Cost-effectiveness of a novel urethral catheter safety device in preventing catheterization injuries in the UK

AIMS

Intraurethral catheter balloon inflation is a substantial contributor to significant catheter-related urethral injury. A novel safety valve has been designed to prevent these balloon-inflation injuries. The purpose of this evaluation was to assess the cost-effectiveness of urethral catheterisation with the safety valve added to a Foley catheter versus the current standard of care (Foley catheter alone).

MATERIALS AND METHODS

The analysis was conducted from the UK public payer perspective on a hypothetical cohort of adults requiring transurethral catheterization. A decision tree was used to capture outcomes in the first 30 days following transurethral catheterization, followed by a Markov model to estimate outcomes over a person's remaining lifetime. Clinical outcomes included catheter balloon injuries [CBIs], associated short-term complications, urethral stricture disease, life years and QALYs. Health-economic outcomes included total costs, incremental cost-effectiveness ratio, net monetary benefit (NMB) and net health benefit.

RESULTS

Over a person's lifetime, the safety valve was predicted to reduce CBIs by 0.04 per person and CBI-related short-term complications by 0.03 per person, and nearly halve total costs. The safety valve was dominant, resulting in 0.02 QALYs gained and relative cost savings of £93.19 per person. Probabilistic sensitivity analysis indicated that the safety valve would be cost-saving in 97% of simulations run versus standard of care.

CONCLUSIONS

The addition of a novel safety valve aiming to prevent CBIs during transurethral catheterization to current standard of care was estimated to bring both clinical benefits and cost savings.

Pain Intensity and Functional Outcomes for Activities of Daily Living, Gait and Balance in Older Adults Accessing Outpatient Rehabilitation Services: A Retrospective Study

Purpose

Older adults are referred for outpatient physical therapy to improve their functional capacities. The goal of the present study was to determine if pain had an influence on functional outcomes in older adults who took part in an outpatient physical rehabilitation program.

Patients and Methods

A retrospective study was performed on the medical records of patients aged 65 and over referred for outpatient physical therapy to improve physical functioning (n=178). Pain intensity (11-point numeric pain scale) and results from functional outcome measures (Timed Up and Go [TUG], Berg Balance Scale [BBS], 10-meter walk test, 6-minute walk test and Functional Autonomy Measuring System [SMAF]) were extracted at initial (T1) and final (T2) consultations. Paired t-tests were performed to determine if there were differences in functional outcome measures between T1 and T2 in all the patients. Patients were stratified to those with pain (PAIN, n=136) and those without pain (NO PAIN, n=42). Differences in functional outcome measures between T1 and T2 (delta scores) were compared between groups with independent t-tests with Welch corrections for unequal variances. Pearson correlation coefficients between initial pain intensity and changes in functional outcome measures (T2-T1) were also performed. Correcting for multiple comparisons, a p-value of p≤0.01 was considered as statistically significant.

Results

The TUG, BBS, 10-meter walk test, 6-minute walk test all demonstrated improvement between T1 and T2 (all p<0.01). There was no difference between groups for delta scores for TUG (p=0.14), BBS (p=0.03), 10-meter walk test (p=0.54), 6-minute walk test (p=0.94) and SMAF (p=0.23). Pearson correlation coefficients were weak between initial pain intensity and changes in functional outcome scores between T1 and T2 (r= −0.16 to 0.15, all p-values >0.10).

Conclusion

These results suggest that pain is not an impediment to functional improvements in older individuals who participated in an outpatient physical rehabilitation program.

Long-term outcomes of urethral catheterisation injuries: a prospective multi-institutional study

PURPOSE

There are no prospective data describing the incidence and spectrum of long-term complications associated with traumatic urethral catheterisation (UC). We prospectively monitored the long-term clinical outcomes and complications of patients with traumatic UC injuries.

METHODS

A prospective study at two tertiary university hospitals was performed to record all referrals for iatrogenic urethral injuries caused by UC. Long-term follow-up was prospectively maintained by regular outpatient department visits and by monitoring all urological interventions and their outcomes from urinary catheter-related injuries.

RESULTS

The incidence of traumatic UC was 13.4 per 1000 catheters inserted in male patients and 37 iatrogenic urethral injuries were recorded. The mean age was 74 ± 12 years and the mean length of follow-up was 37 ± 3.7 months. Urethral injuries were caused by inflating the catheter anchoring balloon in the urethra (n = 26) or by creating a false passage with the catheter tip (n = 11). In total, 29 patients (78%) developed urethral stricture disease during their follow-up; of which 11 have required at least one urethral dilation and two have required one urethrotomy. Three patients required long-term indwelling suprapubic catheter placement and seven patients opted for a long-term indwelling urethral catheter. There were eight patient mortalities; one of which was due to severe urosepsis resulting from catheter balloon inflation in the urethra.

CONCLUSION

Catheter-related injuries are associated with significant long-term complications in this vulnerable patient cohort. In future, such injuries may be preventable if the safety profile of the urinary catheter is modified.

Abstract P6-08-17: Pregnancy associated breast cancer: Evaluating maternal outcomes. A multicentre study

Background

Pregnancy associated breast cancer (PABC) is defined as breast cancer (BC) diagnosed during the gestational period (GP) or in the first year postpartum (PP). Despite its infrequent occurrence, the incidence of PABC appears to be rising due to the increasing propensity for women to delay childbirth. We have established the first combined prospective and retrospective registry study of PABC in Ireland to examine specific clinicopathological characteristics, treatments and maternal outcomes. We present the retrospective findings to date.

Methods

We performed a retrospective multicentre observational study of patients (pts) with PABC treated in the eight Irish cancer centres from August 2001 to March 2017. Data extracted included information on pt demographics, tumour biology, staging, treatment administered and maternal outcomes. Standard biostatistical methods were used for analysis.

Results

111 PABC patients were identified. Sixty pts (54%) were diagnosed during the GP and 51 (46%) within 1 year PP. Median age at diagnosis was 36 years (yrs). Table 1 illustrates baseline characteristics. Two thirds of pts were node positive and a similar proportion had grade 3 pathology. Seventy pts (63%) were estrogen receptor (ER) positive, 36 (32%) HER2 positive, 25 (22%) triple negative. Twenty-two pts (20%) were metastatic at presentation. Seven pts (6%) had a known BRCA 1/2 mutation. The median OS (overall survival) and DFS (disease free survival) for the entire cohort was 107.4 and 94.2 months respectively (resp). There was no survival difference between those diagnosed during the GP versus PP. 5 yr DFS and OS was 68.6% and 69.2% resp. This compares unfavourably to results reported by the National Cancer Registry of Ireland in a similar age-matched BC population between 2000-2012 where the 5 yr OS was 86.5%. Variables in our study associated with poorer outcomes included younger age, tumour size, node positivity and lack of estrogen expression.

Baseline characteristics PABC patients (n=11) %(n)Diagnosed in GP (n=60) %(n)Diagnosed 1yr PP (n=51) %(n)p valueDemographic    Age at diagnosis3636(25-49)36(21-44)0.31Stage    I-II54(60)55(33)53(27)0.85III23(26)23(14)23(12)1IV20(22)18(11)22(11)0.81Unknown3(3)3(2)2(1)1Pathology    Grade 366(74)70(42)63(32)0.43Node positive66(73)68(41)63(32)0.55ER+/HER2-41(45)38(23)43(22)0.69ER+/HER2+23(25)28(17)16(8)0.17ER-/HER2+14(16)17(10)12(6)0.59Triple negative22(25)17(10)29(15)0.11Surgery    Breast conservation23(26)25(15)21(11)0.82Mastectomy56(63)57(34)59(30)0.84Adjuavnt/Neoadjuvant treatment    Chemotherapy73(81)77(46)69(35)0.39Anthracycline68(55)78(36)54(19)0.03Taxane89(72)93(43)83(29)0.16Anti HER2 agent21(23)18(11)24(12)0.63Endocrine therapy64(52)63(29)66(23)0.84Radiotherapy79(64)74(34)86(30)0.85Relapse in Stage I-III    Local relapse15(13)12(6)18(7)0.55Distant relapse24(21)22(11)25(10)0.80

Conclusions

PABC patients may have a poorer outcome. Our study reported higher rates of triple negative and HER2 positive breast cancer which are associated with more aggressive biology. Prospective evaluation of clinicopathological features, pharmacokinetics of treatments selected and maternal and fetal outcomes is imperative in this distinct pt group.

Citation Format: Prior L, Teo M, Greally M, Ward C, O'Leary C, Aslam R, Darwish W, Ahmed N, Watson G, Kelly D, Kiely L, Hassan A, Gleeson J, Featherstone H, Lim M, Murray H, Gallagher D, Westrup J, Hennessy B, Leonard G, Grogan L, Breathnach O, Horgan A, Coate L, O'Mahony D, Coate L, O'Reilly S, Gupta R, Keane M, Duffy K, O'Connor M, Kennedy J, McCaffrey J, Higgins M, Kelly C, Carney D, Gullo G, Crown J, Walshe J. Pregnancy associated breast cancer: Evaluating maternal outcomes. A multicentre study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-08-17.

ICORG 10-14: NEOadjuvant trial in Adenocarcinoma of the oEsophagus and oesophagoGastric junction International Study (Neo-AEGIS)

BACKGROUND

Neoadjuvant therapy is increasingly the standard of care in the management of locally advanced adenocarcinoma of the oesophagus and junction (AEG). In randomised controlled trials (RCTs), the MAGIC regimen of pre- and postoperative chemotherapy, and the CROSS regimen of preoperative chemotherapy combined with radiation, were superior to surgery only in RCTs that included AEG but were not powered on this cohort. No completed RCT has directly compared neoadjuvant or perioperative chemotherapy and neoadjuvant chemoradiation. The Neo-AEGIS trial, uniquely powered on AEG, and including comprehensive modern staging, compares both these regimens.

METHODS

This open label, multicentre, phase III RCT randomises patients (cT2-3, N0-3, M0) in a 1:1 fashion to receive CROSS protocol (Carboplatin and Paclitaxel with concurrent radiotherapy, 41.4Gy/23Fr, over 5 weeks). The power calculation is a 10% difference in favour of CROSS, powered at 80%, two-sided alpha level of 0.05, requiring 540 patients to be evaluable, 594 to be recruited if a 10% dropout is included (297 in each group). The primary endpoint is overall survival, with a minimum 3-year follow up. Secondary endpoints include: disease free survival, recurrence rates, clinical and pathological response rates, toxicities of induction regimens, post-operative pathology and tumour regression grade, operative in-hospital complications, and health-related quality of life. The trial also affords opportunities for establishing a bio-resource of pre-treatment and resected tumour, and translational research.

DISCUSSION

This RCT directly compares two established treatment regimens, and addresses whether radiation therapy positively impacts on overall survival compared with a standard perioperative chemotherapy regimen Sponsor: Irish Clinical Research Group (ICORG).

TRIAL REGISTRATION

NCT01726452 . Protocol 10-14. Date of registration 06/11/2012.

Visceral fat enhances blood pressure reactivity to physical but not mental challenges in male adolescents

BACKGROUND

Excess visceral fat is a major risk factor for hypertension. Enhanced blood pressure (BP) reactivity and delayed BP recovery from physical and mental challenges predict future hypertension.

OBJECTIVES

Determine whether visceral fat is associated with higher BP reactivity and delayed BP recovery from physical and mental challenges during adolescence.

METHODS

In a community-based sample of 283 male and 308 female adolescents, we measured visceral fat with magnetic resonance imaging, total body fat with bioimpedance, and beat-by-beat BP with a Finometer at rest and during physical (10-min standing) and mental (2-min math stress) challenges.

RESULTS

Males vs. females showed greater BP reactivity and no differences in BP recovery from either type of challenges. Visceral fat was positively associated with BP reactivity to standing up only and in males only (+8.4 ± 3.6 mmHg per 1 log cm(3) of visceral fat, P = 0.008), and this association was independent of total body fat. No association was seen between visceral fat and BP recovery from either type of challenge in either sex. All these associations were independent of age, puberty stage, height and initial BP.

CONCLUSIONS

Adolescent males vs. females demonstrate greater BP reactivity but similar BP recovery from physical and mental challenges. Excess visceral fat enhances BP reactivity to physical but not mental challenges in males only.

Saguenay Youth Study: a multi-generational approach to studying virtual trajectories of the brain and cardio-metabolic health

This paper provides an overview of the Saguenay Youth Study (SYS) and its parental arm. The overarching goal of this effort is to develop trans-generational models of developmental cascades contributing to the emergence of common chronic disorders, such as depression, addictions, dementia and cardio-metabolic diseases. Over the past 10 years, we have acquired detailed brain and cardio-metabolic phenotypes, and genome-wide genotypes, in 1029 adolescents recruited in a population with a known genetic founder effect. At present, we are extending this dataset to acquire comparable phenotypes and genotypes in the biological parents of these individuals. After providing conceptual background for this work (transactions across time, systems and organs), we describe briefly the tools employed in the adolescent arm of this cohort and highlight some of the initial accomplishments. We then outline in detail the phenotyping protocol used to acquire comparable data in the parents.

Finding paradise: cues directing the migration of the waterfall climbing Hawaiian gobioid Sicyopterus stimpsoni

A series of waterfall-climbing trials were conducted to identify cues that direct the climbing of juvenile Sicyopterus stimpsoni. In the first experiment, whether climbing juveniles preferentially ascend water sources with conspecifics or whether the presence of just stream water is sufficient to attract fish to ascend a climbing path were assessed. In the second experiment, whether climbing juveniles create a trail of mucus that facilitates the ability of conspecifics to follow their lead was determined. The results indicate that juvenile S. stimpsoni are less likely to climb in waters devoid of organic cues but are strongly attracted to stream water with or without the odour of conspecifics. Once climbing, performance did not differ for juveniles climbing in differing water choices, suggesting an all-or-nothing commitment once climbing commences. Climbing S. stimpsoni did produce a mucous trail while climbing that was associated with a mucous gland that dramatically increases in size just prior to juveniles gaining the ability to climb. The trail was not followed closely by subsequent juveniles traversing the same channel, however, suggesting only weak trail-following in waterfall climbing S. stimpsoni. Previous genetic studies suggest that juvenile S. stimpsoni do not home to natal streams in the face of strong near-shore oceanic currents. Instead, these fish appear primarily to rely on cues that suggest the presence of organic growth in streams, a factor that may indicate suitable habitat in an ever-changing stream environment but which may also be vulnerable to interference through human activity.

Influence of the amount of use on hand motor cortex representation: effects of immobilization and motor training

Converging evidence from animal and human studies has revealed that increased or decreased use of an extremity can lead to changes in cortical representation of the involved muscles. However, opposite experimental manipulations such as immobilization and motor training have sometimes been associated with similar cortical changes. Therefore, the behavioral relevance of these changes remains unclear. The purpose of this study was to observe the effect of the amount of use on hand muscle motor cortex representation by contrasting the effect of unspecific motor training and immobilization. Nine healthy volunteers were tested prior and after a 4-day exposure to two experimental conditions using a randomized cross-over design: a motor training condition (to play Guitar Hero 2h/day with the tested (nondominant) hand on the fret board) and an immobilization condition (to wear an immobilization splint 24h/day). Before and after each condition, motor cortex representation of the nondominant first dorsal interosseous (FDI) muscle was mapped using image-guided transcranial magnetic stimulation (TMS). At the behavioral level, results show that the training condition led to a 20% improvement in the trained task, while the immobilization condition resulted in a 36% decrease in the FDI maximal voluntary contraction. At the neurophysiological level, corticospinal excitability (e.g. Motor-evoked potential amplitude) was found to be decreased in response to immobilization, while no change was observed in response to motor training. No change was found for other TMS variables (motor thresholds or map location/volume/area) in either condition. In conclusion, our results indicate that a 4-day decrease, but not increase, in the amount of use of nondominant hand muscles is sufficient to induce a change in corticospinal excitability. The lack of a training effect might be explained by the use of an unspecific task (that is nevertheless representative of "real-life" training situations) and/or by insufficient duration/intensity to induce long-lasting changes.

P2-18-04: Pilot Evaluation of Bevacizumab (Bev) in Combination with Docetaxel (T) and Cyclophosphamide (C) as Adjuvant Treatment (AdjRx) for Patients (pts) with Early Stage (ES) Breast Cancer (BrCa)

Background

The combination of Bev + chemotherapy (CRx) has been shown to produce superior response rates and progression free survival compared to CRx alone, providing a rationale for the study of Bev with AdjCRx for pts with ESBrCa. As Bev can cause hypertension (HTN) and may increase the risk of cardiac failure, there is a rationale for studying a standard non-anthracycline (Anth) AdjCRx with Bev, e.g. TC (docetaxel-cyclophosphamide). We performed a pilot phase II study to evaluate the feasibility and toxicity of TC+Bev in pts with ESBrCa in preparation for participation in a random assignment trial. We have previously reported preliminary toxicity data.

Methods: Eligibility criteria included: ESBrCa which was HER-2 normal, node+ or, N- and primary tumour (T) &gt;2 cm and receptor negative, or T &gt;3 cm, normal left ventricle ejection fraction (LVEF), no active/uncontrolled cardiovascular disease, normal organ and marrow function. Treatment consisted of four 3-weekly cycles of docetaxel 75 mg/m2 together with cyclophosphamide 600 mg/m2. Patients commenced Bev 15 mg/kg i.v. on day 1, and then every 3 weeks to a total of 18 cycles of treatments. Pts were monitored clinically, with echocardiograms and with serial estimations of BNP and troponin.

Results: A total of 106 female pts were accrued in 9 ICORG sites between 11/2008 and 7/2010. Ages ranged from 25–75 (median 52). On 20/06/2011, 105 pts have completed study Rx, 1 will finish 7/2011. A total of 36 serious adverse events (SAEs) have been reported so far, 33 involving hospital admission, 3 serious for other reasons. In 25 (24%) pts study Rx was discontinued due to: HTN-9, intestinal perforation-2, consent withdrawl-7, infection-2, proteinuria-1, anaphylaxis-1, cancer relapse-1, arthralgia-1, anal fistula-1. The two perforations occurred at cycles 1 and 16 of Bev respectively. Neither pt with perforation had history of prior abdominal surgery. The median number of cycles achieved by the discontinued pts was 9. HTN of any grade occurred in 49 out of 103 (48%) pts who had no HTN at baseline (BL) and 42 of them required Rx. Among pts who experienced HTN on study Rx and completed Bev, 34 (81%) were still on anti-hypertensive 4 weeks after last infusion of Bev. Forty-one (39%) pts had LVEF drop &gt;10% from BL during study Rx. In 8 (7.5%) pts LVEF declined below 50%, 6 are documented to have recovered to normal, 2 had no further LVEF measurements (1 declined, 1 unknown reason). No episodes of CCF were reported. Troponin and BNP levels were normal in all 57 pts with serial measurements. Fourteen pts required treatment for neutropenia-related infection or for abscess/fistula.

Conclusions: In this study Bev overall toxicity in ESBC pts was similar to that reported for pts with MBC, and Bev discontinuation due to toxicity was relatively frequent. Although no pt developed CCF 7.5% of decline in LVEF&lt;50% was observed. Intestinal perforation can occur in ESBC pts in absence of prior intestinal surgery and in the post-CRx phase of Bev. Pts receiving Bev with non-Anth AdjCRx require careful monitoring for toxicity.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-18-04.

Abstract P5-10-17: Bevacizumab (Bev) in Combination with Docetaxel (T) and Cyclophosphamide (C) as Adjuvant Treatment (AdjRx) for Patients (pts) with Early Stage (ES) Breast Cancer (BrCa) and Normal HER-2 Status. A Pilot Evaluation

In random assignment trials, the combination of Bev+ chemotherapy has been shown to produce superior response rates and progression free survival compared to chemotherapy alone, providing a rationale for the study of Bev in the AdjRx of pts with ESBrCa. As a principal side effect of Bev is hypertension (HTN), anthracycline-containing (Anth) AdjRx may pose additional cardiovascular risks. The role of Anth in Her2 normal ESBC is uncertain. TC is a standard non-Anth AdjRx. We performed a single arm pilot study to evaluate the feasibility and toxicity of TC+Bev in pts with ESBC in preparation for participation in a random assignment trial. Methods: Eligibility criteria included: ESBC which was HER-2 normal, node-positive or &gt;2 cm and receptor negative, or &gt;3 cm and receptor positive, normal cardiac ejection fraction (EF), no active or uncontrolled cardiovascular disease, normal organ and marrow function. Treatment consisted of four 3 weekly cycles of docetaxel 75 mg/m2 together with cyclophosphamide 600 mg/m2. Patients commenced bevacizumab 15 mg/kg i.v. on day 1, and q 3 weeks to a total of 19 treatments. Pts were monitored clinically, with echocardiograms and with serial estimations of BNP and troponin.

Results: A total of 105 female pts were accrued in 9 ICORG sites between Dec 2008 and June 2010. Ages ranged from 26-86 (median 55). At June 2010, 33 have completed all phases of therapy, 54 are still on treatment. Eighteen pts have been removed from study due to: HTN -7, intestinal perforation -2, withdrew consent-4, proteinuia-1, anaphylaxis-1, infection-3. The perforations occurred at cycles 9 and 19. Neither pt. with perforation had prior abdominal surgery. The median number of cycles achieved by the discontinued pts was 9. HTN requiring Rx occurred in 25 pts. Among 12 with HTN who have completed Bev, 2 are off HTN meds, and 9 are on reducing doses. The median EF at base line was 67%, at 13 cycles (42 pts) 63%, 18 cycles (27 pts) 66%. Six pts had EF drop &gt;10%, in 3 of these EF fell below 50% as last recorded value. There were no episodes of clinical cardiac failure. Troponin and BNP levels were normal in all 57 pts with serial measurements. Thirteen pts required treatment for neutropenia-related infection or for abscess.

Conclusions: The spectrum and frequency of bevacizumab toxicity in our population of healthy adjuvant pts is similar to that reported for pts with metastatic BC and other malignancies. Hypertension is the principal cause of treatment discontinuation, but cardiac toxicity appears to be limited, with this non-anth chemotherapy +Bev. Intestinal perforation can also occur in pts with ESBC. These toxicities can occur in the post chemotherapy phase of Bev therapy. Pts enrolled on random assignment trials of Bev containing AdjRx require careful monitoring for toxicity.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-10-17.

Sexual dimorphism in the adolescent brain: Role of testosterone and androgen receptor in global and local volumes of grey and white matter

Here we examined sex differences in the volumes of grey and white matter, and in grey-matter "density," in a group of typically developing adolescents participating in the Saguenay Youth Study (n=419; 12-18 years). In male adolescents, we also investigated the role of a functional polymorphism in androgen-receptor gene (AR) in moderating the effect of testosterone on volumes of grey and white matter and grey-matter density. Overall, both absolute and relative volumes of white matter were larger in male vs. females adolescents. The relative grey-matter volumes were slightly larger in female than male adolescents and so was the grey-matter density in a large number of cortical regions. In male adolescents, functional polymorphism of AR moderated the effect of testosterone on relative white- and grey-matter volumes. Following a discussion of several methodological and interpretational issues, we outline future directions in investigating brain-behavior relationships vis-à-vis psychopathology.

Sex differences in the growth of white matter during adolescence

The purpose of this study was to examine sex differences in the maturation of white matter during adolescence (12 to 18 years of age). We measured lobular volumes of white matter and white-matter "density" throughout the brain using T1-weighted images, and estimated the myelination index using magnetisation-transfer ratio (MTR). In male adolescents, we observed age-related increases in white-matter lobular volumes accompanied by decreases in the lobular values of white-matter MTR. White-matter density in the putative cortico-spinal tract (pCST) decreased with age. In female adolescents, on the other hand, we found only small age-related increase in white-matter volumes and no age-related changes in white-matter MTR, with the exception of the frontal lobe where MTR increased. White-matter density in the pCST also increased with age. These results suggest that sex-specific mechanisms may underlie the growth of white matter during adolescence. We speculate that these mechanisms involve primarily age-related increases in axonal calibre in males and increased myelination in females.

Maternal cigarette smoking during pregnancy and cognitive performance in adolescence

BACKGROUND

The incidence of cigarette smoking during pregnancy remains high. Maternal smoking during pregnancy is known to be associated with cognitive and behavioural sequelae in childhood and adolescence. We assessed the relationship between maternal cigarette smoking during pregnancy and cognitive abilities in adolescent offspring (n = 503, 12- to 18-years old) using an extensive 6-h battery of tests.

METHODS

Non-exposed adolescents (controls) were matched to exposed adolescents (cases) by maternal education and school attended. Cognitive abilities were evaluated using a neuropsychological battery consisting of 33 tasks measuring verbal abilities, visuo-spatial skills, verbal and visual memory, processing speed, resistance to interference and motor dexterity.

RESULTS

We found no differences between cases and controls in any of the cognitive domains whether potential confounders were included in the model or not. In addition to maternal smoking during pregnancy, we also evaluated the effect of sex and age on the various cognitive abilities in this large adolescent sample and found that most of the abilities continue to improve during adolescence to the same extent in girls and boys, with several age-independent sex differences.

CONCLUSIONS

We found no effect of maternal cigarette smoking during pregnancy on cognitive abilities of the adolescent offspring when matching cases and controls by maternal education, the most common confounder of maternal cigarette smoking during pregnancy.

Corpus callosum in adolescent offspring exposed prenatally to maternal cigarette smoking

Teratogens, such as alcohol or anti-epileptic drugs, affect the size of the corpus callosum. Here we report findings obtained in a case-control study that investigated possible effects of teratogens contained in cigarette smoke on the size and structural properties of this structure. We recruited and scanned with magnetic resonance imaging a total of 408 adolescents (12 to 18 years of age); a subsample of 300 adolescents is considered in this report. Cases (n=146) were exposed to maternal cigarette smoking during pregnancy; non-exposed controls (n=154) were matched to cases by maternal education. We measured the size of corpus callosum (CC) and its sections (corrected for brain size), as well as mean values of magnetization-transfer ratio (MTR) in each CC section. Corpus callosum, and especially its posterior part, was smaller in the exposed vs. non-exposed female adolescents; no significant effects were found in males. Exposed and non-exposed subjects did not differ in the MTR-based index of myelination in either gender in any CC section. Given the lack of exposure effect on the myelination index, this finding might reflect a lower number of inter-hemispheric connections in female offspring of mothers who smoked during pregnancy.

Effect of polymer molecular weight on the production of drug nanoparticles

Stable, polymer-coated nanoparticles of two hydrophobic drugs, namely nabumetone and halofantrine, have been prepared by a wet-bead milling process performed in the presence of a stabilizing homopolymer, either hydroxypropylmethylcellulose (HPMC) or polyvinylpyrrolidone (PVP), of differing molecular weights and concentrations. Although nabumetone nanoparticles could only be produced when HPMC was used as stabilizing polymer, halofantrine nanoparticles could be prepared using either HPMC or PVP. Stable nanoparticles of nabumetone could be produced using a HPMC solution of viscosity average molecular weight, M(v), of 5 kg/mol over an approximate four fold polymer concentration range (0.63-2.5% w/w) when a drug loading of 20% w/w was used. Increasing the molecular weight of HPMC up to a limiting M(v) of 89 kg/mol did not result in the formation of nanoparticles at any of the polymer concentrations examined. The amount of polymer absorbed onto the nanoparticles was determined by measuring the depletion of polymer from solution based on either an ultra-violet (PVP) or optical rotatory dispersion (ORD) (HPMC) assay. The slightly lower concentration of HMPC found to be present on the surface of the halofantrine nanoparticles compared with the nabumetone nanoparticles suggested a differing affinity of the polymer for the surface of the two drugs.

The 2.4-A crystal structure of the penicillin-resistant penicillin-binding protein PBP5fm from Enterococcus faecium in complex with benzylpenicillin

Penicillin-binding proteins (PBPs) are membrane proteins involved in the final stages of peptidoglycan synthesis and represent the targets of beta-lactam antibiotics. Enterococci are naturally resistant to these antibiotics because they produce a PBP, named PBP5fm in Enterococcus faecium, with low-level affinity for beta-lactams. We report here the crystal structure of the acyl-enzyme complex of PBP5fm with benzylpenicillin at a resolution of 2.4 A. A characteristic of the active site, which distinguishes PBP5fm from other PBPs of known structure, is the topology of the loop 451-465 defining the left edge of the cavity. The residue Arg464, involved in a salt bridge with the residue Asp481, confers a greater rigidity to the PBP5fm active site. In addition, the presence of the Val465 residue, which points into the active site, reducing its accessibility, could account for the low affinity of PBP5fm for beta-lactam. This loop is common to PBPs of low affinity, such as PBP2a from Staphylococcus aureus and PBP3 from Bacillus subtilis. Moreover, the insertion of a serine after residue 466 in the most resistant strains underlines even more the determining role of this loop in the recognition of the substrates.

Crystal structure of GerE, the ultimate transcriptional regulator of spore formation in Bacillus subtilis

The small, DNA-binding protein GerE regulates gene transcription in the terminally differentiated mother-cell compartment during late stages of sporulation in Bacillus subtilis. This versatile transcription factor shares sequence homology with the LuxR/FixJ/UhpA family of activators and modulates the expression of a number of genes, in particular those encoding the components of the coat that surrounds the mature spore. GerE orchestrates the final stages of coat deposition and maturation that lead to a spore with remarkable resistance properties but that must be responsive to low levels of germination signals. As this germination process is largely passive and can occur in the absence of de novo protein synthesis, the correct assembly of germination machinery, including germinant receptors and energy storage compounds, is crucial to the survival of the cell. The crystal structure of GerE has been solved at 2.05 A resolution using multi-wavelength anomalous dispersion techniques and reveals the nature of the GerE dimer. Each monomer comprises four alpha-helices, of which the central pair forms a helix-turn-helix DNA-binding motif. Implications for DNA-binding and the structural organisation of the LuxR/FixJ/UhpA family of transcription activator domains are discussed.

Maturation of white matter in the human brain: a review of magnetic resonance studies

This review focuses on the maturation of brain white-matter, as revealed by magnetic resonance (MR) imaging carried out in healthy subjects. The review begins with a brief description of the nature of the MR signal and its possible biological underpinnings, and proceeds with a description of MR findings obtained in newborns, infants, children and adolescents. On MR images, a significant decrease in water content leads to a decrease of longitudinal relaxation times (T1) and transverse relaxation times (T2) and consequent "adult-like" appearance of T1-weighted and T2-weighted images becomes evident towards the end of the first year of life. Owing to the onset of myelination and the related increase of lipid content, MR images gradually acquire an exquisite grey-white matter contrast in a temporal sequence reflecting the time course of myelination. Albeit less pronounced, age-related changes in white matter continue during childhood and adolescence; white matter increases its overall volume and becomes more myelinated in a region-specific fashion. Detection of more subtle changes during this "late" phase of brain development is greatly aided by computational analyses of MR images. The review also briefly outlines future directions, including the use of novel MR techniques such as diffusion tensor imaging and magnetization transfer, as well as the suggestion for the concurrent use of experimental behavioral test-batteries, with structural MR imaging, to study developmental changes in structure-function relationships.

Structure of the AAA ATPase p97

p97, an abundant hexameric ATPase of the AAA family, is involved in homotypic membrane fusion. It is thought to disassemble SNARE complexes formed during the process of membrane fusion. Here, we report two structures: a crystal structure of the N-terminal and D1 ATPase domains of murine p97 at 2.9 A resolution, and a cryoelectron microscopy structure of full-length rat p97 at 18 A resolution. Together, these structures show that the D1 and D2 hexamers pack in a tail-to-tail arrangement, and that the N domain is flexible. A comparison with NSF D2 (ATP complex) reveals possible conformational changes induced by ATP hydrolysis. Given the D1 and D2 packing arrangement, we propose a ratchet mechanism for p97 during its ATP hydrolysis cycle.

The purification, crystallization and preliminary structural characterization of glucose-1-phosphate thymidylyltransferase (RmlA), the first enzyme of the dTDP-L-rhamnose synthesis pathway from Pseudomonas aeruginosa

Glucose-1-phosphate thymidylyltransferase (RmlA; E.C. 2.7.7.24) is the first of four enzymes involved in the biosynthesis of dTDP-L-rhamnose, the precursor of L-rhamnose, a key component of the cell wall of many pathogenic bacteria. RmlA catalyses the condensation of thymidine triphosphate (dTTP) and alpha-D-glucose-1-phosphate (G1P), yielding dTDP-D-glucose. RmlA from Pseudomonas aeruginosa has been overexpressed and purified. Crystals of the enzyme have been grown using the sitting-drop vapour-diffusion technique with PEG 6000 and lithium sulfate as precipitant. Several diffraction data sets of single frozen crystals were collected to a resolution of 1.66 A. Crystals belonged to space group P1, with unit-cell parameters a = 71.5, b = 73.1, c = 134.7 A, alpha = 89.9, beta = 80.9, gamma = 81.1 degrees. The asymmetric unit contains eight monomers in the form of two RmlA tetramers with a solvent content of 51%. Selenomethionine-labelled protein has been obtained and crystallized.

Growth-related oncogene-alpha expression in human nasal polyps

The cytokine growth-related oncogene-alpha (GRO-alpha) is a potent mediator of leukocyte recruitment and proliferation in inflammatory diseases. We hypothesized that GRO-alpha is produced in the inflammatory nasal polyp microenvironment. Evaluation of nasal polyps from 27 patients for distribution and content of GRO-alpha antigen, by use of immunohistochemical techniques and ELISA, revealed its presence in all 27 tissue samples. It was found predominantly within the eosinophils and neutrophils, with tissue levels ranging from 34 pg/mg total protein (TP) to 1746 pg/mg TP, with a mean value of 631 +/-98 pg/mg TP. Control tissues contained between 82 pg/mg TP and 316 pg/mg TP (mean 176+/-38 pg/mg TP). These results were statistically significant (P<0.03). Clinical correlations and statistical comparisons were calculated. These data suggest that GRO-alpha may be an important factor in the recruitment and activation of leukocytes in nasal polyposis, making it a potential target for therapeutic intervention.

Domain swapping in the sporulation response regulator Spo0A

Adaptive responses of micro-organisms, such as chemotaxis and sporulation, are governed by two-component systems consisting of sensor kinases, that interpret environmental signals, and response regulators which activate the appropriate physiological responses. Signal transduction via response regulator proteins is mediated through transient phosphorylation of aspartic acid residues. In Spo0A, the key regulator of development (sporulation) in Bacillus, phosphorylation of the N-terminal receiver domain (N-Spo0A) at aspartate-55 switches on the transcription activation functions residing in the C-terminal effector domain. Here we report the crystal structure of N-Spo0A from Bacillus stearothermophilus at 1.6 A spacing, revealing a dimer formed by an alpha-helix swap. Comparison of this structure with the recently described structure of phosphorylated N-Spo0A shows that dimer formation results from a cis-trans isomerization of the Lys106--Pro107 peptide bond. The quaternary reorganization is associated with alterations in the active site stereochemistry which may have implications for signalling. Remarkably, this 3-D domain swapped N-Spo0A dimer has an identical topology to a hypothetical CheY-like dimer, recently proposed as an intermediate in the evolution of the family of periplasmic substrate binding proteins.

The high-resolution structure of the NADP(H)-binding component (dIII) of proton-translocating transhydrogenase from human heart mitochondria

BACKGROUND

Transhydrogenase, located in the inner membranes of animal mitochondria and the cytoplasmic membranes of bacteria, couples the transfer of reducing equivalents between NAD(H) and NADP(H) to proton pumping. The protein comprises three subunits termed dI, dII and dIII. The dII component spans the membrane. The dI component, which contains the binding site for NAD(+)/NADH, and the dIII component, which has the binding site for NADP(+)/NADPH, protrude from the membrane. Proton pumping is probably coupled to changes in the binding affinities of dIII for NADP(+) and NADPH.

RESULTS

The first X-ray structure of the NADP(H)-binding component, dIII, of human heart transhydrogenase is described here at 2.0 A resolution. It comprises a single domain resembling the classical Rossmann fold, but NADP(+) binds to dIII with a reversed orientation. The first betaalphabetaalphabeta motif of dIII contains a Gly-X-Gly-X-X-Ala/Val 'fingerprint', but it has a different function to that in the classical Rossmann structure. The nicotinamide ring of NADP(+) is located on a ridge where it is exposed to interaction with NADH on the dI subunit. Two distinctive features of the dIII structure are helix D/loop D, which projects from the beta sheet, and loop E, which forms a 'lid' over the bound NADP(+).

CONCLUSIONS

Helix D/loop D interacts with the bound nucleotide and loop E, and probably interacts with the membrane-spanning dII. Changes in ionisation and conformation in helix D/loop D, resulting from proton translocation through dII, are thought to be responsible for the changes in affinity of dIII for NADP(+) and NADPH that drive the reaction.

Molecular detection of Gluconacetobacter sacchari associated with the pink sugarcane mealybug Saccharicoccus sacchari (Cockerell) and the sugarcane leaf sheath microenvironment by FISH and PCR

Molecular tools for the detection of the newly described acetic acid bacterium Gluconacetobacter sacchari from the pink sugarcane mealybug, Saccharicoccus sacchari Cockerell (Homiptera: Pseudococcidae), and in the sugarcane leaf sheath microenvironment were developed. G. sacchari specific 16S rRNA-targeted oligonucleotide primers were designed and used in PCR amplification of G. sacchari DNA directly from mealybugs, and in a nested PCR to detect low numbers of the bacteria from sugarcane leaf sheath fluid and cane internode scrapings. A sensitivity level of detection of 40-400 cells/reaction was obtained using PCR from exponentially grown bacterial cultures and of 1-10 cells in cane internode scrapings and leaf sheath fluid samples using nested PCR. The specificity of the primer set was demonstrated by the lack of amplification product formation in PCR by closely related acetic acid bacteria, including Gluconacetobacter liquefaciens, and Gluconacetobacter diazotrophicus. A Cy3 labeled probe for G. sacchari was designed and shown to be specific for the species. Investigation of the mealybug microenvironment by whole cell fluorescent in situ hybridization revealed that G. sacchari appears to represent only a minor proportion of the population of the microbiota in the mealybugs tested. This study has shown the usefulness of 16S rRNA-based molecular tools in the identification and detection of G. sacchari from environmental samples and will allow these tools to be used in further ecological research.

Description of Gluconacetobacter sacchari sp. nov., a new species of acetic acid bacterium isolated from the leaf sheath of sugar cane and from the pink sugar-cane mealy bug

A new species of the genus Gluconacetobacter, for which the name Gluconacetobacter sacchari sp. nov. is proposed, was isolated from the leaf sheath of sugar cane and from the pink sugar-cane mealy bug, Saccharicoccus sacchari, found on sugar cane growing in Queensland and northern New South Wales, Australia. The nearest phylogenetic relatives in the alpha-subclass of the Proteobacteria are Gluconacetobacter liquefaciens and Gluconacetobacter diazotrophicus, which have 98.8-99.3% and 97.9-98.5% 16S rDNA sequence similarity, respectively, to members of Gluconacetobacter sacchari. On the basis of the phylogenetic positioning of the strains, DNA reassociation studies, phenotypic tests and the presence of the Q10 ubiquinone, this new species was assigned to the genus Gluconacetobacter. No single phenotypic characteristic is unique to the species, but the species can be differentiated phenotypically from closely related members of the acetic acid bacteria by growth in the presence of 0.01% malachite green, growth on 30% glucose, an inability to fix nitrogen and an inability to grow with the L-amino acids asparagine, glycine, glutamine, threonine and tryptophan when D-mannitol was supplied as the sole carbon and energy source. The type strain of this species is strain SRI 1794T (= DSM 12717T).

Crystal structure of intact elongation factor EF-Tu from Escherichia coli in GDP conformation at 2.05 A resolution

The crystal structure of intact elongation factor Tu (EF-Tu) from Escherichia coli in GDP-bound conformation has been determined using a combination of multiple isomorphous replacement (MIR) and multiwavelength anomalous diffraction (MAD) methods. The current atomic model has been refined to a crystallographic R factor of 20.3 % and free R-factor of 26.8 % in the resolution range of 10-2.05 A. The protein consists of three domains: domain 1 has an alpha/beta structure; while domain 2 and domain 3 are beta-barrel structures. Although the global fold of the current model is similar to those of published structures, the secondary structural assignment has been improved due to the high quality of the current model. The switch I region (residues 40-62) is well ordered in this structure. Comparison with the structure of EF-Tu in GDP-bound form from Thermus aquaticus shows that although the individual domain structures are similar in these two structures, the orientation of domains changes significantly. Interactions between domains 1 and 3 in our E. coli EF-Tu-GDP complex are quite different from those of EF-Tu with bound GTP from T. aquaticus, due to the domain rearrangement upon GTP binding. The binding sites of the Mg2+ and guanine nucleotide are revealed in detail. Two water molecules that co-ordinate the Mg2+ have been identified to be well conserved in the GDP and GTP-bound forms of EF-Tu structures, as well as in the structure of Ras p21 with bound GDP. Comparisons of the Mg2+ binding site with other guanine nucleotide binding proteins in GDP-bound forms show that the Mg2+ co-ordination patterns are well preserved among these structures.

Transforming growth factor-beta expression in otitis media with effusion

OBJECTIVE

To characterize the existence and role of transforming growth factor-beta (TGF-beta) in otitis media with effusion (OME).

STUDY DESIGN

Retrospective.

METHODS

The levels of two major TGF-beta isoforms, TGF-beta1 and TGF-beta2, in the middle ear effusions (MEEs) of 44 children were evaluated using enzyme-linked immunospecific assays (ELISAs). Forty-eight MEEs were separated into three clinically relevant groups (i.e., serous, mucoid, and purulent), and TGF-beta levels were correlated with clinical parameters of disease for these MEEs.

RESULTS

Both TGF-beta1 and TGF-beta2 were present in the samples. Mean levels of TGF-beta1 (920.36 +/- 437.75 pg/mg total protein) were generally 100-fold greater than those of TGF-beta2 (9.65 +/- 11.19 pg/mg total protein). TGF-beta1 levels were elevated in association with a history of previous tympanostomy tube placements (TTPs) (P = .029) and mucoid effusions (P = .042). TGF-beta2 levels were elevated in association with a history of previous TTPs (P = .100) and chronic (i.e., serous or mucoid) effusions (P = .003).

CONCLUSIONS

TGF-beta1 is present in the MEEs of children with OME. Furthermore, TGF-beta1 and TGF-beta2 levels were elevated differentially in the presence of chronic disease indicators in OME, suggesting that these isoforms may have differing roles in the inflammatory processes that characterize OME.

Characterization of the eosinophil chemokine RANTES in nasal polyps

Previous studies have demonstrated that the cytokine RANTES (Regulated And Normal T cell Expressed and Secreted) has been shown to be a potent mediator of eosinophil chemotaxis in vitro and of leukocyte recruitment. Because eosinophils are the hallmark cells in nasal polyposis, we hypothesize that RANTES is locally produced within the nasal polyp microenvironment and is responsible for the eosinophil recruitment seen in nasal polyposis. To begin to test this hypothesis, we evaluated nasal polyps from 17 patients and 3 control specimens for distribution and content of RANTES using immunohistochemical techniques and enzyme-linked immunosorbent assay technology. Our immunohistochemical studies demonstrated that in nasal polyposis, RANTES antigen staining occurred predominantly within eosinophils and epithelial cells. To quantify the relative levels of RANTES in normal and nasal polyp specimens, tissue homogenates were prepared, quantified, and normalized to protein levels. We detected RANTES in all 17 nasal polyp tissue homogenates (566 +/- 16 pg/mg total protein). The RANTES levels in nasal polyp homogenates were nearly 40-fold higher than the RANTES levels in normal tissue (15.7 +/- 28.2 pg/mg total protein). Thus, it appears that increased expression of RANTES by eosinophils and epithelial cells within the nasal polyp microenvironment promotes eosinophil recruitment and activation within nasal polyps. We hypothesize that RANTES induces increased recruitment and activation of eosinophils, presumably contributing to the increased tissue changes associated with nasal polyposis.