The World Organisation for Animal Health - current and potential roles in safe international trade of bees and other insects

The World Organisation for Animal Health (WOAH, founded as OIE) is the recognised intergovernmental standard-setting organisation for animal health and welfare. The WOAH mandate is to support its members in the prevention of the spread of animal diseases of concern, as listed in the Terrestrial Animal Health Code (Terrestrial Code). Once a disease, infection or infestation is listed, national Veterinary Authorities have the obligation regularly to notify WOAH of the presence or absence of the listed disease. In regard to insects, the scope of the Terrestrial Code limits its recommendations to preserving the health of bees (species of the genus Apis, extended to the genus Bombus and to the stingless bees for one disease). However, it does not include standards to mitigate the potential animal health risks associated with the international trade of other insects. A description of the standard-setting process and a review of the history of the standards for bee health highlight the resources and requirements to expand the scope of the Terrestrial Code to include recommendations for animal health risk mitigation measures for the safety of international trade in insects. Any initiative to develop guidance on insect trade should include WOAH in its role as the sole global standard-setting organisation on animal health and welfare matters. This aligns with the WOAH commitment to a One Health approach.

O-026 Advanced Glycation Endproducts: A new player in obesity related infertility

Globally, 39% of the adult population is overweight or obese, with the prevalence of obesity following an upward trajectory over the recent decades (WHO). Up to 30% of women of reproductive age in Western countries are obese before conception, and obese women experience higher rates of infertility and pregnancy complications than lean women; however, the mechanisms underpinning obesity-related infertility are poorly understood. Advanced Glycation Endproducts (AGEs) are a proinflammatory modification of proteins exposed to sugars, formed through the Maillard reaction. AGEs are elevated four-fold in the uterine fluid of obese, infertile women, compared to lean. AGEs equimolar to those in the obese microenvironment negatively impact the functions of endometrial epithelial and stromal cells, and adhesion and invasion of trophoblast cells, reducing the potential for successful maternal-fetal interactions (Antoniotti et al., 2018). This research further investigated preimplantation embryo development and endometrial cell functions in the presence of AGEs equimolar to those in obese uterine fluid.

Altered local environments in very early life can set offspring up for a lifetime of health or disease (DoHAD); thus, uterine AGEs may contribute to the prevalence of non-communicable disease in children of obese parents. Preimplantation mouse embryos were cultured in vitro with AGEs equimolar with uterine fluid concentrations from lean and obese women, and their development and implantation potential assessed. “Obese” AGEs did not impact the proportion of embryos reaching blastocyst stage by day 4, but significantly reduced the proportion of blastocysts hatching by day 5 (P < 0.01). AGEs equimolar with the obese uterine environment detrimentally impacted trophectoderm formation and function: reduced trophectoderm cell number (P < 0.01), reduced outgrowth on fibronectin (indicative of reduced implantation potential, (P < 0.01), but did not increase cell apoptosis (TUNEL assay). RAGE antagonism, but neither metformin nor antioxidants, improved trophectoderm cell number. Thus, obesity-associated AGEs link obesity and reduced fertility through poor placentation potential of embryos (Hutchison et al, 2020).

Endometrial epithelial cell function was examined in the presence of lean and obese concentrations of AGEs. Obese AGEs significantly reduced the rate of proliferation (xCelligence real time cell analysis) of the endometrial epithelial cell line ECC-1 versus lean AGEs (P = 0.04). Antioxidants successfully restored the rate of proliferation in the presence of obese AGEs (P = 0.7 versus lean AGEs). Subsequently, human endometrial epithelial organoid culture was utilised as a more physiologically relevant experimental paradigm. When cultured as organoids, primary endometrial epithelial cells were functionally responsive to obesity-associated AGEs, expressing both RAGE and TLR4. The morphology of organoids in culture was not impacted by the presence of obese AGEs versus lean; however, the proliferation of epithelial cells retrieved from organoid culture was altered by obese AGEs versus lean. Obese AGEs also increased the secretion of proinflammatory CXCL16 versus vehicle control (P = 0.04) while increased secretion of other proinflammatory cytokines and chemokines including TNFa approached significance in the presence of obese AGEs. As the inflammatory milieu is altered in the uterine fluid of infertile women, elevated AGEs may promote an infertile endometrial inflammatory environment.

AGEs link obesity and reduced fertility, being detrimental to preimplantation embryo development and endometrial cell function when present at concentrations equal to those in obese uterine fluid. Antioxidants and RAGE antagonism provide beneficial effects to cell function in the presence of obesity-associated AGEs. This research provides evidence supporting AGEs as a factor contributing to obesity related infertility, and as an emerging frontier for reproductive health. Clinically, reduction of uterine AGEs may improve fertility for obese couples wishing to conceive.

Antoniotti et al (2018). Hum Rep. 33(4), 654-665. PMID: 29471449

Hutchison et al (2020). RBMO. 41(5), 757-766. PMID: 32972872

96 Validation of the candidate mutation responsible for embryonic lethality in Holstein haplotype 2 carriers

Holstein haplotype 2 (HH2) is embryonic lethal and carried by 1.21% of the US Holstein population. Using next-generation sequencing, we identified a high-impact frameshift mutation in intraflagellar protein 80 (IFT80) as the putative causal mutation. In bovine embryos, IFT80 expression begins at the 8-cell stage and decreases by the blastocyst stage. We hypothesised that the loss of function of IFT80 early in development causes the lethal phenotype. The aim of this study was to mimic the mutation observed invivo using a CRISPR-Cas9 approach to determine its effect on embryo development. Two guide RNAs (gRNAs) were designed to disrupt exon 11 (Ex11), one before and one after the known IFT80 mutation site, creating a 317-nucleotide (nt) cut to facilitate genotyping. Then, gRNAs annealed to a tracr-Cas9mRNA complex were delivered to 1-cell embryos by microinjection. Each replicate contained control embryos injected with only Cas9mRNA and treated embryos injected with gRNAs targeting IFT80. Embryos from each group were collected at the 8-cell stage for genotyping and gene expression analysis (n=47), or on Day 8 to validate genotypes of embryos left to develop (n=50). DNA sequences containing gRNA target sequences were amplified and visualised on an agarose gel. IFT80 expression was determined in biallelic embryos (n=13) using quantitative PCR and normalized to GAPDH. Primers were designed for the transcript regions before and after gRNAs target sequences, exons 9 and 12, respectively. Expression data were analysed using SAS software (v. 9.4; SAS Institute Inc.) using PROC GLM and LSMEANS to determine expression differences. Biallelic samples (n=9) were Sanger-sequenced (SS) and aligned with the reference sequence to determine exact cut sites. Protein amino acid (AA) sequences were predicted using SS data. Protein models were constructed using the I-Tasser platform, and then aligned and visualised using PyMol 2.4. Biallelic edits showed a significant decrease in exon 12 expression (P<0.05), and no difference in exon 9 compared with controls (P>0.05), indicating that the transcript was severely affected downstream of the edited sites. The reference protein model contained 777 AA, whereas the biallelic sample with the most accurate cut sites yielded a 385-AA protein, indicating that the mutation severely altered protein conformation and possible function. Embryos injected with CRISPR-Cas9 targeting Ex11 arrested at the 8-cell stage and failed to form blastocysts. Day 8 embryos were genotyped (n=24) and 58% were biallelic, 21% were monoallelic, and 21% appeared wild-type. Given the high rate of edits, the observed embryonic arrest is likely due to disruption of IFT80, and wild-type embryos may contain small edits not visible by gel. In conclusion, generation of CRISPR-Cas9 IFT80 knockouts demonstrated that the frameshift mutation in Ex11 results in a seemingly nonfunctional protein that is responsible for the embryonic lethality seen in HH2 carriers. Future research is needed to determine how IFT80 regulates embryonic development. This research was supported by USDA-NIFA National Needs Fellowship, USDA-NIFA AFRI Grant No. 2019-67015-28998.

The changing case-mix of hip fractures in Scotland - evidence from the Scottish Hip Fracture Audit

Until discontinued in 2008, the Scottish Hip Fracture Audit collected and reported on data relating to the quality of care of hip fracture patients in Scotland. In 2013, the audit was recommenced under the umbrella of the MSK Audit group, which audits high volume orthopaedic pathways across Scotland. Our aim is to report on the changes in the demographics of hip fracture patients in Scotland between 2003 and 2013. There was an increase in the proportion of male patients from 2003 to 2013 (22.4% to 29.5%; p < 0.0001). An increased percentage of hip fracture patients were admitted from their own home (63.9% to 73.1%; p < 0.0001). Both these factors have deleterious effects on the outcome, and use of necessary resources, following hip fracture. There was also an increase in the percentage of patients who were American Society of Anesthesiologists Grade 3 (52.9% to 56.4%). Over the last decade, there has been a shift in the demographics of Scotland's hip fracture patients. If hip fracture incidence increases as predicted, this potentially more-challenging case-mix will likely impact on multiple health resources.

Health professionals' experiences of behavioural family therapy for adults with intellectual disabilities: a thematic analysis

WHAT IS KNOWN ON THE SUBJECT?: Behavioural Family Therapy (BFT) has been shown to help people with some severe mental health conditions, such as schizophrenia, by reducing relapse rates and stress within families. It can be difficult to put family interventions, like BFT, into clinical practice. Families where someone has an intellectual disability can experience more stress compared to those who do not, but we know very little about using BFT with families where a member has an intellectual disability. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: We interviewed nine Community Learning Disability Nurses and Allied Health Professionals about their experiences delivering BFT to families where one member has an intellectual disability. We found that therapists' experiences of delivering BFT were broadly positive, although they found some aspects of their service frustrating. EXPLAIN THE IMPORTANCE OF THE PAPER'S FINDINGS FOR A NON-SPECIALIST AUDIENCE: The study identifies the perceived benefits of BFT as a model to work with families, where a member has an intellectual disability. The study highlights some of the challenges experienced by practitioners, notably issues with engagement and some issues specific to working with adults with an intellectual disability. The findings suggest that it needs to be clear which families would benefit most from BFT, that interventions need to be adapted for people with intellectual disabilities and that Community Learning Disability Nurses and Allied Health Professionals should have support from management to deliver these interventions.

ABSTRACT

Introduction Studies have found family interventions (FIs) to be effective in reducing stress and relapse rates for a variety of mental health conditions. However, implementing FIs into clinical practice is challenging. Studies have suggested that levels of stress within some families of people with intellectual disabilities can be high. However, there is little reported about the use and implementation of FIs, such as Behavioural Family Therapy (BFT), in adult intellectual disability services. Purpose of study To explore the experiences of practitioners delivering BFT to adults with intellectual disabilities. Method A qualitative methodology was employed, using semi-structured individual interviews with BFT therapists from a health professional background (n = 9). Data were analysed thematically. Results Two overarching themes were identified: positivity and frustration. Discussion Implementation of therapy was identified as being broadly successful but with some underlying challenges, notably wider organizational issues and some issues specific to working with adults with intellectual disabilities. Implications for practice The broadly positive experiences reported provide encouragement for the delivery of FIs, such as BFT, to adults with intellectual disabilities, by professions outwith psychology. However, there is a need to provide clarity on referral processes, adapt materials accordingly for this client group and ensure that supportive management and supervision is available to therapists.

Coherent coupling of molecular resonators with a microcavity mode

The optical hybridization of the electronic states in strongly coupled molecule–cavity systems have revealed unique properties, such as lasing, room temperature polariton condensation and the modification of excited electronic landscapes involved in molecular isomerization. Here we show that molecular vibrational modes of the electronic ground state can also be coherently coupled with a microcavity mode at room temperature, given the low vibrational thermal occupation factors associated with molecular vibrations, and the collective coupling of a large ensemble of molecules immersed within the cavity-mode volume. This enables the enhancement of the collective Rabi-exchange rate with respect to the single-oscillator coupling strength. The possibility of inducing large shifts in the vibrational frequency of selected molecular bonds should have immediate consequences for chemistry.

Coherent coupling of light with electronic transitions has led to phenomena such as polariton lasing and superfluidity. Shalabney et al. now couple the optical modes of micro-cavity to the vibrational modes of a molecule at room temperature and thereby alter the chemical behaviour of the molecule.

A pilot open label, single dose trial of fenobam in adults with fragile X syndrome

Objective:

A pilot open label, single dose trial of fenobam, an mGluR5 antagonist, was conducted to provide an initial evaluation of safety and pharmacokinetics in adult males and females with fragile X syndrome (FXS).

Methods:

Twelve subjects, recruited from two fragile X clinics, received a single oral dose of 50–150 mg of fenobam. Blood for pharmacokinetic testing, vital signs and side effect screening was obtained at baseline and numerous time points for 6 h after dosing. Outcome measures included prepulse inhibition (PPI) and a continuous performance test (CPT) obtained before and after dosing to explore the effects of fenobam on core phenotypic measures of sensory gating, attention and inhibition.

Results:

There were no significant adverse reactions to fenobam administration. Pharmacokinetic analysis showed that fenobam concentrations were dose dependent but variable, with mean (SEM) peak values of 39.7 (18.4) ng/ml at 180 min after the 150 mg dose. PPI met a response criterion of an improvement of at least 20% over baseline in 6 of 12 individuals (4/6 males and 2/6 females). The CPT did not display improvement with treatment due to ceiling effects.

Conclusions:

Clinically significant adverse effects were not identified in this study of single dose fenobam across the range of dosages utilised. The positive effects seen in animal models of FXS treated with fenobam or other mGluR5 antagonists, the apparent lack of clinically significant adverse effects, and the potential beneficial clinical effects seen in this pilot trial support further study of the compound in adults with FXS.

A systematic review of the clinical effectiveness and cost-effectiveness and economic modelling of minimal incision total hip replacement approaches in the management of arthritic disease of the hip

OBJECTIVES

To assess the clinical effectiveness and cost-effectiveness of minimal incision approaches to total hip replacement (THR) for arthritis of the hip.

DATA SOURCES

Major electronic databases were searched from 1966 to 2007. Relevant websites were also examined and experts in the field were consulted.

REVIEW METHODS

Studies of minimal (one or two) incision THR compared with standard THR were assessed for inclusion in the review of clinical effectiveness. A systematic review of economic evaluations comparing a minimal incision approach to standard THR was also performed and the estimates from the systematic review of clinical effectiveness were incorporated into an economic model. Utilities data were sourced to estimate quality-adjusted life-years (QALYs). Due to lack of data, no economic analysis was conducted for the two mini-incision surgical method.

RESULTS

Nine randomised controlled trials (RCTs), 17 non-randomised comparative studies, six case series and one registry were found to be useful for the comparison of single mini-incision THR with standard THR. One RCT compared two mini-incision THR with standard THR, and two RCTs, five non-randomised comparative studies and two case series compared two mini-incision with single mini-incision THR. The RCTs were of moderate quality. Most had fewer than 200 patients and had a follow-up period of less than 1 year. The single mini-incision THR may have some perioperative advantages, e.g. blood loss [weighted mean difference (WMD) -57.71 ml, p<0.01] and shorter operative time, of uncertain practical significance. It may also offer a shorter recovery period and greater patient satisfaction. Evidence on long-term outcomes (especially revision) is too limited to be useful. Lack of data prevented subgroup analysis. With respect to the two-incision approach, data were suggestive of shorter recovery compared with single-incision THR, but conclusions must be treated with caution. The costs to the health service, per patient, of single mini-incision THR depend upon assumptions made, but are similar at one year (7060 pounds sterling vs 7350 pounds sterling for standard THR). For a 40-year time horizon the costs were 11,618 pounds sterling for mini-incision and 11,899 pounds sterling for standard THR. Two existing economic evaluations were identified, but they added little, if any, value to the current evidence base owing to their limited quality. In the economic model, mini-incision THR was less costly and provided slightly more QALYs in both the 1- and 40-year analyses. The mean QALYs at 1 year were 0.677 for standard THR and 0.695 for mini-incision THR. At 40 years, the mean QALYs were 8.463 for standard THR and 8.480 for mini-incision. At 1 year the probabilistic sensitivity analyses indicate that mini-incision THR has a 95% probability of being cost-effective if society's willingness to pay for a QALY were up to 50,000 pounds sterling. This is reduced to approximately 55% for the 40-year analysis. The results were driven by the assumption of a 1-month earlier return to usual activities and a decreased hospital length of stay and operation duration following mini-incision THR. If mini-incision THR actually required more intensive use of resources it would become approximately 200 pounds sterling more expensive and would only be cost-effective (cost per QALY>30,000 pounds sterling) if recovery was 1.5 weeks faster. A threshold analysis around risk of revision showed, using the same cost per QALY threshold, mini-incision THR would have to have no more than a 7.5% increase in revisions compared with standard THR for it to be no longer considered cost-effective (one more revision for every 200 procedures performed). Further sensitivity analysis involved relaxing assumptions of equal long-term outcomes where possible. and broadly similar results to the base-case analysis were found in this and further sensitivity analyses.

CONCLUSIONS

Compared with standard THR, minimal incision THR has small perioperative advantages in terms of blood loss and operation time. It may offer a shorter hospital stay and quicker recovery. It appears to have a similar procedure cost to standard THR, but evidence on its longer term performance is very limited. Further long-term follow-up data on costs and outcomes including analysis of subgroups of interest to the NHS would strengthen the current economic evaluation.

Femoral head viability after Birmingham resurfacing hip arthroplasty: assessment with use of [18F] fluoride positron emission tomography

BACKGROUND

Total hip resurfacing has become increasingly popular over the last decade. There remains concern about the effect of the surgical approach on femoral head viability and the role of resurfacing in the management of established osteonecrosis. In view of these concerns, we examined femoral head viability following resurfacing through a modified anterolateral approach.

METHODS

The viability of the femoral heads of ten patients who had undergone successful unilateral Birmingham hip resurfacing was assessed with use of positron emission tomography in conjunction with the injection of fluorine at a mean of twenty months after surgery. For each patient, in both the hip that had undergone resurfacing and the contralateral nonresurfaced hip, activity was measured in four regions of interest: the lateral aspect of the femoral head, the medial aspect of the femoral head, the lateral aspect of the femoral neck, and the proximal aspect of the femur. The uptake of fluorine in each area was converted to standard uptake volumes.

RESULTS

No areas of osteonecrosis were seen in the femoral head of any patient. There were no significant differences in the standard uptake volumes as measured in the four regions of the nonresurfaced hips, whereas the median values were higher in all four regions of the resurfaced hips. The difference between the values in the resurfaced hips compared with those in the nonresurfaced hips was only significant (p < 0.05) in the lateral aspect of the femoral head.

CONCLUSIONS

This study establishes positron emission tomography in conjunction with injection of fluorine as a possible modality for the assessment of femoral head viability after hip resurfacing. Viability following successful Birmingham hip resurfacing performed through a modified anterolateral approach has also been demonstrated. The increase in bone activity that was seen in the resurfaced hips in our study group may be related to bone remodeling or reperfusion of small areas of osteonecrosis. This technique offers the potential to study femoral head perfusion and viability following all types of resurfacing.

LEVEL OF EVIDENCE

Diagnostic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Hypothermia pediatric head injury trial: the value of a pretrial clinical evaluation phase

BACKGROUND

The utility of a pretrial clinical evaluation or run-in phase prior to conducting trials of complex interventions such as hypothermia therapy following severe traumatic brain injury in children and adolescents has not been established.

METHODS

The primary objective of this study was to prospectively evaluate the ability of investigators to adhere to the clinical protocols of care including the cooling and rewarming procedures as well as management guidelines in patients with severe traumatic brain injury (Glasgow Coma Scale<or=8) treated with 24 h of hypothermia therapy. A secondary objective was to evaluate the ability of study research assistants to complete the study case report form using a procedures manual. The study was conducted at 18 sites in Canada, the United Kingdom and France prior to proceeding to a randomized controlled trial (RCT). After 2 patients were enrolled at each center, an independent clinical evaluation committee examined the process of care and the completeness of data collection. Centers were permitted to enroll patients in the RCT once they met pre-established adherence criteria.

RESULTS

Seventeen of the 18 centers completed the pretrial clinical evaluation phase demonstrating compliance with study procedures and proceeded to an RCT of hypothermia therapy. One center enrolled only 1 patient in the pretrial clinical evaluation phase due to small numbers of patients with traumatic brain injury, and therefore, did not proceed to the RCT. Three centers were required to enroll more than 2 patients in the pretrial clinical evaluation phase prior to proceeding to the RCT because of problems with adherence to the clinical protocols at two centers and the training of new study personnel at another center. Of the 39 patients enrolled during the pretrial clinical evaluation phase, 8 (20.5%) died and 22 (62.9%) had a good outcome defined as normal, mild or moderate disability assessed using the Pediatric Cerebral Performance Category score at 6 months following injury.

DISCUSSION

The pretrial clinical evaluation phase was useful to ensure compliance with complex hypothermia therapy and consensus-based clinical management guidelines of care successfully implemented across 17 of 18 centers. This study maneuver allowed us to complete a subsequent RCT in 225 children following severe traumatic brain injury.

Peri-acetabular radiolucent lines: inter- and intra-observer agreement on post-operative radiographs

Peri-acetabular radiolucent lines (RLLs) seen on "early" post-operative radiographs have been identified as a potential predictor of long-term implant performance. This study examines the inter- and intra-observer variation encountered when assessing such radiographs. Four consultant orthopaedic surgeons assessed the presence, extent and width of RLLs in 220 radiographs performed on 50 patients taken one to two weeks, six weeks, six months and one year following surgery. Inter-observer agreement was fair at 7-14 days but improved to moderate to good in films at six and 12 months. Intra-observer agreement was moderate to good at 7-10 days but again improved to good at 6 and 12 months. When only the presence or absence of RLLs was considered, both inter-observer and intra-observer agreement improved for both the six-month and one-year radiographs. This experiment shows that caution must be used for the interpretation of RLLs on hip radiographs taken during the very early post-operative period. We recommend that films taken at least six weeks to six months following surgery should be used for assessment to reduce observer variation. For optimum results, a single experienced observer should do the assessment with a simple classification.

Early dialysis in a neonate with intrauterine lisinopril exposure

In general, angiotensin converting enzyme (ACE) inhibitors should be discontinued in pregnancy, as they can induce an ACE fetopathy. For the treatment of the latter, early peritoneal dialysis is recommended for in utero exposure to captopril and enalapril, although the outcome is poor. Early peritoneal dialysis has not previously been reported for lisinopril induced multiorgan failure. A case is reported in which treatment was given on postnatal day 3. The patient recovered from oligoanuria to almost normal renal function, and heart, brain, and musculoskeletal injury was reversible. This is despite relatively poor clearance of the drug through peritoneal dialysis. Analysis of the pharmacokinetic data suggests that haemodialysis or haemofiltration would be more efficacious for removal of the drug, and these treatments should be performed if available.

Indomethacin and cyclosporin a inhibit in vitro ischemia-induced expression of ICAM-1 and chemokines in human brain endothelial cells

Brain inflammation has been implicated in the development of brain edema and secondary brain damage in ischemia and trauma. Mechanisms involved in leukocyte infiltration across the blood-brain barrier are still unknown. In this study, we show that human cere-bromicrovascular endothelial cells (HCEC) subjected to a 4 h in vitro ischemia (hypoxia + glucose deprivation) followed by a 4-24 h recovery express elevated levels of ICAM-1, IL-8, and MCP-1 mRNAs (semi-quantitative RT-PCR) and secrete increased amounts of the immunoreactive chemokines IL-8 and MCP-1 (ELISA). The ischemia-induced expression of ICAM-1 in HCEC, and the expression/release of IL-8 and MCP-1 in HCEC were abolished by the non-steroid anti-inflammatory drug, indomethacin (100-300 microM). The immunosuppressant cyclosporin A (50 microM) partially reduced the ischemia-stimulated IL-8 and MCP-1 secretion by HCEC. Both indomethacin and cyclosporin A also inhibited the ischemia-induced neutrophil chemotaxis elicited by HCEC media. The study indicates that in vitro ischemia augments the expression of adhesion molecules and leukocyte chemoattractants at the site of the BBB. This ischemic pro-inflammatory activation of HCEC may constitute a key event in initiating post-ischemic inflammation, and it can be suppressed by the anti-inflammatory drugs, indomethacin and cyclosporin A.

A role for platelets and endothelial selectins in tumor necrosis factor-alpha-induced leukocyte recruitment in the brain microvasculature

The mechanisms mediating leukocyte recruitment into the cerebral nervous system during inflammation are still poorly understood. The objective of this study was to investigate the leukocyte recruitment in the brain microcirculation by intravital microscopy. Superfusion of the brain with artificial cerebrospinal fluid did not induce leukocyte rolling or adhesion. However, intraperitoneal tumor necrosis factor-alpha (TNF-alpha) caused marked leukocyte rolling and adhesion in the brain microcirculation. Histology revealed that the recruitment was primarily of neutrophils. Both E- and P-selectin were required for TNF-alpha-induced leukocyte recruitment, as rolling was reduced after treatment with either anti-E- or anti-P-selectin antibody and eliminated in E- or P-selectin-deficient mice. A significant increase in brain P- and E-selectin expression was seen after TNF-alpha treatment, but both were an order of magnitude less than in any other tissue. We observed significant platelet paving of TNF-alpha-stimulated endothelium and found that anti-platelet antibody reduced leukocyte rolling and adhesion, as did acetylsalicylic acid (aspirin). However, depletion of platelets did not reduce cerebral P-selectin expression. Moreover, chimeric mice lacking P-selectin on endothelium but not platelets had significantly decreased P-selectin expression and reduced leukocyte recruitment in the brain. This suggests a role for endothelial P-selectin in cerebral leukocyte recruitment. In conclusion, TNF-alpha-induced neutrophil recruitment into the brain requires both endothelial E-selectin and P-selectin as well as platelets, but platelet P-selectin was not a major contributor to this process.

Mycoplasma pulmonis genital disease: effect of rat strain on pregnancy outcome

BACKGROUND AND PURPOSE

Mycoplasma pulmonis is a natural pathogen of the respiratory and genital tracts of rats. Differential susceptibility and severity of the respiratory form of the disease, known as murine respiratory mycoplasmosis (MRM), exist between rat strains. We now report that specific rat strains vary in susceptibility to genital tract infection and pregnancy outcome.

METHODS

Specific-pathogen-free (SPF) female F344, LEW, Wistar (WIS) and Sprague Dawley (SD) rats were intravaginally inoculated with 3 x 10(7) colony-forming units (CFU) of M. pulmonis strain X1048 or sterile diluent, and allowed to breed at 10 days after inoculation. Pregnant dams and pups were necropsied within 24 hours of parturition. At necropsy, culture for M. pulmonis was performed on dam and pups, and adverse effects on pregnancy outcome were assessed by determination of the incidence of infertility, fetal resorption, stillbirths, changes in litter size, and pup birth weight. Blood from dams was collected prior to inoculation and at time of necropsy for measurement of IgM and IgG antibodies to M. pulmonis.

RESULTS

At time of necropsy, WIS (50%) and SD (60%) dams had a higher frequency of M. pulmonis culture positivity in the genital tract than did LEW (22.2%) and F344 (17.6%) dams. Dams that were still infected with M. pulmonis at time of necropsy had various complications. The SD rats had the greatest degree of adverse effects on pregnancy outcome, which were: infertility, decreased litter size (P < or = 0.01), decreased pup birth weight (P < or = 0.01), increased frequency of resorptions, stillbirths (P < or = 0.05), and the highest rate of pup pulmonary infection (23.1%) (P < or = 0.001). Despite a 50% colonization rate, WIS dams were the least adversely affected. The WIS pups born from M. pulmonis. infected dams had slight decrease in birth weight, and only 6% had pulmonary infections. The LEW infected dams developed infertility and lower numbers of liveborn pups without evidence of vertical transmission. The F344 infected dams had lower numbers of liveborn pups that were smaller than their control counterparts, and none had pulmonary infections. None of the animals had detectable IgM and IgG antibodies to M. pulmonis before inoculation. At time of necropsy, all animals inoculated with M. pulmonis developed significantly (P < or = 0.001) higher amounts of M. pulmonis IgG and IgM antibodies, with SD rats developing the highest amounts (P < or = 0.005).

CONCLUSIONS

Both F344 and LEW rats are more resistant to vaginal inoculation with M. pulmonis than are WIS and SD rats. However, only SD dams suffered severe adverse effects on pregnancy outcome. The SD dams also had the greatest IgM and IgG antibody response to M. pulmonis. Our studies clearly indicate differences among rat strains in their susceptibility to vaginal inoculation with M. pulmonis and in secondary complications associated with infection. This system may be a useful model for determining host-specific factors that influence the outcome of natural mycoplasmal infections of the genital tract.

A bench-top method for evaluating modular total hip component combinations

A modular total hip prosthesis allows the surgeon to vary head size, neck length, and acetabular coverage. Different combinations, however, may increase the risk of impingement of the prosthesis neck on the acetabular liner, leading to dislocation. We developed a bench-top model to test different modular component combinations to determine how far the femoral component could travel within the acetabular liner before impingement led to dislocation. We tested two hip systems, each from a different manufacturer. Certain components increased the risk of impingement and dislocation: skirted necks, smaller heads, and lipped liners. While the contribution of each component was small, the risk was additive, so that the combination of a small head with a skirted neck in a lipped liner actually reduced the available range of motion by 18 degrees, from 146 degrees to 128 degrees, in the first system, and by 13 degrees, from 156 degrees to 143 degrees in the other. This method could be adapted to test a wide range of component configurations, from a number of manufacturers. These findings may be useful in avoiding potentially unstable configurations when given a choice of modular components.

Increased expression of bioactive chemokines in human cerebromicrovascular endothelial cells and astrocytes subjected to simulated ischemia in vitro

Leukocyte infiltration into the brain has been implicated in the development of ischemic brain damage. In this study, simulated in vitro ischemia/reperfusion and IL-1beta were found to up-regulate both the expression of intercellular adhesion molecule- (ICAM-1) in cultured human cerebromicrovascular endothelial cells (HCEC) and the adhesion of allogenic neutrophils to HCEC. Both HCEC and human fetal astrocytes (FHAS) also responded to IL-1beta and to in vitro ischemia/reperfusion by a pronounced up-regulation of IL-8 and MCP-1 mRNA and by increased release of IL-8 and MCP-1 in cell culture media. FHAS were found to release 30-times higher levels of MCP-1 than HCEC under both basal and ischemic conditions. However, 100 u/ml IL-1beta induced greater stimulation of both IL-8 and MCP-1 secretion in HCEC (50 and 20 times above controls, respectively) than in FHAS (three and two times above controls, respectively). IL-8 was the principal neutrophil chemoattractant released from IL-1beta-treated HCEC, since IL-8 antibody completely inhibited neutrophil chemotaxis enticed by HCEC media. However, the IL-8 antibody neutralized only 50% of IL-1beta-stimulated neutrophil chemoattractants released from FHAS, and 40%-60% of ischemia-stimulated chemotactic activity released by either HCEC or FHAS. These results suggest that simulated in vitro ischemia, in addition to IL-8 and MCP-1, stimulates secretion of other bioactive chemokines from HCEC and FHAS.

The induction of ICAM-1 in human cerebromicrovascular endothelial cells (HCEC) by ischemia-like conditions promotes enhanced neutrophil/HCEC adhesion

Ischemic brain injury is exacerbated by leukocyte infiltration and formation of vasogenic edema. In this study we demonstrate that intercellular adhesion molecule-1 (ICAM-1) is dramatically (3 to 15-fold) up-regulated in human cerebromicrovascular endothelial cells (HCEC) by a 16 h exposure to the cytokine, IL-1 beta (50-200 u/ml), the phorbol ester, TPA (1-100 nM), or by simulated in vitro ischemia/reperfusion. These treatments also significantly increased the adhesion of allogeneic neutrophils to HCEC monolayers. Both IL-1 beta- and TPA-induced expression of ICAM-1 and increased neutrophil adhesion to HCEC were inhibited by the transcriptional inhibitor, actinomycin D (AcD; 1-10 micrograms/ml), and by an anti-ICAM-1 antibody (ICAM-1 Ab). By contrast, ischemia-induced neutrophil adhesion was only slightly affected by AcD and ICAM-1 Ab alone, but it was abolished by the combination of anti-ICAM-1 and anti-CD18 antibodies. The increase in surface expression of ICAM-1 and neutrophil adhesion by IL-1 beta, TPA and ischemia were significantly reduced by the cyclo-oxygenase (COX) inhibitors, indomethacin (100-300 microM) and dexamethasone (10-50 microM). These results indicate that ICAM-1 expression in HCEC can lead to enhanced neutrophil adhesion and that COX activation in HCEC likely plays a role in the processes by which leukocyte adhesion and recruitment take place in the brain during inflammation and ischemia in vivo.

Lower anion gap increases sensitivity in predicting elevated lactate

OBJECTIVE

The normal reference range for the anion gap (AG) has recently been questioned by several authors. Lowering the upper limit of normal of the AG has been found to be more sensitive in predicting elevated lactate in critically ill adults. The objectives of this study are i) to define a new upper limit of normal of the AG in a study population of healthy adult volunteers, ii) to determine the sensitivity, specificity, the positive predictive value and the negative predictive value of the new upper limit for AG in detecting elevated lactate in critically ill children and to compare these results to the old upper limit of normal of AG (16 mmol/l), iii) to construct a receiver-operating-characteristic (ROC) curve for anion gap as a predictor of elevated lactate, iv) to determine the relationship between anion gap and serum lactate levels in critically ill patients.

DESIGN

A prospective, cohort study.

SETTING

Paediatric Intensive Care Unit of a University Hospital.

SUBJECTS

Part I: Convenience sample of healthy adult volunteers to provide a reference range for anion gap calculation. Part II: Consecutive children admitted to the Paediatric Intensive Care Unit who had lactate levels measured for clinical reasons.

MEASUREMENTS

Part I: Electrolytes and blood gases were measured from blood samples drawn from 25 adult volunteers. The reference range for AG was calculated using the equation, AG = Na - (Cl + HCO3). The upper limit of normal was calculated as mean + 2 SD. Part II: Eligible ICU patients were included in this study if they had lactate, electrolytes and blood gases obtained simultaneously. The AG was calculated as above. The new upper limit of normal AG was compared to an AG of 16 for diagnosing an elevated plasma lactate.

RESULTS

The mean anion gap in the normal population was 9.4 +/- 1 mmol/l with 11 mmol/l being used as the new upper limit of normal. Thirty-six ICU patients had 189 arterial blood samples from which lactate, electrolytes and blood gas were measured simultaneously. The sensitivity, specificity, positive predictive value and negative predictive value of using an AG of 11 mmol/l as the upper limit of normal were 86%, 40%, 65% and 69% respectively, compared to 49%, 84%, 80% and 55% respectively using the upper limit of normal of AG of 16 mmol/l. The ROC curve supported lowering the upper limit of normal for the anion gap to predict an elevated lactate. There was a linear relationship between anion gap and serum lactate levels.

CONCLUSIONS

An AG of 11 mmol/l as the upper limit of normal has a higher sensitivity and higher negative predictive value but lower specificity and lower positive predictive value for detecting elevated lactate in critically ill children.

Cellular aspects of corpus luteum function in the primate

The primate corpus luteum produces progesterone for a period of 14-16 days, at which time, in non-fertile cycles, steroidogenesis ceases and the tissue regresses. Studies completed in this laboratory have established that while luteinizing hormone (LH) is necessary to maintain luteal steroidogenesis, changes in LH secretion are not causal to luteolysis. The studies presented here demonstrate that luteal cell synthetic capacity, as reflected in steady-state levels of messenger ribonucleic acid (mRNA) encoding steroidogenic enzymes, is maximal shortly after ovulation and steadily declines thereafter, independently of progesterone and LH secretion. In addition, the loss of luteal mRNA expression for steroidogenic enzymes following LH withdrawal occurs 24 h after the decline in progesterone levels. Finally, the detection of mRNA encoding vascular endothelial growth factor within the corpus luteum throughout the luteal phase in the subhuman primate may provide the first identification of a potential secreted, non-steroidal factor responsible for the vast degree of angiogenesis that occurs within the corpus luteum.

The clinicopathologic, light, and scanning electron microscopic features of eperythrozoonosis in four naturally infected llamas

The hematologic, biochemical, and light and scanning electron microscopic features of eperythrozoonosis in four llamas are described. One female and three male yearling llamas were presented for evaluation of chronic weight loss. Three of four llamas had historical evidence of chronic inflammatory conditions. On examination, multiple clinical problems were apparent, including poorly to non-regenerative anemia, inflammatory disease, and hypoproteinemia. Coccoid- and ring-shaped basophilic organisms were present on the erythrocytes of all the llamas. On scanning electron microscopy, individual, pairs, and clusters of coccoid-shaped organisms were present on the erythrocytes. The organisms measured 0.4 to 0.6 micron in diameter and caused no marked deformation of the erythrocyte membrane. A rare organism could be found that produced a slight indentation into the erythrocyte membrane. The light and scanning electron microscopic morphologic features suggested that the organism was an Eperythrozoon. Serial evaluation of serum iron concentrations of the llamas showed a decrease serum iron in all animals, with a concurrent decrease in the total iron binding capacity and percent transferrin saturation in two of the llamas. Common abnormalities seen on serum electrophoresis included a decrease in albumin and beta serum fraction in all llamas and a decrease in the gamma globulin fraction of two individuals.

Differential effects of photoperiodic history on the responses of gonadotrophins and prolactin to intermediate daylengths in the male Syrian hamster

The effect of photoperiodic history on the neuroendocrine response to intermediate daylengths (11-13.5 hr of light) was investigated in the male Syrian hamster. The duration of the nocturnal peak of pineal melatonin content was inversely proportional to photoperiod and independent of photoperiodic history. Serum levels of prolactin were lower in animals exposed to shorter photoperiods. Photoperiodic history had little effect on the response of serum prolactin to intermediate daylengths. Serum luteinizing hormone (LH) concentrations were also lower in shorter photoperiods, but in addition were sensitive to the direction of photoperiodic change, so that a single photoperiod could be interpreted as either stimulatory or inhibitory to LH secretion. This effect of photoperiodic history was expressed at intermediate photoperiods with 12-13.5 hr of light. The sensitivity of serum follicle-stimulating hormone (FSH) levels to photoperiodic history was masked by an early onset of photorefractoriness. Testicular size and serum testosterone levels revealed weaker effects of photoperiodic history; these were attributed to the dissociation between gonadotrophin and prolactin secretion induced by intermediate daylengths. The contrasting effects of photoperiodic history on the secretion of LH and prolactin may represent the expression of multiple photoperiodic time-measuring systems.

Efficacy of ciprofloxacin in the treatment of various bacterial infections

The efficacy and safety of ciprofloxacin (500 mg administered every 12 hours) were evaluated in 62 patients enrolled in a prospective, open study. Fifty-three courses in the treatment of 56 infection sites suitable for evaluation were assessed. The infection sites involved were skin and skin structure (28), respiratory tract (21), urinary tract (5), and gastrointestinal tract (2). Bacterial isolates included 16 Pseudomonas aeruginosa, 13 Staphylococcus aureus, and 8 Escherichia coli. Signs and symptoms of infection completely resolved in 46 (82%) of the infection sites. Nine (16%) improved, and one (2%) failed to respond. Ciprofloxacin was well tolerated.

A regimen for obtaining mature human oocytes from donors for research into human fertilization in vitro

Patients awaiting laparoscopic sterilization were canvassed to allow oocytes to be aspirated from their ovaries at the time of operation for the purpose of testing the fertilizing capacity of spermatozoa from clinically infertile men. Because these patients were volunteers, the standard techniques for stimulation, ovulation prediction, operation, and oocyte recovery had to be modified for maximum safety and for convenience to both patient and staff. Superovulation was induced with 100 mg or 150 mg clomiphene citrate on days 2 to 6 or 5 to 9 of the menstrual cycle. Final maturation of oocytes was stimulated with 5000 IU of human chorionic gonadotropin administered between days 11 and 15 of the cycle, and the operation was performed 34 to 36 hours later on the routine gynecology operation lists. Of the 157 patients canvassed , 47% were willing to donate oocytes to the project. Despite the variability of the stimulation regimens, the simplified operative technique, and the fact that more than half the patients were on oral contraceptives in the previous cycle, one or more oocytes were retrieved in 75% of the patients. At the initial assessment, 83% of these were considered suitable for in vitro fertilization.

Breast screening results from a healthy working population

The early results of a breast screening service in a large retail company have been analysed. Female employees over 35 years of age were offered mammography, thermography and clinical examination, periodically over 51/2 years. One hundred and two cases of proven cancer were found in 21 186 women (4.8 per thousand). Non palpable cancers accounted for 56.9% of the total and 37.3% of these were less than 1 cm in size. Twenty tumours were microscopic. Only 13.7% of cases were known to be node positive and 43% of the cancers occurred in women of less than 50 years of age. The results throughout the whole age range encouraged the original hope that screening and early diagnosis will influence the prognosis of female breast cancer.

Nuclear magnetic resonance of iron and copper disease states

The tissue levels of paramagnetic ions are an important factor in the determination of T1 values as observed by nuclear magnetic resonance (NMR) imaging. The increased levels of iron present in human disease states such as hemochromatosis lead to decreased T1 values. The mean liver T1 of three patients with iron storage disease was determined to be 130 msec, significantly different from the value of 154 msec, the mean for 14 normal controls. Whether NMR will be able to detect the increased copper levels in liver and brain in Wilson disease remains for further clinical trials to evaluate. NMR imaging, however, does serve as a noninvasive method for the diagnosis of states of iron overload and as a technique to follow progression of disease or response to medical therapy.

Excision of bullae without pleurectomy in patients with spontaneous pneumothorax

In a retrospective review of 294 patients with spontaneous pneumothorax (398 episodes), 45 patients came to surgical treatment. The period of the study was 7 1/2 years, with a mean follow-up of 3 years in which there was no recurrence of pneumothorax after surgery. Operation consisted of simple excision of bullous lesions, usually located at the apex of the upper lobe, without pleurectomy. This simplified surgical approach has met with excellent result, indicating that pleurectomy is unnecessary in the treatment of this disease.

Mechanical suture methods in thoracic and abdominal surgery

Mechanical suturing procedures on the bowel, lung, bronchi and pulmonary vessels have been used on 264 occasions in 180 thoracic and abdominal operations. The instruments proved simple to use and produced reliable good quality closures, for the most part without manual reinforcement. There were 2 technical failures, one ending fatally, after colo-colostomy. Two minor postoperative suture leaks were encountered in 122 operations on the alimentary tract, but no leakage or other problem has arisen in 58 pulmonary cases. The staple-suturing methods described are safe and straightforward, and it is believed that they represent a significant advance in the techniques of thoracic and abdominal surgery, which can usefully be applied in many situations.

Secondary carcinoma of the thyroid gland

Two patients are described who presented with clinically solitary thyroid nodules which were found to be due to metastatic disease from the kidney and colon respectively. Removal of the solitary metastatis in one patient resulted in disease-free survival for over 5 years.