Use of CTA Test Dose to Trigger a Low Cardiac Output Protocol Improves Acute Stroke CTP Data Analyzed with RAPID Software

BACKGROUND AND PURPOSE

Contrast curve truncation in CTP protocols may introduce errors. We sought to identify risk factors and design a protocol to avoid truncation while limiting radiation.

MATERIALS AND METHODS

In an initial fixed-timing cohort, patients underwent a 65-second CTP with 2-second delay postcontrast injection. Multivariable analysis identified factors associated with truncation. A later case-specific cohort underwent either the original protocol or a low cardiac output protocol with a 7-second delay and 75-second scanning window, with selection determined by CTA test-dose enhancement upswing delay. Time-density curves were assessed for truncation and compared between the 2 groups, and the radiation dose was evaluated.

RESULTS

From September 2017 through May 2018, one hundred fifty-three patients underwent the standard fixed-timing protocol. Age (OR, 1.82/10-year increase; P = .019), reduced left ventricle ejection fraction (OR, 9.23; P = .001), and hypertension (OR, 0.32; P = .06) were independently associated with truncation in an exploratory multivariable model. From May 2018 through April 2019, one hundred fifty-seven patients underwent either the standard (72 patients) or low cardiac output protocol (85 patients). The fixed-timing cohort had 15 truncations (9.8%) versus 4 in the case-specific cohort (2.5%; P = .009). If the low cardiac output protocol were applied to those with >10.6% predicted risk of truncation based on age, left ventricle ejection fraction, and hypertension, the number of truncations would have decreased from 15 to 4 in the fixed-timing cohort.

CONCLUSIONS

Older age, left ventricle ejection fraction, and the absence of hypertension increase the risk of time-density curve truncation. However, a CTA test-dose-directed case-specific protocol can reduce truncation to ensure accurate data while mitigating radiation dose increases.

Evaluation of intranasal nafamostat or camostat for SARS-CoV-2 chemoprophylaxis in Syrian golden hamsters

Successful development of a chemoprophylaxis against SARS-CoV-2 could provide a tool for infection prevention implementable alongside vaccination programmes. Camostat and nafamostat are serine protease inhibitors that inhibit SARS-CoV-2 viral entry in vitro but have not been characterised for chemoprophylaxis in animal models. Clinically, nafamostat is limited to intravenous delivery and while camostat is orally available, both drugs have extremely short plasma half-lives. This study sought to determine whether intranasal dosing at 5 mg/kg twice daily was able to prevent airborne transmission of SARS-CoV-2 from infected to uninfected Syrian golden hamsters. SARS-CoV-2 viral RNA was above the limits of quantification in both saline- and camostat-treated hamsters 5 days after cohabitation with a SARS-CoV-2 inoculated hamster. However, intranasal nafamostat-treated hamsters remained RNA negative for the full 7 days of cohabitation. Changes in body weight over the course of the experiment were supportive of a lack of clinical symptomology in nafamostat-treated but not saline- or camostat-treated animals. These data are strongly supportive of the utility of intranasally delivered nafamostat for prevention of SARS-CoV-2 infection and further studies are underway to confirm absence of pulmonary infection and pathological changes.

P6308Use of cell-embedded fully implantable biosensor system for real-time, in-vivo monitoring of NF-Kappa B inflammatory pathway

Background

21st century health care remains anchored to sporadic measurements of traditional physiologic variables such as heart rate, blood pressure, weight, physical exam findings and general biochemical values. Currently there is no sensor capable of monitoring in intra-cellular protein and gene level signaling in real-time and in-vivo. This gap between biological signaling and its translation into clinically relevant therapeutics targeting the individual has limited precision medicine approaches to heart and vascular diseases. Inflammatory processes have been implicated in numerous cardiovascular diseases providing an ideal target for using Biologically based-Implantable Electronic Devices (BIED) approaches.

Objective

We aimed to test an implantable electro-photonic biosensor system in which living cells are integrated within the BIED and 1) serve as the primary sensor element providing in-vivo, real-time monitoring of intra-cellular processes such as gene expression, protein signaling, and target pathway activation, and 2) provide intelligent biologically based-processing in which the the output reflects biological response to an event. The engineered sensor cells provide real-time monitoring and respond to prespecified biologic signals using green fluorescence protein (GFP). The fluorescence is then detected via the BIED's photonic system and the cellular response data transmitted providing remote monitoring capabilities to facilitate the development of innovative personalized therapeutics.

Methods

A biologically-based implantable biosensor (BIED) platform which provides fluorescence detection, data acquisition and transmission from living cells integrated within the device was tested. The sensor cells communicate with the surrounding implant environment via a biomembrane. NRK rat cells engineered to express GFP in response to NF-κB pathway activation were cultured and housed within the sensor. Prior implant studies confirmed NRK sensor cells remained viable for 21 days in-vivo as part of a fully functional implanted BIED hardware system. Ex-vivo experiments characterized the expected magnitude and time course of NRK response to TNF-α and Lipopolysaccharide (LPS) exposure used to elicit a proinflammatory inflammatory response. The biosensor was implanted in the subcutaneous space of male Sprague Dawley rats (n=2) for a total of 11 days consisting of a baseline post-surgical recovery period of 7 days, with subsequent challenge with intraperitoneal LPS on Day 8 and 96 hours of post LPS monitoring.

Results

Rats implanted with the Biological based sensor and challenged with intraperitoneal LPS showed real-time expression of GFP under NF-κB transcriptional control following time course similar to ex-vivo experiments (p<0.05) (Figure 1).

Figure 1. Implantable Cell-Embedded Biosensor

Conclusion

We present the first in-vivo use of a new class of BIEDs to detect biological cell response which may herald real-time personalize health management at the molecular and cellular level.

Acknowledgement/Funding

Clinical and Translational Sciences Institute-University of Rochester, Efferent Labs

Street-level diplomacy and local enforcement for meat safety in northern Tanzania: knowledge, pragmatism and trust

BACKGROUND

With increasing demand for red meat in Tanzania comes heightened potential for zoonotic infections in animals and humans that disproportionately affect poor communities. A range of frontline government employees work to protect public health, providing services for people engaged in animal-based livelihoods (livestock owners and butchers), and enforcing meat safety and food premises standards. In contrast to literature which emphasises the inadequacy of extension support and food safety policy implementation in low- and middle-income countries, this paper foregrounds the 'street-level diplomacy' deployed by frontline actors operating in challenging contexts.

METHODS

This research is based on semi-structured interviews with 61 government employees, including livestock extension officers/meat inspectors and health officers, across 10 randomly-selected rural and urban wards.

RESULTS

Frontline actors combined formal and informal strategies including the leveraging of formal policy texts and relationships with other state employees, remaining flexible and recognising that poverty constrained people's ability to comply with health regulations. They emphasised the need to work with livestock keepers and butchers to build their knowledge to self-regulate and to work collaboratively to ensure meat safety. Remaining adaptive and being hesitant to act punitively unless absolutely necessary cultivated trust and positive relations, making those engaged in animal-based livelihoods more open to learning from and cooperating with extension officers and inspectors. This may result in higher levels of meat safety than might be the case if frontline actors stringently enforced regulations.

CONCLUSION

The current tendency to view frontline actors' partial enforcement of meat safety regulations as a failure obscures the creative and proactive ways in which they seek to ensure meat safety in a context of limited resources. Their application of 'street-level diplomacy' enables them to be sensitive to local socio-economic realities, to respect local social norms and expectations and to build support for health safety interventions when necessary. More explicitly acknowledging the role of trust and positive state-society relations and the diplomatic skills deployed by frontline actors as a formal part of their inspection duties offers new perspectives and enhanced understandings on the complicated nature of their work and what might be done to support them.

One Health contributions towards more effective and equitable approaches to health in low- and middle-income countries

Emerging zoonoses with pandemic potential are a stated priority for the global health security agenda, but endemic zoonoses also have a major societal impact in low-resource settings. Although many endemic zoonoses can be treated, timely diagnosis and appropriate clinical management of human cases is often challenging. Preventive 'One Health' interventions, e.g. interventions in animal populations that generate human health benefits, may provide a useful approach to overcoming some of these challenges. Effective strategies, such as animal vaccination, already exist for the prevention, control and elimination of many endemic zoonoses, including rabies, and several livestock zoonoses (e.g. brucellosis, leptospirosis, Q fever) that are important causes of human febrile illness and livestock productivity losses in low- and middle-income countries. We make the case that, for these diseases, One Health interventions have the potential to be more effective and generate more equitable benefits for human health and livelihoods, particularly in rural areas, than approaches that rely exclusively on treatment of human cases. We hypothesize that applying One Health interventions to tackle these health challenges will help to build trust, community engagement and cross-sectoral collaboration, which will in turn strengthen the capacity of fragile health systems to respond to the threat of emerging zoonoses and other future health challenges. One Health interventions thus have the potential to align the ongoing needs of disadvantaged communities with the concerns of the broader global community, providing a pragmatic and equitable approach to meeting the global goals for sustainable development and supporting the global health security agenda.This article is part of the themed issue 'One Health for a changing world: zoonoses, ecosystems and human well-being'.

Examination of the recommended safe and unsafe zone for placement of surgical instruments in thoracentesis and video-assisted thoracic surgery: a cadaveric study

BACKGROUND

Thoracentesis and video-assisted thoracic surgery procedures can result in haemorrhage as a consequence of severing the collateral branches of the posterior intercostal artery. These branches have been shown to be most common in the 5th intercostal space (ICS). Tortuosity has been shown to be especially prevalent nearer to midline. A group of investigators have recommended the 4th and 7th ICS, 120 mm lateral to midline as a safe zone, least likely to hit branches when cutting into the ICS. The present study aimed to investigate that safe zone as a better entry points for procedures. In addition, investigation of the least safe 5th ICS was also performed.

MATERIALS AND METHODS

A total of 56 embalmed human cadavers were selected for the study. With the cadavers laid prone, 2 cm incisions were made at the 4th, 5th and 7th ICS, 120 mm lateral to midline bilaterally. The cadavers were then placed supine and the incisions were dissected. Careful attention was paid to identify if any collateral branches were cut.

RESULTS

After thorough dissection of the 4th, 5th and 7th ICS incision sites, it was shown that damage to the 5th intercostal was seen most frequently.

CONCLUSIONS

Based on this cadaveric study, a 2 cm incision at the 4th, 5th and 7th ICS 120 mm lateral from midline resulted in the most damage at the level of the 5th ICS. The 4th ICS had the least damage seen. Therefore, it is recommended that insertion should be placed at the level of the 4th ICS bilaterally.

Oligonucleotides complementary to c-myb messenger RNA inhibit growth and induce apoptosis in human Burkitt lymphoma cells

A 24-mer (antisense) phosphorothioate oligonucleotide (ODN) corresponding to the codons 2-9 of the c-myb gene was evaluated for its effects on the growth of a human Burkitt lymphoma cell line (Raji) in vitro. Raji cells incubated with different concentrations of c-myb antisense ODN (5-15 mu g/ml) for 24-72 h showed a significant dose-dependent decrease in growth. The same concentrations of control (sense) or scrambled c-myb phosphorothioate ODNs did not inhibit Raji cell growth. The c-myb antisense ODN, but not the control ODNs, significantly decreased c-myb mRNA levels in treated cells as determined by RT-PCR. Additionally, the c-myb antisense ODN induced apoptosis of Raji cells as demonstrated by i) flow cytometry to enumerate the A(o) (apoptotic cell population) population of propidium iodide stained cells; ii) electron microscopy to evaluate the cell morphology; and iii) DNA fragmentation pattern. Thus, an antisense c-myb ODN causes significant growth inhibition of Burkitt lymphoma cells, and one mechanism of growth inhibition is the induction of apoptosis of the lymphoma cells. In addition, antisense c-myb ODN did not reduce CFU-GM or BFU-e colony-forming ability of normal hematopoietic stem/progenitor cells. Because the inhibition is sequence-specific and Burkitt lymphoma cell selective, evaluation of the therapeutic effects of c-myb antisense ODN against Burkitt lymphoma is warranted.

Referrals to a liaison psychiatry outpatient clinic

This study aimed to describe the demographic and clinical characteristics of consecutive referrals to a liaison psychiatry outpatient clinic, based within a National Health Service (NHS) general hospital. All outpatient referrals to the service between January 2005 and January 2008 were subjected to retrospective completion of a proforma for post hoc data collection. Data relating to characteristics of the referral, patients, diagnosis, and nature and extent of contact were extracted for scrutiny. The majority (60.2%) of referrals to the service came from physicians based within the general hospital. Where conveyed, depression (26.7%) was the most commonly cited reason for referral. Diagnoses of both mood (affective) disorders (32.9%) and neurotic, stress-related and somatoform disorders (54.7%) were common. Cognitive behaviour therapy (56.1%) was the most commonly used intervention followed by pharmacological therapy (25.4%). In conclusion, the study provides a description of the nature of the work encountered in a liaison psychiatry setting and demonstrates the extent of services provided for medical specialties within the general hospital.

Rheumatoid arthritis joint progression in sustained remission is determined by disease activity levels preceding the period of radiographic assessment

OBJECTIVE

Joint damage is related to disease activity in rheumatoid arthritis (RA), but the degree of its progression and the temporal associations between disease activity and joint damage are unclear. The aim of this study was to evaluate whether there is a latency in the effect of disease activity on radiographic progression in patients with RA.

METHODS

Data were obtained from the PREMIER trial, a 2-year randomized, controlled clinical trial of adalimumab plus methotrexate versus methotrexate alone or adalimumab alone in early RA. Radiographic progression of joint damage was calculated using the modified total Sharp score in a subset of patients whose disease was in remission (Simplified Disease Activity Index<or=3.3) in the second year of the trial. The progression of damage in the second year was compared between groups of patients whose disease was already in remission for an additional period of 3, 6, or 9 months during the first year. Analysis of variance was used to test for a linear trend.

RESULTS

Among 794 patients with early RA, 119 (15%) achieved sustained remission during the second year, with no difference in radiographic progression across the 3 treatment groups. Radiographic progression in the second year was significantly different between patients with 3, 6, or 9 additional months of remission during year 1 (mean change in the modified Sharp score 1.19 in those with 3 additional months of remission versus 0.20 in those with 6 additional months of remission and -0.32 in those with 9 additional months of remission; P<0.05). The results were supported by similar findings in a series of sensitivity analyses.

CONCLUSION

These data indicate that the level of disease activity as well as the duration of remission affect subsequent progression of radiographic damage in RA. This latency between disease activity and its effects on radiographic progression should be considered when evaluating radiographic outcomes in trials of RA.

Challenges for retrospective cohort studies: A profile of patients who refuse participation or are lost to follow-up

6615

Background: As hematopoietic cell transplantation (HCT) has increasingly become a curative option for many diseases, studying long-term complications has assumed critical importance. A major issue in conducting scientifically rigorous long-term follow up studies with large cohorts is the ability to track patients, and obtain informed consents. High participation rates are critical to avoid selection bias and ensure generalizability. Methods: A mass consenting process was implemented to obtain informed consents from 1056 City of Hope HCT patients transplanted during 1976–2006 who were one+ year survivors and alive in June 2007. This process involved mailing consent forms followed by phone calls. Patients were classified as consented, refused, or lost-to-follow-up (LTFU). Sociodemographic and clinical characteristics indicative of higher risks for refusal or LTFU were identified. Results: Study patients comprised 58% males, and 53% Caucasians. Median age at HCT was 34 years (0.6–73); median age at study initiation was 47 years (6–81); and median time from HCT to study initiation was 10 years (1–30). Primary diagnoses included acute/chronic leukemia (43%), Hodgkin/non-Hodgkin lymphoma (36%), multiple myeloma (9%), and other miscellaneous diagnoses (12%). Fifty percent received allogeneic HCT. At the end of the process, 46% consented, 17% refused, and 37% were LTFU. Compared to consented patients, males, Asians, and younger patients were more likely to refuse consent. Patients LTFU were more likely to have lower SES, a longer time since HCT, in addition to being males, Asians and younger at HCT (Table). Conclusions: This study demonstrates the critical need for maintaining up-to-date contact information on patients after HCT in order to obtain valid long-term follow-up data. It also describes the characteristics of the sub-population that are more likely to refuse or be LTFU, information necessary for planning targeted interventions in long-term follow-up initiatives.

[Table: see text]

No significant financial relationships to disclose.

UV treatment of microorganisms on artificially-contaminated surfaces using excimer and microwave UV lamps

An XeBr excilamp having a peak emission at 283 nm, and microwave UV lamps with peak emissions at 253.7 nm that also generate ozone, have been tested for ability to eradicate high populations of microbial vegetative cells and spores (of bacteria and fungi) artificially added to filter surfaces. The study examined the energy required to completely eradicate large populations on filter surfaces. It was found that both the excilamp and microwave UV lamps were effective at killing large populations on surfaces with killing efficiency dependant on the type of organism, and, whether present in its vegetative or spore forms. The main killing factor is UV radiation following short treatment times. It is considered that for longer irradiation periods that are required to facilitate complete destruction of surface microorganisms, ozone and other oxidising species produced by microwave UV lamps would act to enhance microbial destruction.

High-resolution three-dimensional imaging of dislocations

Dislocations and their interactions govern the properties of many materials, ranging from work hardening in metals to device pathology in semiconductor laser diodes. However, conventional electron micrographs are simply two-dimensional projections of three-dimensional (3D) structures, and even stereo microscopy cannot reveal the true 3D complexity of defect structures. Here, we describe an electron tomographic method that yields 3D reconstructions of dislocation networks with a spatial resolution three orders of magnitude better than previous work. We illustrate the method's success with a study of dislocations in a GaN epilayer, where dislocation densities of 1010 per square centimeter are common.

Critical clinical appraisal of the role of ultrasound guided fine needle aspiration cytology in the management of parotid tumours

Objective: Fine needle aspiration cytology is a well established tool for investigating many head and neck conditions. Its application in parotid tumours is, however, controversial. This article is aimed at defining the role of ultrasound guided fine needle aspiration cytology (FNAC) in the diagnostic work up of parotid tumours. The accuracy and utility of FNAC of parotid tumours was also assessed.

Design: Retrospective case note review.

Setting: District general hospital.

Participants: Review of 69 patient records who had parotid surgery under one surgeon’s care (JS). Clinical opinion, FNAC results and final pathology findings were examined.

Main outcome measures: The results of the FNAC were compared to the histopathological diagnosis obtained from the surgical specimen.

Results: Histological evaluation revealed 13 malignant tumours and 56 benign lesions. The overall sensitivity of FNAC was 84.6 per cent and specificity was 96.4 per cent. We noted 11 true positive, 54 true negative, two false negative and two false positive results. Positive predictive value for diagnosing malignancy was 84.6 per cent and negative predictive value for malignancy was 96.4 per cent. The overall accuracy of FNAC of parotids in this study was 94.2 per cent.

Conclusions: FNAC results provide useful preoperative information. FNAC enables more reliable patient counselling and reduces pathological surprises. Pre-operative recognition of malignant tumours may help prepare both the surgeon and patient for an appropriate surgical procedure. Its enhancement of the pre-operative recognition of malignant parotid tumours may alert more stringent attention to the operative margin and hence better tumour clearance. Ultrasound guided FNAC was found to be highly specific for malignancy and its sensitivity for malignancy was good.

Psoriatic arthritis imaging: a review of scoring methods

Structural damage assessed on conventional radiographs is an important outcome measure in psoriatic arthritis. This article reviews the available scoring methods. A full description of the methods is given as well as information on various aspects of validity.

Use of quantitative 16S ribosomal DNA detection for diagnosis of central vascular catheter-associated bacterial infection

Many central vascular catheters (CVCs) are removed unnecessarily because current diagnostic methods for CVC-associated infection are unreliable. A quantitative PCR assay using primers and probe targeted to bacterial 16S ribosomal DNA was used to measure the levels of bacterial DNA in blood samples drawn through the CVC in a population of patients receiving intravenous nutrition. Bacterial DNA concentrations were raised in 16 of 16 blood samples taken during episodes of probable bacterial CVC-associated infection. Bacterial DNA concentrations were raised in 4 of 29 episodes in which bacterial CVC-associated infection was unlikely. The use of this technique has the potential to substantially reduce the unnecessary removal of CVCs.

Good practice in head and neck fine needle aspiration cytology as assessed by CUSUM

Providing data as evidence of good practice is becoming imperative to meet the demands of professional revalidation and clinical governance. Sensitivity and specificity are common performance measures in fine needle aspiration (FNA) but are vulnerable to discordant analytical methods. We introduce a CUSUM technique and show how it may be used to show attainment and maintenance of proficiency in head and neck (H&N) FNA. In addition, we show how it can be used to compare practices and demonstrate different performance for FNAs from different tissues; a fact that must be recognized by anyone devising minimum performance values.

Two-year, blinded, randomized, controlled trial of treatment of active rheumatoid arthritis with leflunomide compared with methotrexate. Utilization of Leflunomide in the Treatment of Rheumatoid Arthritis Trial Investigator Group

OBJECTIVE

Three 6-12-month, double-blind, randomized, controlled trials have shown leflunomide (LEF; 20 mg/day, loading dose 100 mg x 3 days) to be effective and safe for the treatment of rheumatoid arthritis (RA). This analysis of the North American trial assessed whether the clinical benefit evident at month 12 was sustained over 24 months of treatment with LEF as compared with the efficacy and safety of methotrexate (MTX), an equivalent disease-modifying antirheumatic drug, at 24 months.

METHODS

The year-2 cohort, comprising patients continuing into the second year of treatment with > or = 1 dose of study medication and > or = 1 followup visit after week 52, consisted of 235 patients (LEF n = 98; placebo n = 36; MTX n = 101). The mean (+/- SD) maintenance dose of LEF was 19.6 +/- 1.99 mg/day in year 2 and that of MTX was 12.6 +/- 4.69 mg/week. Statistical analyses used an intent-to-treat (ITT) approach. Statistical comparisons of the active treatments only were prospectively defined in the protocol.

RESULTS

In total, 85% and 79% of LEF and MTX patients, respectively, who entered year 2 completed 24 months of treatment. From month 12 to month 24, the American College of Rheumatology improvement response rates of > or = 20% (LEF 79% versus MTX 67%; P = 0.049), > or = 50% (LEF 56% versus MTX 43%; P = 0.053), and > or = 70% (LEF 26% versus MTX 20%; P = 0.361) were sustained in both of the active treatment groups. The mean change in total Sharp radiologic damage scores at year 2 compared with year 1 and baseline (LEF 1.6 versus MTX 1.2) showed statistically equivalent sustained retardation of radiographic progression in the active treatment groups. Maximal improvements evident at 6 months in the Health Assessment Questionnaire (HAQ) disability index (HAQ DI) and the physical component score of the Medical Outcomes Survey 36-item short form were sustained over 12 months and 24 months; improvement in the HAQ DI with LEF4(-0.60) was statistically significantly superior to that with MTX (-0.37) at 24 months (P = 0.005). Over 24 months in the ITT cohort, serious treatment-related adverse events were reported in 1.6% of the LEF-treated patients and 3.7% of the MTX-treated patients. Frequently reported adverse events included upper respiratory tract infections, diarrhea, nausea and vomiting, rash, reversible alopecia, and transient liver enzyme elevations.

CONCLUSION

The safety and efficacy of LEF and MTX were maintained over the second year of this 2-year trial. Both active treatments retarded radiographic progression over 24 months. LEF was statistically significantly superior to MTX in improving physical function as measured by the HAQ DI over 24 months of treatment. Results indicate that LEF is a safe and effective initial treatment for active RA, with clinical benefit sustained over 2 years of treatment without evidence of new or increased toxicity.

Association study of a dopamine transporter polymorphism and attention deficit hyperactivity disorder in UK and Turkish samples

Molecular genetic studies in attention deficit hyperactivity disorder (ADHD) have focussed on candidate genes within the dopamine system, which is thought to be the main site of action of stimulant drugs, the primary pharmacological treatment of the disorder. Of particular interest are findings with the dopamine transporter gene (DAT1), since stimulant drugs interact directly with the transporter protein. To date, there have been eight published association studies of ADHD with a 480 base-pair allele of a variable number tandem repeat (VNTR) polymorphism in the 3'-untranslated region of the gene, five that support an association and three against. We have analysed the same VNTR marker in a dataset of UK Caucasian children and an independent dataset of Turkish Caucasian children with DSM-IV ADHD, using the transmission disequilibrium test (TDT). Results from the UK (chi(2) = 8.97, P = 0.001, OR = 1.95), but not the Turkish sample (chi(2) = 0.93, P = 0.34) support association and linkage between genetic variation at the DAT1 locus and ADHD. When considered alongside evidence from other published reports, there is only modest evidence for the association, consistent with a very small main effect for the 480-bp allele (chi(2) = 3.45, P = 0.06, OR = 1.15), however we find significant evidence of heterogeneity between the combined dataset (chi(2) = 22.64, df = 8, P = 0.004).

Attention deficit hyperactivity disorder (ADHD) and the dopamine D4 receptor gene: evidence of association but no linkage in a UK sample

Recent studies report association and linkage between attention deficit hyperactivity disorder (ADHD) and the 7-repeat allele of a 48 base-pair repeat in the dopamine D4 receptor gene (DRD4). We examined the frequency of this allele in a sample of probands with DSM-IV ADHD using a case-control design, as well as the transmission disequilibrium test (TDT) and haplotype-based haplotype relative risk (HHRR) in the subset of probands with DNA available from both parents. One hundred and thirty-two ADHD probands were compared with 189 controls (chi(2) = 6.17, 1 df, P = 0.01, OR = 1.73, 95% CI = 1.11--2.71). A total of 85 complete trios were available for within-family tests of association and linkage. Fifty-two heterozygous parents carrying one copy of the 7-repeat were informative for the TDT (29 transmitted vs 23 non-transmitted, chi(2) = 0.69). Analysis of the entire sample of 132 probands using TRANSMIT provided no additional evidence for excess transmission of the 7-repeat allele (58 transmitted vs 54 non-transmitted). HHRR gave similar results. We conclude that the case-control findings are likely to be falsely positive, resulting from genetic stratification. However we can not rule out alternative explanations of low statistical power and gene-environment correlation.

Haemodialysing infants: theoretical limitations, and single versus double lumen lines

Haemodialysing small infants is difficult because of vascular access limitations. We show that Poiseuille's law (that flow through a tube varies with its radius4) makes it inevitable that the blood flow that can be achieved in smaller patients will fall disproportionately compared to their need for dialysis. Poiseuille's law also predicts that for single and multiple lumen cannulae of the same outside gauge, blood flow through the single lumen will be several times greater. Measurements confirmed this. It is argued that haemodialysis efficiency will therefore be improved by using a single lumen cannula to alternately withdraw and return blood, compared to sampling and returning continuously through a multiple lumen cannula, despite only withdrawing for half the time.

The engineering of an interventional MRI with a movable 1.5 Tesla magnet

The engineering of a novel intra-operative MRI system is described. A movable, 1.5 Tesla MRI magnet was placed in a neurosurgical operating room without affecting established neurosurgical procedure. The system allows fast, high-quality MR intra-operative imaging of the brain and spine without the necessity of patient transportation. A neuro-navigational device capable of displaying and updating spatially referenced MR images in the operating room was integrated with the MRI system. Over 100 procedures have been carried out with this system without limiting surgical access and without compromising traditional neurosurgical, nursing or anesthetic techniques. J. Magn. Reson. Imaging 2001;13:78-86.

Oral health in children with renal disease

Thirty-eight children (aged 2-16 years) attending a regional kidney unit had a full clinical and radiological dental examination. Twenty had previously undergone a renal transplant, 11 had chronic renal failure and 7 had other renal diseases. Periodontal disease was uncommon The presence of gingival hyperplasia (gum overgrowth), as recorded in 22 of the children, did not show any relationship with the use of immunosuppressant therapy. However, gingival overgrowth was so excessive in 2 patients that surgical removal was required. The prevalence of dental caries was low. Enamel defects were common, and of an unusual pattern, with a much higher prevalence of diffuse opacities and enamel hypoplasia than in the normal child population, 83% and 22%, respectively. This increased prevalence is probably due to disordered calcium and phosphate metabolism. The prevalence of these defects may reflect an early onset of renal disease, since there were a number of very young children in the programme. Dental and medical care should be closely integrated for children with renal disease to avoid the undesirable dental sequelae of, in particular, gingival overgrowth, carcinoma and enamel hypoplasia.

Treatment of active rheumatoid arthritis with leflunomide compared with placebo and methotrexate. Leflunomide Rheumatoid Arthritis Investigators Group

CONTEXT

Leflunomide is a reversible inhibitor of de novo pyrimidine synthesis shown to be effective in a phase 2 trial in 402 patients with active rheumatoid arthritis (RA).

OBJECTIVE

To compare the efficacy and safety of leflunomide treatment with placebo and methotrexate treatment in patients with active RA.

DESIGN

Randomized, double-blind, placebo, and active-controlled 12-month study.

SETTING

Forty-seven university and private rheumatology practices in the United States and Canada.

PATIENTS

Diagnosis of RA by the American College of Rheumatology (ACR) criteria for duration of 6 months or longer and no previous methotrexate treatment.

INTERVENTION

Leflunomide treatment (20 mg/d), placebo, or methotrexate treatment (7.5-15 mg/wk).

MAIN OUTCOME MEASURES

American College of Rheumatology success rate (completed 52 weeks of treatment and met the ACR > or = 20% response criteria), disease progression as assessed by x-ray films, and improvement in function and health-related quality of life using the intent-to-treat population.

RESULTS

The 482 patients studied were predominantly women (mean age, 54 years; mean disease duration, 6.7 years) for whom a mean of 0.8 disease-modifying antirheumatic drugs had failed. The ACR response and success rates for patients receiving leflunomide treatment (52% and 41%, respectively) and methotrexate treatment (46% and 35%, respectively) were significantly higher than those for patients receiving placebo (26% and 19%, respectively) (P<.001), and they were statistically equivalent, with mean time to initial response at 8.4 weeks for patients receiving leflunomide vs 9.5 weeks for patients receiving methotrexate therapy. X-ray analyses demonstrated less disease progression with leflunomide (P=.001) and methotrexate (P = .02) therapy than with placebo. Leflunomide and methotrexate treatment improved measures of physical function and health-related quality of life significantly more than placebo (P<.001 and P<.05, respectively). Common adverse events for patients receiving leflunomide treatment included gastrointestinal complaints, skin rash, and reversible alopecia. Asymptomatic transaminase elevations resulted in treatment discontinuations for 7.1% of patients receiving leflunomide therapy, 1.7% of patients receiving placebo, and 3.3% of patients receiving methotrexate therapy.

CONCLUSIONS

Clinical responses following administration of leflunomide, a new therapeutic agent for the treatment of RA, were statistically superior to those with placebo and equivalent to those with methotrexate treatment. Both active treatments improved signs and symptoms of active RA, delayed disease progression as demonstrated by x-ray films, and improved function and health-related quality of life.

The neuronal ceroid lipofuscinoses in human EPMR and mnd mutant mice are associated with mutations in CLN8

The neuronal ceroid lipofuscinoses (NCLs) are a genetically heterogeneous group of progressive neurodegenerative disorders characterized by the accumulation of autofluorescent lipopigment in various tissues. Progressive epilepsy with mental retardation (EPMR, MIM 600143) was recently recognized as a new NCL subtype (CLN8). It is an autosomal recessive disorder characterized by onset of generalized seizures between 5 and 10 years, and subsequent progressive mental retardation. Here we report the positional cloning of a novel gene, CLN8, which is mutated in EPMR. It encodes a putative transmembrane protein. EPMR patients were homozygous for a missense mutation (70C-->G, R24G) that was not found in homozygosity in 433 controls. We also cloned the mouse Cln8 sequence. It displays 82% nucleotide identity with CLN8, conservation of the codon harbouring the human mutation and is localized to the same region as the motor neuron degeneration mouse, mnd, a naturally occurring mouse NCL (ref. 4). In mnd/mnd mice, we identified a homozygous 1-bp insertion (267-268insC, codon 90) predicting a frameshift and a truncated protein. Our data demonstrate that mutations in these orthologous genes underlie NCL phenotypes in human and mouse, and represent the first description of the molecular basis of a naturally occurring animal model for NCL.

The changing faces of a parotid mass

The development of a neurofibroma in the temporal and parotid regions of the facial nerve is rare. We report a case occurring in a 32-year-old male, where the initial presentation was a parotid mass. Cytologically this was initially thought to be a pleomorphic adenoma. However, the diagnosis was then changed to a schwannoma and finally a neurofibroma after complete excision of the lesion. The case illustrates how fine needle aspiration cytology under ultrasound guidance, and even histological examination of an incision biopsy can sometimes fail to give the correct diagnosis. In this case magnetic resonance imaging was used to help plan definitive surgery.

Seven year follow up of children presenting to the accident and emergency department with irritable hip

OBJECTIVE

To assess an established protocol for managing children with irritable hip in the accident and emergency department.

METHODS

Retrospective seven year follow up of all children managed under an established hip pain protocol. The main outcome measure was of failure of the protocol to identify serious pathology.

RESULTS

A total of 103 children met the criteria for assessment using the protocol. Sixty were allowed home, and outpatient follow up arranged. All of these children except one were diagnosed as having transient synovitis. This child had Perthes' disease and was diagnosed at first presentation. Forty three children were admitted, with eight subsequently having a diagnosis other than transient synovitis of the hip. It was possible to review 80 children seven years later. Of these children no long term problems were encountered.

CONCLUSION

The protocol used in the department for children with irritable hip is successful in identifying those children with transient synovitis of the hip, or other benign causes, and therefore not requiring hospital admission. Long term follow up showed that no serious pathology was missed.

Cytosolic phospholipase A2 is induced in reactive glia following different forms of neurodegeneration

Many recent studies have emphasized the deleterious role of inflammation in CNS injury. Increases in free fatty acids, eicosanoids, and products of lipid peroxidation are known to occur in various conditions of acute and chronic CNS injury, including cerebral ischemia, traumatic brain injury, and Alzheimer's disease. Although an inflammatory response can be induced by many different means, phospholipases, such as cytosolic phospholipase A(2) (cPLA(2)), may play an important role in the production of inflammatory mediators and in the production of other potential second messengers. cPLA(2) hydrolyzes membrane phospholipids and its activity liberates free fatty acids leading directly to the production of eicosanoids. We investigated the cellular localization of cytosolic phospholipase A(2) in the CNS following: (1) focal and global cerebral ischemia, (2) facial nerve axotomy, (3) human cases of Alzheimer's disease, (4) transgenic mice overexpressing mutant superoxide dismutase, a mouse model of amyotrophic lateral sclerosis, and (5) transgenic mice overexpressing mutant amyloid precursor protein, which exhibits age-related amyloid deposition characteristic of Alzheimer's disease. We show that in every condition evaluated, cytosolic phospholipase A(2) is present in reactive glial cells within the precise region of neuron loss. In conditions where neurons did not degenerate or are protected from death, cytosolic phospholipase A(2) is not observed. Both astrocytes and microglial cells are immunoreactive for cytosolic phospholipase A(2) following injury, with astrocytes being the most consistent cell type expressing cytosolic phospholipase A(2). The presence of cytosolic phospholipase A(2) does not merely overlap with reactive astroglia, as reactive astrocytes were observed that did not exhibit cytosolic phospholipase A(2) immunoreactivity. In most conditions evaluated, inflammatory processes have been postulated to play a pivotal role and may even participate in neuronal cell death. These results suggest that cytosolic phospholipase A(2) may prove an attractive therapeutic target for neurodegeneration.