blade, and the ovarian tissues were randomly assigned to vitrification using 15% dimethyl sulphoxide (DMSO) and 15% ethylene glycol (EG) and fresh tissues (control) groups. For histological evaluations, fresh and post-thawing ovarian tissues were immediately fixed, serially sectioned into 5-μm sections and stained with haematoxylin and eosin (H&E). Nine serial sections per fragment were subjected for morphological assessment. The diameter of the antral follicles was determined and classified into four groups: 1 (≤1 mm), 2 (>1-2 mm), 3 (>2-3 mm) and 4 (>3-4 mm). Then, follicular morphology was evaluated in relation to atresia and categorized into seven grades: Grade A (healthy follicle); Grades B, C and D (early atresia); Grades E and F (moderate atresia); and Grade G (advanced atresia). The results revealed that small diameters of antral follicles (1 and 2 mm) were more susceptible for cryoinjury. The normal follicular morphology (Grade A) was not affected by vitrification throughout follicle diameters. Nevertheless, some damage features were monitored after vitrification. In conclusion, the morphological structure of bovine antral follicles could be successfully preserved by ovarian tissue vitrification.

PDT in squamous cell carcinoma of the skin

Topical photodynamic therapy (PDT) has been demonstrated to be an effective and safe treatment option for pre-malignancies such as actinic keratoses (AK) and Bowen's disease (BD), with an increasing amount of evidence indicating good long term outcomes. Studies comparing PDT to other options such as cryotherapy and 5-fluorouracil generally demonstrate that PDT is equal to or better than these therapies with respect to patient satisfaction, cosmesis, and efficacy for AK and BD. While there are studies using squamous cell carcinoma (SCC) cells to elucidate the cellular and molecular mechanisms of PDT, this therapy is currently not indicated for treating SCC and surgery is still the first line of therapy. There has been special interest in using PDT to prevent warts, basal cell carcinoma, AK, and BD in solid organ transplant recipients, as these skin lesions are more common in immunosuppressed patients, and trials have been somewhat successful and very promising. Pain remains an obstacle for some patients and techniques such as nerve blocks, cooling packs, and hydration have been attempted to mitigate pain with an overall reduction in pain scores. Optimizing PDT is still a priority and the delivery of pro-drug as well as induction of cellular differentiation are being explored as ways to improve the efficacy of PDT. Perhaps the most interesting use of PDT in treating SCC is the potential for a tumor-specific vaccine, which is currently being developed.

The inducible cyclic adenosine 3’,5’-monophosphate early repressor (ICER) enhances drug sensitivity in acute myeloid leukemia

e22045

Background: The Inducible Cyclic Adenosine 3’,5’-monophosphate early repressor (ICER) is a transcription factor that principally counteracts the cAMP response element binding protein (CREB) activity. CREB was previously demonstrated to be overexpressed in acute leukemia, whereas ICER was found rapidly degradated being unable to control gene transcription. ICER exogenous expression was demonstrated to repress CREB targets preventing leukemia progression. We hypothesized that ICER restoration deserves a special consideration for playing a role in CREB oncogenic feature and in modeling leukemic cell phenotype. Methods: We constructed an expression vector for ICER and induced its exogenous expression in HL60 cells (HL60+ICER). We monitored transcription and translation of a series of genes involved in different pathways by quantitative gene expression and western blot analysis. We investigate ICER's role in cell death after treatment with chemotherapic drugs. Results: We revealed that ICER was able to control gene expression in leukemia, principally of genes involved in cell death and survival. In particular, we focused on DUSP1 and DUSP4 phosphatases which were found significantly repressed. HL60+ICER after being treated with drugs increased apoptosis. Cell cycle analyses revealed a block in G2 phase, a lowered cell proliferation and clonogenic potential with respect to HL60 treated at the same conditions. DUSPs downstream targets (IL6, RB, RAS) were lowered expressed and p38 constitutively phosphorylated confirming their role in mediating cellular stress. ICER driven apoptosis was found to be caspases mediated. An enhanced activity of p38 was observed in treated HL60+ICER, and by the use of specific p38 inhibitors apoptosis decreased. Other possible apoptotic pathways (AKT, ERK, JNK) were excluded because found severely disrupted. Conclusions: Finally, we described an enhanced sensibility to drugs in HL60 induced by ICER exogenous expression and that p38 stress signaling pathway is the direct target of this phenomenon. The ability of ICER to modify leukemic cells phenotype respect to chemotherapeutic treatment gave an important information for targets and therapeutic possibilities.

No significant financial relationships to disclose.

Effect of reducing the dose of stavudine on body composition, bone density, and markers of mitochondrial toxicity in HIV-infected subjects: a randomized, controlled study

BACKGROUND

Stavudine is widely used in developing countries. Lipoatrophy and mitochondrial toxicity have been linked to stavudine use, but it is unclear whether switching to a lower dose can reduce these toxicities while maintaining human immunodeficiency virus (HIV) suppression.

METHODS

HIV-infected subjects receiving standard-dose stavudine with undetectable HIV type 1 RNA for > or =6 months were randomized (ratio, 3:2) to receive one-half of the stavudine dose (switch arm) or to maintain the dose (continuation arm) while continuing to receive all other prescribed antiretrovirals. The following measurements were obtained at baseline and week 48: fasting lactate, pyruvate, and lipid levels; results of whole-body dual-energy x-ray absorptiometry; and mitochondrial DNA (mtDNA) measurements in fat and peripheral blood mononuclear cells. Change from baseline to week 48 was compared within and between groups.

RESULTS

Twenty-four patients (79% of whom were men and 79% of whom were African American; median age, 45 years) were enrolled in the study, 15 were enrolled in the switch arm, and 9 were enrolled in the continuation arm. The median duration of stavudine treatment was 55 months (range, 21-126 months). The median CD4 cell count was 558 cells/mm(3) (range, 207-1698 cells/mm(3)). At baseline, the study arms had similar demographic characteristics and laboratory indices, except for body mass index, total lean body mass, and triglyceride levels (all of which were higher in the switch arm). Three patients (2 in the switch arm) discontinued the study because of study-unrelated reasons. CD4 cell counts remained unchanged. At 48 weeks, 6 patients (4 [27%] in the switch arm and 2 [22%] in the continuation arm) had detectable HIV RNA levels (median, 972 copies/mL; range, 60-49,400 copies/mL). All patients with detectable HIV RNA levels reported significant lapses in treatment adherence; none exhibited mutations in HIV genotype. After the treatment switch, significant changes from study entry to week 48 were noted only for lactate level (median change, -0.27 mmol/L; range, -1.2 to 0.25 mmol/L; P = .02) and fat mtDNA (median change, 40 copies/cell; range, -49 to 261 copies/cell; P = .02). In the continuation arm, a significant loss of bone mineral density was seen at week 48 (median change, -1.7%; range, -6.3% to 0.8%; P = .02). The only significant between-group difference was the change in bone mineral density from baseline (P = .003).

CONCLUSIONS

Reducing stavudine dose by one-half increased fat mtDNA and decreased lactate levels, suggesting improvement in mitochondrial indices while preserving HIV suppression in subjects who maintained adherence. A significant loss of bone mineral density was seen in patients receiving standard-dose stavudine but not in those receiving low-dose stavudine. These results suggest that switching to low-dose stavudine may improve mitochondrial indices while maintaining virological suppression.

Uridine supplementation in HIV lipoatrophy: pilot trial on safety and effect on mitochondrial indices

OBJECTIVES

Uridine abrogates mitochondrial toxicities of nucleoside reverse transcriptase inhibitor in adipocyte cell culture. We aim to study the effect of uridine supplementation on human adipocyte mitochondrial DNA (mtDNA) levels in subjects with human immunodeficiency (HIV) lipoatrophy.

METHODS

Sixteen patients with lipoatrophy on stavudine-containing antiretroviral therapy were enrolled, and received NucleomaxX, a dietary supplement with a high bioavailability of uridine (36 g TID every other day for 16 weeks). Patients were then followed off-uridine for another 16 weeks. Highly active antiretroviral therapy remained unchanged during the trial.

RESULTS

Fourteen patients completed the study. Two subjects dropped out before week 4 for study-unrelated reasons. No adverse events were noted throughout the study. HIV-1 RNA, CD4 counts, liver enzymes and hemoglobin remained unchanged. Body mass index, lactate, lipids, insulin and homeostasis model assessment of insulin resistance were unaltered. Fat and peripheral blood and mononuclear cell mtDNA levels did not correlate with each other and exhibited no changes throughout the study. Lipoatrophy scores by patients and physician improved significantly at weeks 16 and 32 compared to study entry.

CONCLUSION

In this pilot study, NucleomaxX was safe, well tolerated without apparent deleterious effect on HIV indices. In contrast to in vitro data, NucleomaxX did not lead to changes in fat or blood mtDNA levels.

Impulse initiation and conduction in the murine atria: a basis for future investigation of sinus node dysfunction

The prevalence of atrial conduction defects and sinus node dysfunction increases with age. These age-related changes may play a critical role in establishing the substrate for the development of atrial fibrillation (AF), the most common sustained arrhythmia. Despite the association between atrial arrhythmias and age, little is known of the mechanisms that underlie changes in atrial electrophysiological function. Ongoing studies in our laboratory are focused on determining the mechanisms of atrial conduction defects associated with aging and disease. The purpose of this report is to present some initial studies of the murine sinus node and the approach we have taken to quantify conduction at the site of impulse initiation.

Foodborne Infections in France

To quantify the impact of foodborne diseases on health, and set priorities for data collection, prevention and control of these diseases, we compiled and analyzed information from surveillance systems and other sources on the morbidity and mortality due to foodborne infectious diseases in mainland France in the last decade of the 20th century. Illness due to 13 bacteria, two viruses, and eight parasites were studied. The number of foodborne infections, hospitalizations, and deaths were estimated from multiple data sources. For each agent, several estimates were derived from the different sources. Estimates were ranked according to their plausibility, based on an assessment of the validity of the data source, and are presented as a "plausible interval" consisting of a low and high estimate. We estimate that these pathogens caused 10,200-17,800 hospitalizations per year. Salmonella is the most frequent cause (5,700-10,200 cases), followed by Campylobacter (2,600-3,500 cases) and Listeria (304 cases). Toxoplasmosis accounts for the majority of hospitalizations (426 cases) attributable to the studied parasitic infections. The number of deaths related to foodborne infection was estimated between 228 and 691. Bacterial pathogens account for the majority (191 to 652) of deaths of which 92 to 535 are attributable to salmonellosis, ranking as the first cause of death, and 78 to listeriosis, the second cause. Salmonella, Campylobacter, and Listeria are the main causes of severe foodborne illness in France. For several pathogens, data are insufficient to derive exact estimates of the disease burden. Nevertheless, it has been possible to derive plausible estimates for the majority, and to rank them according to their impact on public health.

Case management of a multidrug-resistant Shigella dysenteriae serotype 1 outbreak in a crisis context in Sierra Leone, 1999-2000

From December 1999 to the end of February 2000, 4218 cases of dysentery were reported in Kenema district, southeastern Sierra Leone, by a Médecins Sans Frontières team operating in this region. Shigella dysenteriae serotype 1 was isolated from the early cases. The overall attack rate was 7.5% but higher among children under 5 years (11.2%) compared to the rest of the population (6.8%) (RR = 1.6; 95% CI 1.5-1.8). The case fatality ratio was 3.1%, and higher for children under 5 years (6.1% vs. 2.1%) (RR = 2.9; 95% CI 2.1-4.1). A case management strategy based on stratification of affected cases was chosen in this resource-poor setting. Patients considered at higher risk of death were treated with a 5 day ciprofloxacin regimen in isolation centres. Five hundred and eighty-three cases were treated with a case fatality ratio of 0.9%. Patients who did not have signs of severity when seen by health workers were given hygiene advice and oral rehydration salts. This strategy was effective in this complex emergency.

Heterogeneous connexin43 expression produces electrophysiological heterogeneities across ventricular wall

Recently we found that electrophysiological (EP) heterogeneities between subepicardial and midmyocardial cells can form a substrate for reentrant ventricular arrhythmias. However, cell-to-cell coupling through gap junctions is expected to attenuate transmural heterogeneities between cell types spanning the ventricular wall. Because connexin43 (Cx43) is the principal ventricular gap junction protein, we hypothesized that transmural EP heterogeneities are in part produced by heterogeneous Cx43 expression across the ventricular wall. The left ventricles of eight dogs were sectioned to expose the transmural surface. To determine whether heterogeneous Cx43 expression influenced EP function, high-resolution transmural optical mapping of the arterially perfused canine wedge preparation was used to measure transmural conduction velocity (thetaTM), dV/dt(max), transmural space constant (lambdaTM), and transmural gradients of action potential duration (APD). Relative Cx43 expression, quantified by confocal immunofluorescence, was significantly lower (by 24 +/- 17%; P < 0.05) in subepicardial compared with deeper layers. Importantly, reduced subepicardial Cx43 was associated with transmural heterogeneities of EP function evidenced by selectively reduced subepicardial thetaTM (by 18 +/- 9%; P < 0.05) compared with deeper layers. In subepicardial regions, dV/dt(max) was fastest (by 19 +/- 15%) and lambdaTM was smallest (by 18.1 +/- 2%), which suggests that conduction slowing was attributable to localized uncoupling rather than reduced excitability. The maximum transmural APD gradients occurred in the same regions where Cx43 expression was lowest; this suggests that Cx43 expression patterns served to maintain APD gradients across the transmural wall. These data demonstrate that heterogeneous Cx43 expression is closely associated with functionally significant EP heterogeneities across the transmural wall. Therefore, Cx43 expression patterns can potentially contribute to arrhythmic substrates that are dependent on transmural electrophysiological heterogeneities.

High Plasmodium falciparum resistance to chloroquine and sulfadoxine-pyrimethamine in Harper, Liberia: results in vivo and analysis of point mutations

In Liberia, little information is available on the efficacy of antimalarials against Plasmodium falciparum malaria. We measured parasitological resistance to chloroquine and sulfadoxine-pyrimethamine (SP) in Harper, south-west Liberia in a 28-d study in vivo. A total of 50 patients completed follow-up in the chloroquine group, and 66 in the SP group. The chloroquine failure rate was 74.0% (95% confidence interval [95% CI] 59.7-85.4%) after 14 d of follow-up and 84.0% (95% CI 70.9-92.8%) after 28 d (no polymerase chain reaction [PCR] analysis was performed to detect reinfections in this group). In the SP group, the failure rate was 48.5% (95% CI 36.2-61.0%) after 14 d and 69.7% (95% CI 57.1-80.4%) after 28 d, readjusted to 51.5% (95% CI 38.9-64.0%) after taking into account reinfections detected by PCR. Genomic analysis of parasite isolates was also performed to look for point mutations associated with resistance. Genotyping of parasite isolates revealed that all carried chloroquine-resistant K-76T mutations at gene pfcrt, whereas the triple mutation (S108N, N511, C59R) at dhfr and the A437G mutation at dhps, both associated with resistance to SP, were present in 84% and 79% of pretreatment isolates respectively. These results seriously question the continued use of chloroquine and SP in Harper and highlight the urgency of making alternative antimalarial therapies available. Our study confirms that resistance to chloroquine may be high in Liberia and yields hitherto missing information on SP.

Anxiety reaction in children during removal of their plaster cast with a saw

We have had experience of an 18-month-old boy with a cardiomyopathy who died a few minutes after removal of his cast with a saw, apparently from a malignant cardiac arrhythmia triggered by anxiety. We therefore examined the anxiety reaction to this method of removal of a plaster cast in 20 healthy children; ten were provided with hearing protectors and ten were not. The level of anxiety was assessed by measuring the heart rate, a known physiological indicator of anxiety, before, during and five minutes after removal of the cast. The noise level was also measured. The results showed a mean increase in heart rate during the procedure of 27.9 beats per minute (bpm) (26.9%) in the children with no hearing protectors and 10.4 bpm (11.1%) in children who used hearing protectors (p < 0.001). Five minutes after the procedure the heart rate had returned to the baseline rate in all patients. We recommend that hearing protectors should be used in children undergoing removal of a plaster cast to decrease the anxiety reaction. If possible, clinicians should avoid the use of a saw for this purpose in children with a cardiomyopathy.

Anxiety reaction in children during removal of their plaster cast with a saw

We have had experience of an 18-month-old boy with a cardiomyopathy who died a few minutes after removal of his cast with a saw, apparently from a malignant cardiac arrhythmia triggered by anxiety. We therefore examined the anxiety reaction to this method of removal of a plaster cast in 20 healthy children; ten were provided with hearing protectors and ten were not. The level of anxiety was assessed by measuring the heart rate, a known physiological indicator of anxiety, before, during and five minutes after removal of the cast. The noise level was also measured. The results showed a mean increase in heart rate during the procedure of 27.9 beats per minute (bpm) (26.9%) in the children with no hearing protectors and 10.4 bpm (11.1%) in children who used hearing protectors (p < 0.001). Five minutes after the procedure the heart rate had returned to the baseline rate in all patients.

We recommend that hearing protectors should be used in children undergoing removal of a plaster cast to decrease the anxiety reaction. If possible, clinicians should avoid the use of a saw for this purpose in children with a cardiomyopathy.

Acute neurologic deterioration after surgical treatment for thoracic spinal stenosis

Spondylotic changes in the thoracic spine resulting in a myelopathic syndrome is a rare condition. Surgical treatment consists of removal of the hypertrophied ligaments, facet joints and laminae (laminectomy). In this report, we review our experience in treating 12 cases of thoracic spinal stenosis (TSS). From 1989-1998, we identified 12 surgical cases treated by the Department of Neurosurgery at Temple University Hospital. For this report, we reviewed both inpatient and outpatient records and radiographic studies. We also reviewed the world's literature regarding this entity. After reviewing our own cases of TSS and the world's literature, we identified a higher than expected incidence of acute neurologic deterioration (AND) after surgical treatment of TSS (14.5%). This incidence is compared to an expected incidence of AND (0-5.5%) after laminectomy for cervical spinal stenosis (CSS). The seemingly higher incidence of AND after surgical treatment of TSS has implications for discussion of risks with patients undergoing surgical treatment.

Contemporary issues and future directions for research into pathological gambling

The recent healthy increase in research into all aspects of gambling is noted. The dominant theme accounting for most of this research is the mental disorder model of pathological gambling and measures that have been derived from this conceptualization. It is suggested that an alternative approach focusing on the construct of choice or subjective control over gambling may be a research direction that will ensure that progress is maintained. In this paper a context for the discussion is provided by first identifying briefly fundamental conceptual and methodological issues associated with the mental disorder model. In particular it is argued that the heterogeneity of the diagnosis of pathological gambling makes the research task of assessing truly independent variables extremely difficult. Subsequently an illustrative schema is presented that demonstrates both the potential advantages and some of the complexities associated with the dependent variable of self-control over gambling behaviour. The main advantages are argued to be (a) the focus of research is narrowed to one potential cause of harmful impacts rather than the great diversity of impacts themselves, (b) prospective studies of regular gamblers in real gambling venues may be a key source of insight into the development of pathological gambling and (c) it promotes the development of theoretical links with the mainstream of the discipline of psychology. Despite the conceptual difficulties that may be associated with the variable of self-control, it is suggested that these may be overcome because contemporary research into the addictive behaviours has demonstrated considerable success in the definition and measurement of control and related themes such as craving, restraint and temptation.

Cys 618 Arg mutation in the RET proto-oncogene associated with familial medullary thyroid carcinoma and maternally transmitted Hirschsprung's disease suggesting a role for imprinting

The multiple endocrine neoplasia type 2 (MEN2) syndromes and Hirschsprung's disease (HSCR) are inherited neurocristopathies characterized by medullary thyroid carcinoma (MTC), pheochromocytoma, parathyroid disease, and gastrointestinal neuromatosis. Mutations in the RET proto-oncogene are the underlying cause of the MEN2 syndromes and some cases of HSCR. In this report, we show that Cys 618 Arg mutation cosegregates with familial MTC and HSCR in two Moroccan Jewish families in which no involvement of pheochromocytoma or parathyroidism was observed. A single haplotype shared by chromosomes bearing the Cys 618 Arg mutation in both families strongly suggests a founder effect for this mutation. We have observed in our and in several other previously reported families, an excess of maternal over paternal mutated RET alleles in offsprings affected by HSCR. We suggest that parental imprinting may play a role in the ethiology of HSCR caused by mutations in the RET protooncogene.

Multinodular Goiter: The Surgical Procedure of Choice

Surgical management of multinodular goiter (MNG) poses an ongoing dilemma between radical resection with its associated complications and partial resection, which carries the risk of recurrence and increased morbidity and difficulty for rethyroidectomy. This study was designed to evaluate the recurrence rate and need for reoperation in a carefully selected population of MNG patients, after nontotal thyroidectomy. The study addressed a highly selected population of patients who were treated and thoroughly evaluated at one surgical department for several years. We analyzed the recurrence rate of MNG in 124 patients. The follow-up duration extended from 6 to 516 months (mean 93 months). The general recurrence rate for all nontotal bilateral thyroidectomies was 21% (21/100 patients), increasing from 13.4% to 60% according to the extent of resection. The average time for recurrence was 105 months (8.75 years). Among the patients with recurrent MNG, only 4 (4% of the patients with nontotal bilateral thyroidectomy) required secondary surgical interventions with no resultant morbidity. In our series of very highly selected patients, the recurrence rate for nontotal thyroidectomy was high (21%); however, the need for secondary surgical intervention was low (4%). Thus nontotal thyroidectomy for MNG is legitimate. However, we suggest that the surgical procedure of choice be tailored according to the severity of the disease and the patient's general condition.

Multinodular goiter: the surgical procedure of choice

Surgical management of multinodular goiter (MNG) poses an ongoing dilemma between radical resection with its associated complications and partial resection, which carries the risk of recurrence and increased morbidity and difficulty for rethyroidectomy. This study was designed to evaluate the recurrence rate and need for reoperation in a carefully selected population of MNG patients, after nontotal thyroidectomy. The study addressed a highly selected population of patients who were treated and thoroughly evaluated at one surgical department for several years. We analyzed the recurrence rate of MNG in 124 patients. The follow-up duration extended from 6 to 516 months (mean 93 months). The general recurrence rate for all nontotal bilateral thyroidectomies was 21% (21/100 patients), increasing from 13.4% to 60% according to the extent of resection. The average time for recurrence was 105 months (8.75 years). Among the patients with recurrent MNG, only 4 (4% of the patients with nontotal bilateral thyroidectomy) required secondary surgical interventions with no resultant morbidity. In our series of very highly selected patients, the recurrence rate for nontotal thyroidectomy was high (21%); however, the need for secondary surgical intervention was low (4%). Thus nontotal thyroidectomy for MNG is legitimate. However, we suggest that the surgical procedure of choice be tailored according to the severity of the disease and the patient's general condition.