INZ-701, a recombinant ENPP1-Fc protein, effectively treats and prevents neointimal proliferation in WT and ENPP1 Deficient mice

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Inozyme Pharma

Inactivating mutations in ENPP1, which encodes the ecto-nucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1), underlie the rare inherited disorder, generalized arterial calcification of infancy (GACI)/autosomal recessive hypophosphatemic rickets type 2 (ARHR2) also known as ENPP1 Deficiency. ENPP1 Deficiency is characterized by calcification of large and medium sized arteries and marked neointimal proliferation of arteries, leading to arterial stenosis and severe cardiovascular and skeletal complications. ENPP1 Deficiency is associated with a 50% mortality rate in the first six months of life, and there are no approved treatments.

Previous research demonstrated that INZ-701 protein prevented arterial calcification in an ENPP1 deficient mouse model (Enpp1 asj/asj). This study was designed to determine whether INZ-701 can prevent neointimal proliferation in WT and an ENPP1 deficient mouse model (ttw/ttw). Carotid ligation was performed to induce intimal proliferation in the mice.

In the preventive arm of the study, INZ-701 (10mg/kg) or vehicle was administered subcutaneously every other day starting in 6-week-old ttw/ttw-mice. Carotid ligation was performed in these mice at the age of 7 weeks and dosing continued for another 2 weeks. Carotid intimal and medial area caudal from the ligation were analyzed by histomorphometry 14 days and 21 days after carotid ligation. In the therapeutic arm of the study, INZ-701 (10 mg/kg) or vehicle was administered subcutaneously every other day starting 7 days after carotid ligation, when intimal proliferation had already developed, in 8-week-old ttw/ttw-mice. After one week of treatment, histomorphometry was performed.

Fourteen days after carotid ligation, ttw/ttw-mice preventatively treated with INZ-701 showed a significantly reduced intimal area (p<0.001) and intimal/medial (I/M) ratio (p<0.001) compared to those treated with vehicle. This effect was also observed in mice treated with INZ-701, which were treated for 28 days and were subsequently dissected 21 days after carotid ligation. Interestingly, similar effects of INZ-701 were found in WT mice in the preventative study.  In the therapeutic arm of the study, subcutaneous injection of INZ-701 beginning at 7 days post carotid ligation also led to a significant reduction in the I/M ratio (p<0.001) in the INZ-701 treated group compared to vehicle treated ttw/ttw-mice.

These findings demonstrate that INZ-701 prevents neointimal proliferation after carotid injury in a murine model of ENPP1 Deficiency. INZ-701 is hypothesized to restore circulating levels of AMP and adenosine, both potent inhibitors of intimal hyperplasia. Neointimal proliferation is a key feature in the pathophysiology of ENPP1 Deficiency and our results build on prior evidence to support the potential of INZ-701 to treat this rare and life-threatening disease.

Global Forum of Cancer Surgeons: Cancer Surgery During the COVID-19 Pandemic: Impact and Lessons Learned

Background

The purpose of this article is to summarize the opinions of the surgical oncology leaders from the Global Forum of Cancer Surgeons (GFCS) about the global impact of COVID-19 pandemic on cancer surgery.

Methods

A panel session (virtual) was held at the annual Society of Surgical Oncology 2021 International Conference on Surgical Cancer Care to address the impact of COVID-19 on cancer surgery globally. Following the virtual meeting, a questionnaire was sent to all the leaders to gather additional opinions. The input obtained from all the leaders was collated and analyzed to understand how cancer surgeons from across the world adapted in real-time to the impact of COVID-19 pandemic.

Results

The surgical oncology leaders noted that the COVID-19 pandemic led to severe disruptions in surgical cancer care across all domains of clinical care, education, and research. Several new changes/protocols associated with increased costs were implemented to deliver safe care. Leaders also noted that preexisting disparities in care were exacerbated, and the pandemic had a detrimental effect on well-being and financial status.

Conclusions

The COVID-19 pandemic has led to severe disruptions in surgical cancer care globally. Leaders of the GFCS opined that new strategies need to be implemented to prepare for any future catastrophic events based on the lessons learned from the current events. The GFCS will embark on developing such a roadmap to ensure that surgical cancer care is preserved in the future regardless of any catastrophic global events.

Predictive impact of rare genomic copy number variations in siblings of individuals with autism spectrum disorders

Identification of genetic biomarkers associated with autism spectrum disorders (ASDs) could improve recurrence prediction for families with a child with ASD. Here, we describe clinical microarray findings for 253 longitudinally phenotyped ASD families from the Baby Siblings Research Consortium (BSRC), encompassing 288 infant siblings. By age 3, 103 siblings (35.8%) were diagnosed with ASD and 54 (18.8%) were developing atypically. Thirteen siblings have copy number variants (CNVs) involving ASD-relevant genes: 6 with ASD, 5 atypically developing, and 2 typically developing. Within these families, an ASD-related CNV in a sibling has a positive predictive value (PPV) for ASD or atypical development of 0.83; the Simons Simplex Collection of ASD families shows similar PPVs. Polygenic risk analyses suggest that common genetic variants may also contribute to ASD. CNV findings would have been pre-symptomatically predictive of ASD or atypical development in 11 (7%) of the 157 BSRC siblings who were eventually diagnosed clinically.

The economic cost of stroke-associated pneumonia in a UK setting

Introduction Stroke-associated pneumonia (SAP) is common, however, data on the economic impact of SAP are scarce. This study aimed to prospectively evaluate the impact of SAP on acute stroke care costs in a UK setting. Methods Prospective cohort study of 213 consecutive patients with stroke (196 ischemic, 17 hemorrhagic) was admitted to a UK hospital over 1 year. Socio demographic and clinical characteristics were recorded along with all treatments and rehabilitation activity. Patients were classified as having SAP if they fulfilled criteria for "probable" or "definite" respiratory tract infection according to the Centres for Disease Control and Prevention definition, within the first seven days following stroke. Resource use was calculated using a "bottom up" approach of cumulative unit costs. Univariate and multivariate regression analyses were used to establish independent predictors of direct costs. Results Probable or definite SAP occurred in 13.2% (28/213) of patients. Patients with SAP experienced greater inpatient stays (31 days vs. 9 days, p ≤ 0.001) and higher in-hospital mortality (29.2% vs. 10.2%, p = 0.007). Mean (SD) acute care costs per patient was £7035 (6767), but costs were significantly greater for patients with SAP than without [£14,371 (9484) versus £6,103 (5,735); p ≤ 0.001]. SAP was an independent predictor of costs along with increasing stroke severity (NIHSS) and age. Occurrence of SAP resulted in an adjusted incremental additional cost of £5817 (95% CI 4945-6689; p = 0.001) per patient. Conclusions SAP increased acute care costs for stroke by approximately 80%. This provides further impetus for research aimed at reducing SAP, and will inform cost-effectiveness analyses of potential therapeutic strategies.

Phase transitions, phase coexistence, and piezoelectric switching behavior in highly strained BiFeO(3) films

Highly strained BiFeO3 films transition into a true tetragonal state at 430 °C but remain polar to much higher temperatures (∼800 °C). Piezoelectric switching is only possible up to 300 °C, i.e., at temperatures for which strain stabilizes the stripe-like coexistence of multiple polymorphs.

Nutrient database improvement project: the influence of U.S.D.A. Quality and Yield Grade on the separable components and proximate composition of raw and cooked retail cuts from the beef rib and plate

Beef nutrition is important to the worldwide beef industry. The objective of this study was to analyze proximate composition of eight beef rib and plate cuts to update the USDA National Nutrient Database for Standard Reference (SR). Furthermore, this study aimed to determine the influence of USDA Quality Grade on the separable components and proximate composition of the examined retail cuts. Carcasses (n=72) representing a composite of Yield Grade, Quality Grade, gender and genetic type were identified from six regions across the U.S. Beef plates and ribs (IMPS #109 and 121C and D) were collected from the selected carcasses and shipped to three university meat laboratories for storage, retail fabrication, cooking, and dissection and analysis of proximate composition. These data provide updated information regarding the nutrient content of beef and emphasize the influence of common classification systems (Yield Grade and Quality Grade) on the separable components, cooking yield, and proximate composition of retail beef cuts.

Small babies on a small island: survival of very low birthweight infants in Antigua and Barbuda 1986 to 2006

INTRODUCTION

Recent attention has been focussed on pregnancy outcomes in developing countries, with the publication of the World Health Organization Report 2005, Make Every Mother and Child Count and the Neonatal Survival Series from the Lancet in 2005. Scant outcome data from the smaller islands of the Caribbean exist for very low birthweight (VLBW) babies (birthweight < 1500 g).

PATIENTS AND METHODS

A retrospective review of mortality data on VLBW babies in Antigua and Barbuda was performed. Antigua and Barbuda had a population of 71 500 with per capita income of (US) $6054 dollars in 1998. In November 1985, a neonatal Special Care Nursery (SCN) was established. The survival to discharge from SCN for VLBW babies was reviewed from January 1986 to December 2006.

RESULTS

There were 26 455 babies born from 1986 to 2006; 344 (1.3%) were VLBW babies. Survival to SCN discharge was 45% from 1986 to 1992, 46% from 1993 to 1999, and increased to 60% from 2000 to 2006 (p < 0.05 compared with the first two time-periods). Babies from 1000 to 1499 g accounted for 64% of VLBW babies and survival to SCN discharge was 60% from 1986 to 1992, 58% from 1993 to 1999, and increased to 83% from 2000 to 2006 (p < 0.01 compared with the first time period; p < 0.001 compared with the second). Babies < 1000g accounted for 36% of VLBW babies and survival to SCN discharge was 10% from 1986 to 1992, increased to 25% from 1993 to 1999 and to 28% from 2000 to 2006 (trend of p < 0.10 compared with first time period). Conservative newborn care only was available. Antenatal steroids were given from 2000 to 2006.

CONCLUSION

The outlook for VLBW babies using conservative newborn care techniques has significantly improved over 21-years in Antigua and Barbuda.

Structural prerequisites for endotoxic activity in the Limulus test as compared to cytokine production in mononuclear cells

The structural prerequisites for lipopolysaccharide (LPS) and its partial structures for the activation of the Limulus clotting cascade (Limulus amebocyte lysate [LAL] test) are described and compared with the corresponding requirements for the activation of human immune cells such as mononuclear cells. A necessary, but not sufficient, structural motif for this is the presence of the 4′-phosphate-diglucosamine backbone recognition structure (‘epitope’) in lipid A. High activity is only expressed by assemblies of endotoxins, but this is largely independent of the type of supramolecular aggregate structure. A particular conformation of the epitope within the lipid A assembly must be present, which is influenced by addition of further saccharide units to the lipid A moiety, but also reacts slightly to the acylation pattern. In contrast, the cytokine production of human immune cells induced by LPS sensitively depends on the type of its aggregate structure. In the case of a hexa-acylated bisphosphorylated lipid A structure, high activity is only observed with cubic inverted aggregates. Furthermore, addition of antimicrobial agents (such as polymyxin B) leads to a nearly complete inhibition of cytokine production, whereas the reduction in the Limulus assay is much lower. These data are important since a reliable determination of endotoxin concentrations, in particular with respect to its ability to elicit severe infections, is of high interest.

Vorinostat in combination with lenalidomide and dexamethasone in patients with relapsed/refractory multiple myeloma: A phase I study

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Background: Novel drug combinations may improve patient outcome in relapsed/refractory multiple myeloma (MM), which remains especially challenging to treat. Preclinical studies suggest that the histone deacetylase inhibitor vorinostat may have synergistic potential when combined with lenalidomide and dexamethasone. This phase I, multicenter, open-label study evaluated vorinostat plus lenalidomide and dexamethasone in patients (pts) with relapsed or refractory MM. The primary objective was to determine the maximum tolerated dose (MTD); other endpoints included overall safety and tolerability, as well as activity of the combination. Methods: Pts aged ≥18 years with relapsed or refractory MM were enrolled sequentially into 1 of 5 dosing levels ( Table ) using a standard 3+3 design for ≤8 cycles. Barring dose-limiting toxicities (DLTs) in the first cycle, dose escalation continued until the MTD was established. Response was assessed, and adverse events (AEs) were recorded. Results: Of 12 pts accrued to date, 11 (92%) have experienced ≥1 AE, with drug-related AEs reported by 6 pts (96% ≤Grade 2). The most common drug-related AEs (each in 4 pts) were fatigue and thrombocytopenia. Serious AEs in 2 pts (17%) were not considered drug-related. No pts discontinued due to AEs, and no DLT has been observed to date. Dose escalation to dose level (DL) 4 was achieved as no DLTs were observed in DLs 1–3. The MTD has not yet been reached. Of 11 pts evaluable for efficacy, best responses include: complete response in 1 pt, partial response in 2 pts, minimal response in 2 pts, and stable disease in 3 pts; 3 pts had progressive disease (PD). Currently, 9 pts remain on treatment, with 3 pts discontinuing treatment due to PD. Conclusions: These preliminary data suggest that vorinostat with lenalidomide and dexamethasone represents a well tolerated and active novel oral combination therapy for the treatment of relapsed/refractory MM.

[Table: see text]

[Table: see text]

A randomized controlled trial examining combinations of repaglinide, metformin and NPH insulin

AIMS

To compare combination use of repaglinide, metformin and bedtime Neutral Protamine Hagedorn (NPH) insulin with conventional approaches of insulin initiation in patients with Type 2 diabetes (T2DM).

METHODS

Eighty-two patients with T2DM with suboptimal glycaemic control on oral glucose-lowering agents were randomized to one of three treatment regimens for 4 months. Group 1 received metformin and twice daily biphasic 30/70 human insulin mixture (n = 27), group 2 metformin and bedtime NPH insulin (n = 26) and group 3 metformin, bedtime NPH insulin and mealtime repaglinide (n = 25).

RESULTS

Seventy-five patients completed the study. Baseline and end-point mean HbA1c levels fell from 9.0 +/- 1.1 to 7.9 +/- 1.1% in group 1, 10.0 +/- 2.2 to 9.2 +/- 1.4% group 2 and 10.0 +/- 1.7 to 8.1 +/- 1.5% in group 3, respectively. All groups showed improvements in HbA1c. There was no significant difference between groups in the proportions of patients experiencing hypoglycaemia (29.6, 25.0 and 16.7%, respectively; P = 0.55) or in mean weight gain (2.9, 0.7 and 2.2 kg, respectively; P = 0.06). By 4 months, insulin doses were 0.63 +/- 0.32 IU/kg in group 1, 0.58 +/- 0.21 IU/kg in group 2 and 0.37 +/- 0.22 IU/kg in group 3 (group 3 vs. groups 1 and 2: P < 0.002).

CONCLUSIONS

The approach using repaglinide, metformin and NPH insulin improved glycaemic control with a similar safety profile to conventional insulin initiation in T2DM and produced final glycaemic control similar to metformin and a twice daily biphasic insulin mixture.

Nocardia infections in cats: a retrospective multi-institutional study of 17 cases

OBJECTIVE

To record 17 cases of nocardiosis in cats from eastern Australia and to compare this series with cases previously reported.

DESIGN

Retrospective/prospective study.

RESULTS

Nocardia spp infections were diagnosed in 17 cats over 14 years from the three eastern states of Australia. There were no isolates from dogs during this period, but one isolate from a koala and two from dairy cows. The majority of cats presented with spreading lesions of the subcutis and skin associated with draining sinus tract(s). Early cutaneous lesions consisted of circumscribed abscesses. Infections spread at a variable rate, generally by extension to adjacent tissues. Lesions were generally located in regions subjected to cat bite or scratch injuries, including limbs, body wall, inguinal panniculus and nasal bridge. In some other cases, lesions were situated on distal extremities. The clinical course was variable, from chronic, indolent, initially localised infections to acute fulminating disease. Of the 17 cats, 14 were domestic crossbreds and three were purebreds. There was a preponderance of male cats (12 castrated, 1 entire young adult, 1 entire kitten). Nine of 17 cats were 10 years or older. Interestingly, the majority of infections were attributable to N nova. Immediate and/or predisposing causes could be identified in all cases, and included: renal transplantation [one cat]; chronic corticosteroid administration [three cats]; catabolic state following chylothorax surgery [one cat]; fight injuries [seven cats]; FIV infections [three of seven cats tested]. Of the 17 cats, three were apparently cured. Four were thought to be cured, but infection recurred after several months. Three cats responded partially but were euthanased, while another was improving when it died of unrelated complications. Two died despite treatment and two were euthanased without an attempt at therapy. For two cats there were either insufficient records or the patient was lost to follow up.

CONCLUSION

Nocardiosis is a rare, serious disease. Currently it is more common in cats than dogs. Nocardial panniculitis may be clinically indistinguishable from the syndrome caused by rapidly growing mycobacteria. Although the prognosis is guarded, patients with localised infections caused by N nova often respond to appropriate therapy. If definitive treatment is delayed because of misdiagnosis, the disease tends to become chronic, extensive and refractory. Insufficient duration of therapy leads to disease recurrence.

Differences in the patterns of presentation and treatment between proximal and distal gastric cancers

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Background: While the overall incidence of gastric cancer has declined in the United States, the incidence of proximal gastric cancers has increased. Understanding the differences between proximal and distal gastric cancer, may enable us to identify important risk factors and treatment patterns. Methods: Data on 6099 patients diagnosed with gastric adenocarcinoma were collected as a Patient Care Evaluation under the auspices of the American College of Surgeons Commission on Cancer. Clearly defined proximal and distal cancers were compared using the Pearson chi-square test and logistic regression. Results: The proximal cancer group included 1924 patients (87% cardia; 13% fundus) and the distal cancer group included 1312 patients (85% antrum; 15% pylorus). Proximal gastric cancers occurred more often in men (p<0.0001), whites (compared to Black, Hispanic, Native American and Asian races) (p<0.0001), and at younger age (p<0.0001) compared to distal cancers. Risk factors for proximal presentation included tobacco use (Hazard ratio (HR) 1.9, p= 0.002) alchohol use (HR 1.5, p= 0.038) and Barretts (HR 2.7, p<0.0001). Risk factors for distal presentation included H. Pylori (HR 2.3, p= 0.001). Despite increased use of multi-modality therapy, fewer proximal gastric cancers underwent resection compared to distal cancers (p<0.0001). Conclusions: Different risk factors can be identified for proximal and distal gastric cancers, which can impact on risk reduction, screening efforts and help define the pathogenesis of gastric cancer. While proximal cancer patients receive more aggressive multimodality treatments, including adjuvant and neoadjuvant therapy, fewer undergo surgical resection. Long term survival based upon proximal and distal tumor differences will be explored when follow-up data become available.Key Words: gastric adenocarcinoma, proximal gastric cancer, distal gastric cancer, risk factors, treatment.

[Table: see text]

No significant financial relationships to disclose.

The glycosylation site in the envelope protein of West Nile virus (Sarafend) plays an important role in replication and maturation processes

The complete genome of West Nile (Sarafend) virus [WN(S)V] was sequenced. Phylogenetic trees utilizing the complete genomic sequence, capsid gene, envelope gene and NS5 gene/3' untranslated region of WN(S)V classified WN(S)V as a lineage II virus. A full-length infectious clone of WN(S)V with a point mutation in the glycosylation site of the envelope protein (pWNS-S154A) was constructed. Both growth kinetics and the mode of maturation were affected by this mutation. The titre of the pWNS-S154A virus was lower than the wild-type virus. This defect was corrected by the expression of wild-type envelope protein in trans. The pWNS-S154A virus matured intracellularly instead of at the plasma membrane as shown for the parental WN(S)V.

[Assessment of the tetanus immune status in plasma donors of the Blood Donor Service of the Bavarian Red Cross]

BACKGROUND AND OBJECTIVE

Tetanus is nowadays largely under control, as a result of the preventive immunization programme. This prophylactic measure is important also because there is no specific treatment. In Germany tetanus occurs almost exclusively in elderly, not adequately immunized persons. This study determined the existing immune status of plasma donors in the region of Ingolstadt, Bavaria.

SUBJECTS AND METHODS

Tetanus IgG antibody concentrations were measured with the ELISA test in serum of 1742 plasma donors (891 women, 851 men, age range 18-64 years).

RESULTS

An adequately protective immunity against tetanus was found in 98.7% of men and 94.1% of women, while 5 women and 3 men had no protection. Demographic data indicated that the immunization protected males longer than females, regardless of age, especially in those over 50 years of age (85% of females, 99% of males).

CONCLUSION

Adequate tetanus protection was achieved in the overwhelming majority of test subjects. This demonstrates that the prevalence of protection is lower in females than in males, a difference most marked in those over 50 years of age. It is important that this age group in particular should, as part of health care, be informed by their medical practitioner of the dangers of tetanus and the advantages of immunization.

Identifying the region influencing the cis-mode of maturation of West Nile (Sarafend) virus using chimeric infectious clones

West Nile (Sarafend) virus [WN(S)V] has been shown to egress by budding at the plasma membrane of infected cells. However, the region influencing this mode of virus release remains to be deciphered. In this study, we have constructed three chimeric clones in which specific regions of West Nile (Wengler) virus [WN(W)V] were replaced for the corresponding regions of WN(S)V in the full-length infectious clone of WN(S)V to define the region responsible for the cis-mode of WN(S)V maturation. The WN(W)V matures by the trans-mode. All of the resulting chimeric viruses were found to be infective. Transmission electron microscopy analyses performed in Vero cells infected with these chimeric viruses disclosed that the 5' end of the WN(S)V genome plays a major role in influencing the process of maturation at the plasma membrane.

Behavioral treatment of chronic psychogenic polydipsia with hyponatremia: a unique case of polydipsia in a primary care patient with intractable hiccups

Psychogenic polydipsia is recognized as a dangerous and potentially life threatening disorder. Few studies have focused on the treatment of polydipsia presenting in the outpatient setting. A review of the behavioral treatment literature pertaining to psychogenic polydipsia is presented. This review is followed by a case illustration of an outpatient behavioral approach to the treatment of psychogenic polydipsia in a non-psychiatric, primary car, adult, male patient suffering from intractable hiccup. An ABA single-case design was used, with sodium concentration as the dependent variable. This behavioral method appears promising in settings where restriction of fluid intake is not practical.

Linoleic and linolelaidic acids differentially influence proliferation and apoptosis of MOLT-4 leukaemia cells

The effects of varying concentrations of linoleic acid and its transisomer linolelaidic acid on the proliferation the ultrastructural morphology of MOLT-4 T-lymphoblastic leukaemia cells were investigated. At 2 and 4 days after exposure to the fatty acids, the cells were counted by flow cytometry and observed by electron microscopy. After 4 days of treatment, linoleic acid was growth stimulatory at concentrations of 200 microM or less, but was markedly inhibitory at 400 microM. In contrast, linolelaidic acid stimulated proliferation at concentrations of 100 and 200 microM, but inhibited cell growth at 400 microM. Cells treated with 400 microM linoleic acid displayed dense accumulations of characteristic lipid globules and glycogen granules, and exhibited ultrastructural evidence of apoptosis including vacuolization, membrane blebbing and chromatin margination at the nuclear periphery. These results support the notion that geometrical isomerism and concentration of polyunsaturated fatty acids influence the proliferative destiny of cancer cells. Reverse transcription polymerase chain reaction (RT-PCR) analysis revealed a previously documented larger alternatively spliced p53 gene transcript in MOLT-4 cells cultured under reduced serum conditions. However, only wild-type p53 transcripts were amplified by RT-PCR of MOLT-4 cells exposed to phytohaemagglutinin, linoleic acid or linolelaidic acid.

Do Blastocystis hominis colony forms undergo programmed cell death?

Ultrastructural observations were made on colony forms of the protozoan parasite, Blastocystis hominis. Cross-sections of entire colonies were observed by TEM. Cells within a colony were heterogeneous in morphology, consisting of vacuolar, amoeboid, multivacuolar and unusual forms. Dying cells appeared to be in the process of fragmenting into numerous membranebound vesicles, giving rise to empty spaces within the colony. Interestingly, older colonies appeared to show cell fragmentation which resulted in larger, membranebound structures. Numerous cytoplasmic inclusions were present in the central vacuole of some cells, with many containing mitochondria. Amoeboid forms were observed to harbour small membrane-bound vesicles in endosome-like compartments. Other unusual features included margination of chromatin material and distinct blebbing of nuclei. These ultrastructural features suggest that B. hominis colony forms perhaps undergo a form of programmed cell death.

Diagnosis of nipah virus encephalitis by electron microscopy of cerebrospinal fluid

BACKGROUND

between 1998 and 1999, an outbreak of potentially fatal viral encephalitis erupted among pig farm workers in West Malaysia, and later spread to Singapore where abattoir workers were afflicted. Although Japanese encephalitis virus was initially suspected, the predominant aetiologic agent was subsequently confirmed to be Nipah virus, a novel paramyxovirus related to but distinct from Hendra virus.

OBJECTIVE

to describe a case of Nipah virus encephalitis in a pig farm worker from Malaysia.

STUDY DESIGN

the clinical, laboratory and radiological findings of this patient were scrutinized. Special emphasis was placed on the electron microscopic analysis of the cerebrospinal fluid (CSF) specimen from this patient.

RESULTS

the neurological deficits indicative of cerebellar involvement were supported by the magnetic resonance imaging that showed prominent cerebellar and brainstem lesions. CSF examination provided further evidence of viral encephalitis. Complement fixation and/or RT-PCR assays were negative for Japanese encephalitis, herpes simplex, measles and mumps viruses. ELISA for detecting IgM and IgG antibodies against Hendra viral antigens were equivocal for the CSF specimen, and tested initially negative for the first serum sample but subsequently positive for the repeat serum sample. Transmission electron microscopy of negatively-stained preparations of CSF revealed enveloped virus-like structures fringed with surface projections as well as nucleocapsids with distinctive helical and herringbone patterns, features consistent with those of other paramyxoviruses, including Hendra virus.

CONCLUSION

this case report reiterates the relevant and feasible role of diagnostic electron microscopy for identifying and/or classifying novel or emerging viral pathogens for which sufficiently specific and sensitive tests are lacking.

Involving patients in clinical decisions: impact of an interactive video program on use of back surgery

BACKGROUND

Back surgery rates are rapidly rising in the United States. This surgery is usually elective, so patient preferences are important in the treatment decision.

OBJECTIVES

The objective of this study was to determine the impact on outcomes and surgical choices of an interactive, diagnosis-specific videodisk program for informing patients about treatment choices.

RESEARCH DESIGN

This was a randomized, controlled trial at 2 sites comparing the interactive video plus a booklet with the booklet alone.

SUBJECTS

Elective surgery candidates (n = 393) included 171 patients with herniated disks, 110 with spinal stenosis, and 112 with other diagnoses.

MEASURES

Mailed questionnaires were used to assess outcomes and satisfaction; surgery rates were determined by questionnaires and automated records.

RESULTS

Symptom and functional outcomes at 3 months and 1 year were similar between study groups. The overall surgery rate was 22% lower in the videodisk group (26% versus 33%, P = 0.08). Among patients with herniated disks, those in the video group underwent significantly less surgery (32% versus 47%, P = 0.05 by Kaplan-Meier test). Among patients with spinal stenosis, surgery rates in the video group were higher (39% for the video group, 29% for the booklet group; P = 0.4). There was little effect on patient satisfaction, but patients in the video group felt better informed.

CONCLUSIONS

The program appears to facilitate decision making and may help to ensure informed consent. For patients with herniated disks, it reduced the surgery rate without diminishing patient outcomes. Its impact on costs of care depends on the proportion of patients with various diagnoses and on local surgery rates.

Blastocystis hominis: A simplified, high-efficiency method for clonal growth on solid agar

Colony growth of protozoan parasites in agar can be useful for axenization, cloning, and viability studies. This is usually achieved with the pour plate method, for which the parasite colonies are situated within the agar. This technique has been described for Giardia intestinalis, Trichomonas vaginalis, and Entamoeba and Blastocystis species. Extracting such colonies can be laborious. It would be especially useful if parasites could be grown on agar as colonies. These colonies, being exposed on the agar surface, could be conveniently isolated for further investigation. In this study, we report the successful culture of B. hominis cells as colonies on solid agar. Colonies were enumerated and the efficiency of plating was determined. It was observed that B. hominis could be easily cultured on agar as clones. The colonies were dome-shaped and mucoid and could grow to 3 mm in diameter. Flow cytometric analyses revealed that parasite colonies remained viable for up to 2 weeks. Viable colonies were conveniently expanded in liquid or solid media. Scanning electron microscopy revealed that each colony consists of two regions; a dome-shaped, central core region and a flattened, peripheral region. Older colonies possessed numerous strand-like surface coat projections. This study provides the first report of clonal growth of B. hominis on agar and a simple, effective method for cloning and expansion of B. hominis cells.

Scanning electron microscopy of Chilomastix mesnili (Wenyon 1910) Alexieieff, 1912

Scanning electron microscopy of Chilomastix mesnili shows that the cysts are lemon-shaped with one end broadly rounded and the other conical. The trophozoite has five flagella coming out of the anterior end. Four of these are free and the fifth is attached to the body by an undulating membrane. The undulating membrane extends along the whole length of the body of the parasite with the exception of the tail. The tail is an elongated structure almost equal in length to the main body of the parasite.

Ultrastructure of the Endolimax nana cyst

This is the first report on the ultrastructure of the Endolimax nana cyst. These cysts are mostly ovoid in shape and have a distinct cyst wall measuring 80 nm. The nuclear membrane is without pores or associated chromatin deposits. The cytoplasm does not have mitochondria or a Golgi apparatus but shows elongated tubular structures made up of a double row of ribosome-like particles. The nature and function of this structure is not known, but it appears to be characteristic of this species and has not been reported from any other intestinal ameba.

Scanning electron microscopy of the surface coat of Blastocystis hominis

Scanning electron microscopy of Blastocystis hominis showed that its outer coat has a fibrillar structure and individual fibrils may extend up to 5 microm from the periphery of the parasite. The surface coat remains intact during cell division. Bacteria are often seen adhering to it, but for the first time a trophozoite of Chilomastix mesnili was also seen in this position. It is postulated that breakdown of attached organisms may provide nutrients for Blastocystis.

Fetal anticonvulsant syndrome and mutation in the maternal MTHFR gene

Around 6% of infants born to mothers taking anticonvulsants have malformations, including neural tube defects, and a further proportion show developmental delay in later childhood. Three commonly used anticonvulsants, carbamazepine, phenytoin and sodium valproate, interfere with folic acid metabolism. We investigated the common 677 C>T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene in samples from 57 patients and their parents and 152 controls to determine its contribution to the risk of fetal anticonvulsant syndrome. The 677 C>T mutation frequency was significantly higher in the mothers than in the controls, but there was no significant difference in 677 C>T frequency in the patients or in the fathers. Genotype frequencies in the mothers were significantly different from controls, there being an excess of 677 C>T homozygotes. Amongst the patients, there was an apparent excess of heterozygotes (not statistically significant), and the fathers were not significantly different from controls. Mutation in the MTHFR gene in a mother taking sodium valproate, phenytoin or carbamazepine during pregnancy is associated with fetal anticonvulsant syndrome in her offspring. The skewed distribution of genotypes in the affected children probably reflects the association of fetal anticonvulsant syndrome with the maternal genotype.