Outcomes Following Pedestal Cup Reconstruction of (Impending) Pathological Fractures of the Acetabulum due to Metastatic Bone Disease

Management of periacetabular metastatic bone disease (MBD) is challenging, specifically if associated with bone loss or fracture. The aim of this study was to evaluate the complications and outcomes after undergoing peri-acetabular reconstruction using an 'ice-cream cone' pedestal cup endoprostheses for the most severe cases of (impending) pathological acetabular fractures. Fifty cases with severe periacetabular disease were identified. Acetabular defects were classified using the Metastatic Acetabular Classification (MAC). Pre- and post-operative mobility was assessed using the Eastern Cooperative Oncology Group (ECOG) Performance Status. Pain levels were assessed using a verbal rating scale. Surgical complications and patient survival were analysed; the Prognostic Immune Nutritional Index (PINI) was applied retrospectively to survival. There were 32 females and 18 males with a median age of 65 (41-88). Median post-operative follow-up was 16 months (IQR 5.5-28.5 months). Thirty-nine had complete, and 11, impending pathological fractures. The observed five-year survival was 19%, with a median survival of 16 months (IQR 5.8-42.5 months). Significantly worse survival was observed with PINI scores < 3.0 (p = 0.003). Excluding three perioperative deaths, 13 complications occurred in 12 patients: Implant failure in six patients (four aseptic loosening, one dislocation and one infection). At the final follow-up, mobility and pain levels were improved in 85% and 100%, respectively. Reconstruction of significant pelvic MBD with the 'ice-cream cone' reduces pain and improves mobility. Whilst the mortality rate is high, it remains a reasonable option for bed-bound, immobile patients. We advocate the use of an 'ice-cream cone' prosthesis for selected patients balancing the reported risks with the observed benefits.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13193-024-01917-x.

A28 TIME-RESTRICTED FEEDING REDUCES INFLAMMATORY BOWEL DISEASE AND IMPROVES EPITHELIUM COLON REGENERATION

Background

The circadian clock is a time keeping mechanism that drives daily rhythms in the body, including behavior and gastrointestinal digestion, inflammation, and metabolism. These daily rhythms are endogenous to cells, and they must adjust themselves to cyclic environmental cues like feeding schedules and light dark cycles. However, when the cyclical environment is chrono-disrupted (ex. shiftwork and jetlag), the temporal organization in the body is lost. Chrono-disruption is linked to an increase in the risk of Inflammatory Bowel Disease (IBD); studies in rodents shown that IBD is more severe in mice without a circadian clock and intestinal regeneration is compromised

Purpose

Recent studies have shown that time-restricted feeding (TRF, the provision of food at times of peak behavior activity – without caloric restriction), that aligns with circadian behavior improves daily organization in the body and health. Therefore, we hypothesized that time-restricted feeding would be an effective strategy to ameliorate IBD and improve regeneration in chrono-disrupted animals.

Method

To test this, we used the DSS induction of colitis in mutant mice without clock function (Bmal1^-/-) and controls with an intact clock (Bmal1^+/+) and compared ad libitum feeding vs. TRF conditions (food available from 7pm to 7am).

Result(s)

Our results show that TRF ameliorates IBD symptoms and protects against epithelium colon damage in animals without clock function. Our preliminary results suggest that TRF may function by increasing the expression of the anti-inflammatory signal PPARg in the colon. Currently, we are testing if the circadian clock controls the daily expression of PPARg in vivo and in vitro. To further test the effect of TRF during regeneration after colitis, we tested proliferation (Ki67) and regeneration in the colon. (Hopx). Our results show that TRF increases the number of Ki67 positive cells and the expression of fetal-like regenerative precursor Hopx in both animals with and without a functional clock.

Conclusion(s)

Together these data suggest that TRF enhances regeneration in the colon after colitis. Moving forward, we are testing transcriptional pathways that are activated during regeneration in animals under TRF. Our results show that time restricted feeding can ameliorate IBD and highlight the role of circadian rhythms in regeneration and intestinal stem cell biology.

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CIHR, Other

Please indicate your source of funding;

Crohn's and Colitis Canada

Disclosure of Interest

None Declared

AB0309 MEASURING THE DIFFERENCE: COMPARISON OF MEASUREMENT OF FREE INFLIXIMAB ANTI-DRUG ANTIBODIES

Background:

Infliximab (IFX) was one of the first TNF alpha inhibitors to be licenced in inflammatory arthritis and is still commonly used today. Studies have shown that approximately 50% of primary IFX responders will suffer from secondary loss of response within the first 12 months of treatment (1). The development of Anti-Drug Antibodies (ADA’s) plays a significant role in this treatment failure (2).

Monitoring of ADA’s helps identify those patients who fail to respond to treatment due to low IFX trough levels. In this scenario the presence of ADA’s can aid decision-making regarding increasing IFX dosing or switching biologic therapy to optimise treatment. (3).

Objectives:

Despite their potential importance the detection of ADAs varies widely depending on the type of assays used. The aim of this study was to determine the qualitative concordance of three commercially available ELISA kits for measurement of free ADAs to IFX on the Grifols Triturus analyser.

Methods:

150 patient samples from patients with inflammatory conditions and low IFX trough drug levels (≤0.6µg/ml) were analysed for free ADAs using Promonitor, Lisa Tracker and IDKmonitor kits on the Grifols Triturus automated ELISA analyser.

Results:

Kappa coefficient (κ) analysis indicated a moderate agreement between the Promonitor and IDKmonitor assays (κ =0.484 (95% CI, 0.357 to 0.611)) and the IDKmonitor and Lisa Tracker assays (κ = 0.485 (95% CI, 0.348-0.621)) as well as substantial agreement between the Promonitor and Lisa Tracker assays (κ =0.768 (95% CI, 0.667-0.870)). Figure 1 shows the distribution of samples identified as free ADA positive by each kit.

Figure 1.

Distribution of samples identified as free ADA positive by Promonitor, Lisa Tracker, and IDKmonitor assays. Fifty samples were considered positive by all assays. Three samples were considered positive by Promonitor and Lisa Tracker, and eight samples were considered positive by Lisa Tracker and IDKmonitor. No samples were considered positive by Promonitor and IDKmonitor. One sample was considered positive by Promonitor only, seven samples were considered positive by Lisa Tracker only, and twenty-six samples were considered positive by IDKmonitor

Conclusion:

All kits appear amenable for utilisation in a high-throughput laboratory though a true quantitative comparison between these kits was precluded by the absence of any certified reference material for free ADAs to IFX.

Although broad qualitative agreement was found between the three kits, they should not be used interchangeably for patient management.

Further research is required to estimate the impact of free ADAs on efficiency of IFX treatment and patient management.

References:

[1]Quistrebert J, Hässler S, Bachelet D et al.Incidence and risk factors for adalimumab and infliximab anti-drug antibodies in rheumatoid arthritis: A European retrospective multicohort analysis. Seminars in Arthritis and Rheumatism Volume 48, Issue 6, June 2019, Pages 967-975 2.

[2]Moots RJ, Xavier RM, Mok CC, Rahman MU, Tsai W-C, Al-Maini MH, et al. (2017)The impact of anti-drug antibodies on drug concentrations and clinical outcomes in rheumatoid arthritis patients treated with adalimumab, etanercept, or infliximab: Results from a multinational, real-world clinical practice, non-interventional study. PLoS ONE 12(4): e0175207.https://doi.org/10.1371/journal.pone.0175207

[3]Smolen JS, Landewé R, Bijlsma J, et al.EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs:2016 update.Annals of the Rheumatic Diseases 2017;76:960-977.

Disclosure of Interests:

Rhona Hamilton: None declared, Stephanie Shields: None declared, Andrew McGucken: None declared, Jonathan MacDonald: None declared, Martin Perry Grant/research support from: Grifols, Abbvie, Sandoz unrestricted educational grant, Consultant of: Abbvie, Gilead, Celltrion Advisory Board, Speakers bureau: Sandoz, Allan Dunlop: None declared, Elaine Gribben: None declared, Peter Galloway: None declared

AB1186 THE NHS SCOTLAND THERAPEUTIC DRUG MONITORING SERVICE FOR BIOLOGIC MEDICINES: PRELIMINARY ANALYSIS OF UTILISATION AND CLINICAL RESULTS AT YEAR 1

Background:

Anti-tumour necrosis factor α (anti-TNFα) drugs infliximab (IFX) and adalimumab (ADL) are effective treatments for several rheumatic diseases. Therapeutic drug level and anti-drug antibody monitoring (TDM) has emerged as a useful tool for optimising drug effectiveness, by identifying individuals who may benefit from dose or treatment frequency adjustment, or have secondary drug failure due to immunogenicity.

Objectives:

Ensuring safe and effective use of biologic medicines has been identified as a key priority for NHS Scotland. Inequity and inconsistency of access to TDM across the nation was recognised as a barrier to delivering best practice and so a nationally commissioned TDM service was proposed in January 2018 to support clinical practice, providing universal access to TDM for services treating inflammatory diseases across Scotland. Data collection and analysis of results regarding usage and clinical impact of the service were identified as key outcome measures to assess service success and sustainability.

Methods:

A service webpage was developed to provide guidance on testing strategies and interpretation of TDM results (1). An automated search of clinical data and test results recorded within the clinical biochemistry electronic results management system was conducted to identify all TDM tests performed between 01/01/2018 and 31/12/2018. Descriptive analysis outcomes included the number of samples received, processed, overall testing population, service utilisation by Health Board, number and results of TDM tests performed per patient. TDM results were interpreted according to published guidance on the service webpage and comparison was made with previously published data (2).

Results:

3609 specimens were received for testing, from 13 of the 14 Scottish Health Boards. 3561 drug level (DL) tests were performed; 1786IFX, 1775 ADL. 2717 total antidrug anti-body (TABT) tests and 681 free antidrug anti-body tests (FABT) were performed according to service protocol. 2791 individuals had one or more TDM tests during the 12-month period, of whom 541 were tested twice or more (range 2-5).

Table 1.

IFX & ADL DL, TABT and FABT results by category as defined in service guidance (AU/ml = Arbitrary Units/ml)]

INFLIXIMABADALIMUMABDrug level by categorySupratherapeutic DL > 8mcg/ml546 (30.6%)708 (39.9%)Supratherapeutic DL > 10 mcg/mlTherapeutic DL ≥3<8.1mcg/ml738 (41.3%)636 (35.8%)Therapeutic DL ≥5<10.1 mcg/mlSub-therapeutic DL < 3mcg/ml502 (28.1%)431 (24.3%)Sub-therapeutic DL < 5 mcg/mlTABT by categoryNegative (<10 AU/ml)791 (54.2%)905 (71.9%)Negative (<10 AU/ml)Positive (>10 AU/ml)668 (45.8%)353 (28.1%)Positive (>10 AU/ml)FABT by categoryNegative (< 5AU/ml)376 (82.8%)176 (77.6%)Negative (<10 AU/ml)Positive (> 5 AU/ml)78 (17.2%)51 (22.4%)Positive (>10 AU/ml)

Conclusion:

TDM has been enthusiastically embraced. It is estimated that > 50% of individuals treated with IFX or ADL have been tested at least once in the first year. DL results were found to be similar to previously published data, as were rates of antibody positivity. The large volume of data generated by the service may provide additional evidence regarding the utility of TDM in predicting clinical response. Next steps are to conduct a comparative effectiveness analysis where proactive vs reactive TDM testing strategies will be compared, with the primary outcome measure being the proportions of patients with secondary loss of response.

References:

[1]Scottish Biologic therapeutic Drug Monitoring Servicehttps://www.nhsggc.org.uk/about-us/professional-support-sites/biochemistry/biological-therapy-monitoring/

[2]Jani, M. Et al (2015), Clinical Utility of Random Anti–Tumor Necrosis Factor Drug–Level Testing and Measurement of Antidrug Antibodies on the Long-Term Treatment Response in Rheumatoid Arthritis. Arthritis & Rheumatology, 67: 2011-2019. doi:10.1002/art.39169

Acknowledgments:

Biogen GmbH contributed partial funding for this research. Authors had full editorial control and approval of all content

Disclosure of Interests:

Jonathan MacDonald: None declared, Martin Perry Grant/research support from: Grifols, Abbvie, Sandoz unrestricted educational grant, Consultant of: Abbvie, Gilead, Celltrion Advisory Board, Speakers bureau: Sandoz, Peter Galloway: None declared, John-Paul Seenan: None declared, Alan Dunlop: None declared

Bilateral fixation of a periprosthetic intertrochanteric hip fracture below Birmingham hip resurfacing

This case report involves a 59-year-old woman with a traumatic right intertrochanteric hip fracture below a previous Birmingham hip resurfacing (BHR). This woman had almost an identical fracture on the left hip 3 years before which was treated with a proximal femoral locking compression plate. Of note periprosthetic fractures following hip resurfacing are usually subcapital and treated with a revision or conservative management. We present an unusual surgical problem that has occurred twice in the same patient and has been treated effectively on both occasions using proximal femoral plating. To the best of our knowledge, there have been no other reports of bilateral periprosthetic fractures being treated in this way.

A fibre based triature interferometer for measuring rapidly evolving, ablatively driven plasma densities

We report on the first use of a fibre interferometer incorporating triature analysis for measuring rapidly evolving plasma densities of n(e) ∼ 10(13)/cm(3) and above, such as those produced by simple coaxial plasma guns. The resultant system is extremely portable, easy to field in experiments, relatively cheap to produce, and—with the exception of a small open area in which the plasma is sampled—safe in operation as all laser light is enclosed.

An evaluation of a collaborative bibliotherapy scheme delivered via a library service

This paper reports on the evaluation of a bibliotherapy scheme delivered via a local library service, in conjunction with General Practice (GP) practices, local social welfare agencies and through self-referral. The Read Yourself Well (RYW) scheme was based on principles established from other similar schemes and as a way of delivering support for adults experiencing mild to moderate mental health problems for whom clinical treatments are not appropriate. The intervention consisted of initial referral and evaluation by the scheme bibliotherapist, a one-hour session at the beginning and end of the intervention where a purpose-designed questionnaire and two mental health assessments were carried out (the General Health Questionnaire and the Clinical Outcomes in Routine Evaluation questionnaire). Contact and support from the bibliotherapist was provided during the intervention period. One hundred and fifty-seven participants were recruited to the evaluation of whom 114 provided full data. Statistical analyses of the mental health scores showed significant improvements post treatment, for, both male and female participants, for all three referral routes, and for participants who were previously library users, and those who joined the library service to participate in the RYW scheme. The results of this large sample evaluation support the proposal that library-based bibliotherapy can be effective in the treatment of mental health problems.

Self-harm and psychosocial characteristics of looked after and looked after and accommodated young people

Children and young people who are classed as "looked after" and "looked after and accommodated", have been identified as being especially at risk of self-harm, however there is little research that has assessed self-harm among these groups. This study investigates self-harm rates, distinguishing between cognitions and behaviours with non-suicidal and suicidal intent among the looked after and looked after and accommodated population of young people educated within mainstream institutions in West Central Scotland. Looked after young people who self-harmed were compared with looked after young people who had never self-harmed on reasons for living, self-critical style, common life problems and academic self-esteem. An anonymous self-report questionnaire was used to survey 102 looked after (LAC) and looked after and accommodated (LAAC) children and young people across 10 schools within 6 local authority regions in West Central Scotland that compared self-harmers (n = 32) with those who never self-harmed (n = 70). Thirty-two per cent of the looked after sample reported they had either thought about harming themselves or had actually engaged in self-harm behaviour. Self-harmers (including those who either thought about harming themselves and/or engaged in self-harm) differed from those who had never thought about harming themselves or engaged in self-harm behaviour, with significantly fewer reasons for living (RFL-A) and a more maladaptive self-critical style. The self-critical form of self-hate was found to be particularly important in predicting self-harm (thoughts and behaviours) among this sample of looked after and looked after and accommodated young people. Understanding the factors associated with self-harm and suicide risk is especially important given the already existing vulnerabilities to adverse outcomes associated with being looked after and looked after and accommodated. Strategies for the early identification of maladaptive behaviours among risk groups should take a wider approach beyond those already offered by health services. Utilising knowledge of behaviour and performance within additional key areas of young people's lives such as education could see a unique school-based intervention that can quickly and easily assess academic-related factors linked with self-harm and offer a strategy for early identification of at risk children and young people.

Coronary artery bypass grafting in a patient with hereditary hemorrhagic telangiectasia

Hereditary hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu syndrome) is an autosomal dominant condition which usually presents with recurrent epistaxis, due to the presence of mucocutaneous telangiectasia, and circulatory arteriovenous malformations (pulmonary, hepatic, cerebral and spinal). We present a patient with HHT and coronary artery disease, who underwent coronary artery bypass grafting with a successful outcome.

Transverse sinus stenting for idiopathic intracranial hypertension: a review of 52 patients and of model predictions

BACKGROUND AND PURPOSE

Transverse sinus stenosis is common in patients with IIH. While the role of transverse sinus stenosis in IIH pathogenesis remains controversial, modeling studies suggest that stent placement within a transverse sinus stenosis with a significant pressure gradient should decrease cerebral venous pressure, improve CSF resorption in the venous system, and thereby reduce intracranial (CSF) pressure, improving the symptoms of IIH and reducing papilledema. We aimed to determine if IIH could be reliably treated by stent placement in transverse sinus stenosis.

MATERIALS AND METHODS

We reviewed the clinical, venographic, and intracranial pressure data before and after stent placement in transverse sinus stenosis in 52 of our own patients with IIH unresponsive to maximum acceptable medical treatment, treated since 2001 and followed between 2 months and 9 years.

RESULTS

Before stent placement, the mean superior sagittal sinus pressure was 34 mm Hg (462 mm H(2)0) with a mean transverse sinus stenosis gradient of 20 mm Hg. The mean lumbar CSF pressure before stent placement was 322 mm H(2)O. In all 52 patients, stent placement immediately eliminated the TSS pressure gradient, rapidly improved IIH symptoms, and abolished papilledema. In 6 patients, symptom relapse (headache) was associated with increased venous pressure and recurrent stenosis adjacent to the previous stent. In these cases, placement of another stent again removed the transverse sinus stenosis pressure gradient and improved symptoms. Of the 52 patients, 49 have been cured of all IIH symptoms.

CONCLUSIONS

These findings indicate a role for transverse sinus stent placement in the management of selected patients with IIH.

Quality of life in young people with cystic fibrosis: effects of hospitalization, age and gender, and differences in parent/child perceptions

BACKGROUND

The Cystic Fibrosis Questionnaire-Revised version (CFQ-R) was used to evaluate age/gender effects on quality of life (QOL) in Australian young people with cystic fibrosis (CF) who were inpatients/outpatients aged 6-18 years. Parent/child agreement was also examined.

METHOD

The CFQ-R was completed by 18 outpatients, and 15 inpatients at admission for an acute pulmonary exacerbation to a tertiary hospital, Brisbane, Australia, as well as by parents of those aged 6-13 years.

RESULTS

Inpatients scored significantly lower than outpatients for the CFQ-R domains 'emotional state', 'social', 'body image' and 'respiratory symptoms'. Young people aged 6-13 years scored significantly better than those aged 14-18 years for 'emotional state', 'body image' and 'treatment burden'. Women perceived less 'treatment burden' than did men. Young people aged 6-13 years perceived less 'treatment burden' than did their parents. A significant interaction occurred between child/parent report and gender for 'emotional state' and 'eating disturbances'.

CONCLUSION

The CFQ-R found differences between inpatients and outpatients and between younger and older paediatric patients with CF, and between parent and child perceptions of QOL.

Addressing the challenges of renal anaemia: how nurses can make a difference

Nephrology nurses play a central and wide-ranging role in renal care. However, they have inadequate time to manage their responsibilities as patient volume increases due to earlier diagnosis and improved survival, and patient care becomes more complex. The challenge to achieve and maintain target haemoglobin levels with current agents compounds nursing workload. Early recognition and treatment of anaemia, a multidisciplinary approach and patient management algorithms can improve outcomes and nursing time utilisation. Innovative erythropoietic agents produce stable haemoglobin levels at extended administration intervals, offering time-savings. Such initiatives may allow nurses more time to focus on other aspects of patient care.

Therapeutic strategies in gastric cancer

Gastric cancer continues to be a major public health problem and is the second most common cause of cancer-related deaths in the world. These statistics led the American Society of Clinical Oncology (ASCO) International Affairs Committee to choose gastric cancer as the topic for the International Symposium held at the 2003 ASCO Annual Meeting. Dr Yoshiaki Ito will discuss the role of RUNX3 in the genesis and progression of human gastric cancer. Dr Pelayo Correa will present a compelling argument on the use of Helicobacter pylori therapy and antioxidants in selected high-risk population as chemoprevention strategies for gastric cancer. The controversy regarding the role of extended lymph node dissection for gastric cancer will be discussed by Dr Cornelis J.H. Van De Velde and Dr Mitsuru Sasako. Dr Van De Velde will present the European surgical approach to gastric cancer, and Dr Sasako will review the Japanese experience. The issues of whether certain patients benefit from more aggressive surgical dissection and the potential risks compared with benefits will also be discussed. Dr John Macdonald will discuss the role of adjuvant chemotherapy and adjuvant chemoradiotherapy in resected gastric cancer, as well as the role of chemotherapy in metastatic gastric cancer.

Oxidative stress and gene expression in sepsis

Dysregulation of the immuno-inflammatory response, as seen in sepsis, may culminate in host cell and organ damage. Lipopolysaccharide from Gram-negative bacterial cell walls induces gene activation and subsequent inflammatory mediator expression. Gene activation is regulated by a number of transcription factors at the nuclear level, of which nuclear factor kappaB appears to have a central role. The redox (reduction-oxidation) cellular balance is important for normal cellular function, including transcription factor regulation. In sepsis, a state of severe oxidative stress is encountered, with host endogenous antioxidant defences overcome. This has implications for cellular function and the regulation of gene expression. This review gives an overview of the mechanisms by which transcription factor activation and inflammatory mediator overexpression occur in sepsis, together with the events surrounding the state of oxidative stress encountered and the effects on the host's antioxidant defences. The effect of oxidative stress on transcription factor regulation is considered, together with the role of antioxidant repletion in transcription factor activation and in sepsis in general. Other interventions that may modulate transcription factor activation are also highlighted.

The appearance of a second genotype of Japanese encephalitis virus in the Australasian region

In mid-January 2000, the reappearance of Japanese encephalitis (JE) virus activity in the Australasian region was first demonstrated by the isolation of JE virus from 3 sentinel pigs on Badu Island in the Torres Strait. Further evidence of JE virus activity was revealed through the isolation of JE virus from Culex gelidus mosquitoes collected on Badu Island and the detection of specific JE virus neutralizing antibodies in 3 pigs from Saint Pauls community on Moa Island. Nucleotide sequencing and phylogenetic analyses of the premembrane and envelope genes were performed which showed that both the pig and mosquito JE virus isolates (TS00 and TS4152, respectively) clustered in genotype I, along with northern Thai, Cambodian, and Korean isolates. All previous Australasian JE virus isolates belong to genotype II, along with Malaysian and Indonesian isolates. Therefore, for the first time, the appearance and transmission of a second genotype of JE virus in the Australasian region has been demonstrated.

A new injectable bulking agent for treatment of stress urinary incontinence: results of a multicenter, randomized, controlled, double-blind study of Durasphere

OBJECTIVES

To assess the safety and effectiveness of Durasphere compared with bovine collagen in the treatment of stress urinary incontinence (SUI) due to intrinsic sphincter deficiency (ISD).

METHODS

This multicenter, randomized, controlled, double-blind trial was composed of 355 women diagnosed with SUI due to ISD and used a standardized pad test and the Stamey continence grade as the primary endpoints. The participants' ages ranged from 26 to 84 years. All patients had an abdominal leak point pressure of less than 90 cm H(2)O (average 51).

RESULTS

At 12 months after the first injection, the two materials were equivalent with respect to the improvement in continence grade and pad weight testing. Less Durasphere was injected to obtain comparable clinical results (Durasphere 4.83 mL versus bovine collagen 6.23 mL, P <0.001). When examined 1 year after the date of the last treatment, 49 (80.3%) of the 61 women treated with Durasphere showed improvement of 1 continence grade or more compared with 47 (69.1%) of 68 women treated with bovine collagen (P value for difference = 0.162). Although the adverse events reported for both groups were similar, the Durasphere group had an increased short-term risk of urgency and urinary retention.

CONCLUSIONS

The use of Durasphere for the treatment of SUI due to ISD was equally effective as bovine collagen and used less material. The U.S. Food and Drug Administration granted market approval for Durasphere on September 13, 1999. The product design and initial clinical data suggest the potential for greater durability of the clinical benefit, with the possibility of a permanent solution for SUI due to ISD in some patients.

Shame and non-disclosure: a study of the emotional isolation of people referred for psychotherapy

Thirty-four people referred to an NHS psychotherapy department were given a modified form of Oatley and Duncan's (1992) emotion diary which included questions about whether each recorded emotion had been subsequently disclosed to anyone (for example a partner, friend or professional). One week later the diaries were collected and participants interviewed. Interviews focused, among other things, on reasons for nondisclosure of recorded emotional experiences and the relationship between shame and non-disclosure. The results indicated that a majority of the emotional incidents recorded in the diaries were not disclosed (68%). This result contrasts with studies on non-clinical samples in which only approximately 10% of everyday emotions are kept secret. Qualitative analysis of the interview data revealed that participants appeared to be habitual non-disclosers of emotional and personal experiences and that non-disclosure was related to the anticipation of negative interpersonal responses to disclosure (in particular labelling and judging responses) in addition to more self-critical factors including shame. It is suggested that these results add to the existing literature on shame by illustrating the interpersonal effects of shame in a clinical sample.

Acute adrenocortical crisis: three different presentations

The adrenal cortex normally produces three principal steroid hormones: the glucocorticoid cortisol, the mineralocorticoid aldosterone, and a small quantity of sex steroids. In primary adrenocortical insufficiency, there is a deficiency of both cortisol and aldosterone with characteristic clinical and laboratory findings. In contrast, with a pituitary disorder there is isolated hypocortisolism, because its production is dependent on pituitary adrenocorticotropic hormone (ACTH), whereas aldosterone production is controlled by extracellular fluid volume, renin and serum potassium. Acute adrenocortical crisis is an absolute medical emergency and its presentation is not always typical. We describe three recent cases of acute adrenocortical crisis in our hospital who presented in three different ways in three different wards.

Assessment of limb volume by manual and automated methods in patients with limb edema or lymphedema

OBJECTIVE

Limb edema and lymphedema due to chronic venous insufficiency or mastectomy and radiotherapy negatively effects patient well-being, lifestyle, tissue blood flow, oxygenation, and wound healing. Assessment of the efficacy of volume reduction therapy requires adequate estimation of progressive limb-segment volume changes, which are usually done manually with a tape measure. This study investigated the possibility that an optoelectronic automated method--a potentially less time-consuming and less operator-dependent method--might provide adequate limb volume assessment.

DESIGN

A total of 184 manual and automated measurements of limb volume were made in 62 consecutive patients with limb edema of the legs (n = 142) and arms (n = 42).

SETTING

Clinical center.

RESULTS

Comparisons between automated and manual methods showed that inter-method volume estimates were highly correlated (4.14 +/- 0.54% for legs; 6.97 +/- 1.18% for arms). In patients with unilateral edema, the affected limb's percentage of edema was virtually identical when estimated by each method.

CONCLUSION

These findings show that the automated method of measuring limb volume is a useful alternative in suitable patients in clinical and research applications.

Vaccination with inactivated virus but not viral DNA reduces virus load following challenge with a heterologous and virulent isolate of feline immunodeficiency virus

It has been shown that cats can be protected against infection with the prototypic Petaluma strain of feline immunodeficiency virus (FIV(PET)) using vaccines based on either inactivated virus particles or replication-defective proviral DNA. However, the utility of such vaccines in the field is uncertain, given the absence of consistent protection against antigenically distinct strains and the concern that the Petaluma strain may be an unrepresentative, attenuated isolate. Since reduction of viral pathogenicity and dissemination may be useful outcomes of vaccination, even in the absence of complete protection, we tested whether either of these vaccine strategies ameliorates the early course of infection following challenge with heterologous and more virulent isolates. We now report that an inactivated virus vaccine, which generates high levels of virus neutralizing antibodies, confers reduced virus loads following challenge with two heterologous isolates, FIV(AM6) and FIV(GL8). This vaccine also prevented the marked early decline in CD4/CD8 ratio seen in FIV(GL8)-infected cats. In contrast, DNA vaccines based on either FIV(PET) or FIV(GL8), which induce cell-mediated responses but no detectable antiviral antibodies, protected a fraction of cats against infection with FIV(PET) but had no measurable effect on virus load when the infecting virus was FIV(GL8). These results indicate that the more virulent FIV(GL8) is intrinsically more resistant to vaccinal immunity than the FIV(PET) strain and that a broad spectrum of responses which includes virus neutralizing antibodies is a desirable goal for lentivirus vaccine development.

The performance of a CCD digital autoradiography imaging system

Autoradiography is a widely used technique for imaging trace quantities of radioactivity within biological samples, conventionally using photographic film. This method produces images with high spatial resolution, but it suffers from very low sensitivity and poor dynamic range. Digital autoradiography systems with greatly improved sensitivity and linearity are commercially available, but the spatial resolution is usually much less than that achieved using film. We report here the design, construction and characterization of a novel digital autoradiography system based on scientific-grade charged coupled devices (CCDs). Images of x-ray and beta emissions from radionuclides commonly used in autoradiography show that the system can perform high-speed quantitative imaging with a spatial resolution of approximately 30, microm. Using a frame by frame acquisition method the dynamic range is shown to be at least three orders of magnitude. The absolute detection efficiency is comparable to the best of the currently available digital systems. CCD images of 125I and 14C radioisotope distributions in tissue samples are superior to the equivalent film images and have been acquired in 1-10% of the time.