Medium and long-term prognosis in hospitalised older adults with multimorbidity. A prospective cohort study

BACKGROUND

Data about long-term prognosis after hospitalisation of elderly multimorbid patients remains scarce.

OBJECTIVES

Evaluate medium and long-term prognosis in hospitalised patients older than 75 years of age with multimorbidity. Explore the impact of gender, age, frailty, physical dependence, and chronic diseases on mortality over a seven-year period.

METHODS

We included prospectively all patients hospitalised for medical reasons over 75 years of age with two or more chronic illnesses in a specialised ward. Data on chronic diseases were collected using the Charlson comorbidity index and a questionnaire for disorders not included in this index. Demographic characteristics, Clinical Frailty Scale, Barthel index, and complications during hospitalisation were collected.

RESULTS

514 patients (46% males) with a mean age of 85 (± 5) years were included. The median follow-up was 755 days (interquartile range 25-75%: 76-1,342). Mortality ranged from 44% to 68%, 82% and 91% at one, three, five, and seven years. At inclusion, men were slightly younger and with lower levels of physical impairment. Nevertheless, in the multivariate analysis, men had higher mortality (p<0.001; H.R.:1.43; 95% C.I.95%:1.16-1.75). Age, Clinical Frailty Scale, Barthel, and Charlson indexes were significant predictors in the univariate and multivariate analysis (all p<0.001). Dementia and neoplastic diseases were statistically significant in the unadjusted but not the adjusted model. In a cluster analysis, three patterns of patients were identified, with increasing significant mortality differences between them (p<0.001; H.R.:1.67; 95% CI: 1.49-1.88).

CONCLUSIONS

In our cohort, individual diseases had a limited predictive prognostic capacity, while the combination of chronic illness, frailty, and physical dependence were independent predictors of survival.

A Case of Bilateral Hyperglycemic Nonketotic Chorea in an 83-year-old Woman With Normal Brain Imaging

Bilateral hyperglycemic nonketotic chorea is a rare complication of hyperglycemia. In most cases, the literature illustrates patients presenting with unilateral chorea with image findings significant for hyperintense lesions in the basal ganglia on magnetic resonance imaging (MRI) or hyperdensities on computerized tomography (CT). Here, we present a case of an 83-year-old patient who was admitted to the hospital due to acute onset of orofacial and bilateral upper extremity chorea. She had no previous history of infection, genetic mutation, neoplasms, neurodegeneration, stroke, metabolic disease, drug exposure, or autoimmune disease. Surprisingly, her MRI showed only chronic microvascular changes in periventricular white matter without basal ganglia abnormalities. However, she was noted to have marked worsening of her glycemic control over the preceding 12 months based on worsening glycated hemoglobin (HbA1c) levels and elevated serum glucose on presentation. A literature review indicates that chorea caused by hyperglycemia is at times reversible with glycemic control, but as demonstrated in our patient, this is not always necessarily the case. A similar course has only been elaborated in a few other cases in the literature. We will also review the pathogenesis, the usual disease clinical course and standard treatment from the literature.

Novel Use of Time-Resolved Magnetic Resonance Angiography to Evaluate Retrograde Lumbar Vein Flow and Epidural Venous Plexus Enhancement in Chronic Headache Patients With and Without Nutcracker Physiology

OBJECTIVE

Compression of the left renal vein by the superior mesenteric artery, known as nutcracker phenomenon (NCP), can cause retrograde flow and congestion in communicating venous systems. It has recently been speculated that NCP can result in retrograde flow and congestion of the lumbar veins and epidural venous plexus (EVP), thereby affecting the central nervous system. This study describes the novel use of time-resolved magnetic resonance angiography (trMRA) to evaluate for retrograde left second lumbar vein (L2LV) flow and early EVP enhancement in patients with chronic daily headache (CDH) with and without NCP.

METHODS

A retrospective analysis was performed of 31 patients with CDH (27 females and 4 males; median age, 38 years [range, 18-63 years]) who underwent trMRA centered over the L2LV to evaluate the direction of blood flow and presence of early EVP enhancement from May 2020 to March 2022. Descriptive statistics were performed, and anatomic associations were analyzed in patients with and without retrograde L2LV flow and early EVP enhancement. The accuracy of magnetic resonance imaging findings in detecting these flow patterns was also assessed.

RESULTS

Patients with NCP who demonstrated narrowing of the left renal vein, a positive beak sign ( P = 0.052), decreased aortomesenteric distance ( P = 0.038), and decreased SMA angle demonstrated increased rates of retrograde L2LV flow and early EVP enhancement. A positive beak sign was 83% specific, and an aortomesenteric distance of ≤6.5 mm was 61% sensitive and 83% specific for identifying retrograde L2LV flow with early regional EVP enhancement in patients with CDH.

CONCLUSIONS

Retrograde L2LV flow with early EVP enhancement in CDH patients can be effectively evaluated using trMRA and was seen with greater propensity in those patients with NCP.

The level and distribution of selected organochlorine pesticides in water of River Satluj Pakistan

The study was aimed to identify different environmental factors (selected organochlorine pesticides) affecting the river water of Satluj. River Sutlej is about 1400 kilometers long and its water is extensively used for irrigation in Punjab, located both in India and Pakistan, which was also a reason of dispute between both countries for its water share. The study area was divided into four zones, Sulemanki Zone, Islam Zone, Mailsi Syphone Zone and Panjnad Zone. Liquid Liquid Extraction (LLE) technique was used for the collected water samples followed by high performance liquid chromatography (HPLC) UV-Visible detector The current finding revealed that aldrin was not detected during summer period in water samples of SZ-1 (Sulemanki Barrage), SZ-2 and SZ-3 (Maisli Siphon) of the study area. Lindane and DDE were found more in the samples of sediments from the study area at SZ-4 ranging from 2.238-8.226 ppb and 4.234-6.876 ppb, respectively. Heaptachlor (in sediments) was found to be0.032-234 ppb only at SZ-4.Endosulfan concentrations in water (winter) at SZ-3 was 0.06 ppb and at SZ-4,it was 0.05 ppb; dieldrin in water (winter) at SZ-4 was 0.0314 ppb and heptachlor was detected at SZ-1 (0.0315 ppb) and SZ-2 (0.0310 ppb) in water during winter season, were reaching to the Maximum Concentrations Limits (MCL), while all other residues investigated were found below the MCLin all the compartments of the study area set by various agencies like WHO/FAO- Codex Alimenterious. Present findings revealed that although the organochlorine pesticides are banned for agricultural use in many countries, including Pakistan, their presence in various samples might be due to illegal use of these pesticides in the study area and its neighboring regions. The overall study area comprises of mainly urban, suburban and agricultural land being the largest cotton growing area of the country. There is a need to take serious steps to minimize water pollution caused by pesticides to achieve a healthy lifestyle.

Presence of selected organochlorine pesticides (OCPs) in sediments and biota of River Satluj, Pakistan: first report

Abstract In the developed countries, the use of OCPs (organochlorine pesticides) has been banned. However, in South Asia several of them are still in use. In Pakistan and India a constant addition of OCPs into the atmosphere has been indicated by various researchers. In this study levels of selected organochlorine pesticide residues were assessed in sediment and biota collected from four (4) water reservoirs (3 Barrages & 1 Siphon) on the River Satluj Pakistan, along 231 miles (372 km) of River stretch which was further divided into 12 sampling sites. It was aimed to find out the levels of organochlorine pesticide (OCPs) residues in sediments and from selected fish species (Labeo rohita, Wallagu attu, Cyprinus carpio) of the River Satluj Pakistan. The Organochlorine residues (seven pesticides) present in samples of sediments and biota were investigated through multi residue method, using Gas Chromatograph (GC-ECD).In the current study, the concentration of DDT, was investigated in Wallago attu (0.786-3.987 ppb), Labeo rohita (0.779-4.355 ppb) and Cyprinus carpio (1.234-5.654 ppb). DDE was also found in Cyprinus carpio (1.244-6.322 ppb), Wallag attu (0.877-4.221 ppb) and Labeo rohita (2.112-5.897 ppb). Aldrin was not observed in Labeo rohita and Wallago attu. Currently, lindane and DDE was found predominately high in the sediments of study area at SZ-4 (Panjnad Barrage) ranging (2.238-8.226 ppb) and (4.234-6.876 ppb), respectively. Heaptachlor was found only at SZ-4 (Panjnad Barrage) from the sediments with concentration ranging (0.032-234 ppb). In short all other residues investigated were found below the MCL (maximum concentration level) in all the compartments of the study area set by various agencies like WHO/FAO- Codex Alimenterious.

Impact of Spirometrically Confirmed Chronic Obstructive Pulmonary Disease on Arterial Stiffness and Surfactant Protein D After Percutaneous Coronary Intervention. The CATEPOC Study

Background

Several mechanisms have been proposed to explain why chronic obstructive pulmonary disease (COPD) impairs the prognosis of coronary events. We aimed to explore COPD variables related to a worse prognosis in patients undergoing percutaneous coronary intervention (PCI).

Methods

Patients with an acute coronary event treated by PCI were prospectively included. One month after discharge, clinical characteristics, comorbidities measured with the Charlson index, and prognostic coronary scales (logistic EuroSCORE; GRACE 2.0) were collected. Post-bronchodilator spirometry, arterial stiffness, and serum inflammatory and myocardial biomarkers were measured. Lung plasmatic biomarkers (Surfactant protein D, desmosine, and Clara cell secretory protein-16) were determined with ELISA. COPD was defined by the fixed ratio (FEV1/FVC <70%). Spirometric values were also analyzed as continuous variables using adjusted and non-adjusted ANCOVA analysis. Finally, we evaluated the presence of a respiratory pattern defined by non-stratified spirometric values and pulmonary biomarkers.

Results

A total of 164 patients with a mean age of 65 (±10) years (79% males) were included. COPD was diagnosed in 56 (34%) patients (68% previously undiagnosed). COPD patients had a longer smoking history, higher scores on the EuroSCORE (p < 0.0001) and GRACE 2.0 (p < 0.001) scales, and more comorbidities (p = 0.006). Arterial stiffness determined by pulse wave velocity was increased in COPD patients (7.35 m/s vs 6.60 m/s; p = 0.006). Serum values of high sensitive T troponin (p = 0.007) and surfactant protein D (p = 0.003) were also higher in COPD patients. FEV1% remained significantly associated with arterial stiffness and surfactant protein D in the adjusted ANCOVA analysis. In the cluster exploration, 53% of the patients had a respiratory pattern.

Conclusion

COPD affects one-third of patients with an acute coronary event and frequently remains undiagnosed. Several mechanisms, including arterial stiffness and SPD, were increased in COPD patients. Their relationship with the prognosis should be confirmed with longitudinal follow-up of the cohort.

Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

EP-415 The use of gastrografin in the management of adhesive small bowel obstruction

Background

Adhesive small bowel obstruction (aSBO) is a common surgical emergency causing high morbidity and even some mortality. The adhesions causing such small bowel obstructions (SBO) are typically the footprints of previous abdominal surgeries. The National Audit of Small bowel Obstruction (NASBO) recommended that in patients not needing emergency surgery for aSBO, gastrografin should be embedded in clinical management. An audit was undertaken to see our adherence to best practice in the management of aSBO.

Methods

Data of all patients who were admitted with SBO between April and October 2020 were obtained. This list was filtered carefully to extract patients who had aSBO. Data was collected on signs of intestinal ischaemia, administration of gastrografin and progression, need for surgery and length of stay.

Results

26 patients were admitted with aSBO in the above period. Half of all patients needed an emergency operation. Only 30% (8) received gastrografin. Conservative management was successful in 62% (5/8) of patients who received gastrografin. 38% (3/8) needed surgery as they either had signs of intestinal ischaemia or gastrografin failed to pass through. More than half of all patients (55%) who did not receive gastrografin (10/18) required surgery. The average length of stay was significantly higher in patients who did not receive gastrografin.

Conclusion

From the limited data it is evident that the use of gastrografin in patients with aSBO reduces the duration of stay and need for surgery. We have now developed and implemented a local protocol for managing such patients and we aim to re-audit in 6 months.

Antibacterial and antifungal activity of methanolic extracts of Salix alba L. against various disease causing pathogens

The present study was aimed to manifest the antibacterial and antifungal activity of methanolic extracts of Salix alba L. against seven Gram-positive and Gram-negative bacterial pathogens e.g. Streptococcus pyogenes, Staphylococcus aureus (1), S. aureus (2), Shigella sonnei, Escherichia coli (1), E. coli (2) and Neisseria gonorrhoeae and three fungal isolates from the air such as Aspergillus terreus, A. ornatus, and Rhizopus stolonifer. Two different serotypes of S. aureus and E. coli were used. The agar well-diffusion method results showed the dose-dependent response of plant extracts against bacterial and fungal strains while some organisms were found resistant e.g. E. coli (1), S. sonnei, A. terreus and R. stolonifer. The highest antibacterial activity was recorded at 17.000±1.732 mm from 100 mg/mL of leaves methanolic extracts against S. pyogenes while the activity of most of the pathogens decreased after 24 h of incubation. The highest antifungal activity was reported at 11.833±1.0 mm against A. ornatus at 50 mg/mL after 48 h of the incubation period. These experimental findings endorse the use of S. alba in ethnopharmacological formulations and suggest the use of methanolic extracts of the said plant to develop drugs to control the proliferation of resistant disease causing pathogenic microbes.

28 Shifting to Virtual MDT in the COVID-19 Era and Beyond

Aim

The COVID19 pandemic has accelerated the need for staff to work remotely. Our aim was to demonstrate how a next-generation digital platform could be used to create a virtual MDT ecosystem in order to manipulate holographic 2D and 3D images in real-time.

Method

This study involved setting up a mock virtual MDT using de-identified DICOM files from a patient who had been treated for colorectal cancer and then subsequently found to have a liver metastasis. The image file was segmented and converted into a 2D and 3D format for visualisation within Microsoft HoloLens 2 ® (smart glasses) using Holocare Solutions ® (Mixed Reality software).

Results

A seamless cross-border pipeline was developed that involved "clinician" training, DICOM segmentation and virtual connection. We successfully performed a virtual MDT with participants able to visualise and manipulate a virtual 3D organ in real-time. The digital network remotely connected sites in England and Norway. The streaming quality was stable and HIPAA compliant. Each participant could observe others as "avatars" interacting with images within the virtual ecosystem allowing image characteristics to be highlighted.

Conclusions

We successfully conducted a virtual MDT using novel hardware and software. Our intention is to conduct a large-scale study to assess the platform's effectiveness in “Real World" MDTs.

TIPS to the rescue: Preoperative Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement in a patient with caput medusae and colon cancer

Abdominal surgery in patients with cirrhosis and portal hypertension remains a challenge due to higher risk of morbidity and mortality. Preoperative elective transjugular intrahepatic portosystemic shunt (TIPS) is increasingly being used in these patient population. Herein, we report a case of 65-year-old male with biopsy-proven ascending colon cancer and cirrhosis. As a sequalae of portal hypertension, patient also had large caput medusae which posed significant challenge to the surgical approach for resection of the colon cancer. The patient was managed initially with placement of TIPS to decompress the portal pressures and caput medusae and allow safe surgical field for curative resection of the colon cancer. Following this, the patient underwent uneventful laparoscopic right hemicolectomy.

Uterineintravenous leiomyomatosis with cardiac involvement

Intravenous leiomyomatosis is a histologically benign smooth muscle tumor that arises either by direct extension of a uterine leiomyoma into the adjacent veins or by vascular intimal smooth muscle proliferation. Herein, we report the case of a 60-year-old female who was noted to have suspected cardiac mass on elective echocardiography done electively for abnormal electrocardiographic findings. Computed tomography and cardiac magnetic resonance indicated the presence of an intravenous leiomyoma originating from the uterus and extending to the inferior vena cava and right atrium. The patient was managed with a single-stage surgery involving cardiopulmonary bypass and excision of the right atrial mass, excision of the inferior vena cava tumor thrombus, and total abdominal hysterectomy and bilateral salpingo-oophorectomy.

OVERVIEW OF NEUTRON MEASUREMENTS IN JET FUSION DEVICE

The design and operation of ITER experimental fusion reactor requires the development of neutron measurement techniques and numerical tools to derive the fusion power and the radiation field in the device and in the surrounding areas. Nuclear analyses provide essential input to the conceptual design, optimisation, engineering and safety case in ITER and power plant studies. The required radiation transport calculations are extremely challenging because of the large physical extent of the reactor plant, the complexity of the geometry, and the combination of deep penetration and streaming paths. This article reports the experimental activities which are carried-out at JET to validate the neutronics measurements methods and numerical tools used in ITER and power plant design. A new deuterium-tritium campaign is proposed in 2019 at JET: the unique 14 MeV neutron yields produced will be exploited as much as possible to validate measurement techniques, codes, procedures and data currently used in ITER design thus reducing the related uncertainties and the associated risks in the machine operation.

Alopecia areata is characterized by expansion of circulating Th2/Tc2/Th22, within the skin-homing and systemic T-cell populations

BACKGROUND

Characterizing blood profile of alopecia areata (AA) is important not only for treatment advancements, but also for possibly identifying peripheral biomarkers that will eliminate the need for scalp biopsies. We aimed to compare frequencies of skin homing (CLA⁺ ) vs systemic (CLA^- ) "polar" CD4⁺ and CD8⁺ and activated T-cell subsets in AA vs atopic dermatitis (AD) and control blood.

METHODS

Flow cytometry was used to measure IFN-γ, IL-13, IL-9, IL-17, and IL-22 cytokines in CD4⁺ and CD8⁺ T cells. Inducible co-stimulator molecule (ICOS) and HLA-DR were used to define mid- and long-term T-cell activation. We compared peripheral blood from 32 moderate-to-severe AA adults with 43 moderate-to-severe AD patients and 30 age-matched controls.

RESULTS

AA patients had increased CLA⁺ /CLA^- Th2 (P < .007), CLA⁺ Tc2 (P = .04), and CLA⁺ Th22 (P < .05) frequencies than controls. Except of CLA^- Tc1 cells (P = .03), IFN-γ levels were mostly similar between AA, AD, and controls (P > .1). ICOS and HLA-DR activation were significantly higher in AA than controls (P < .05). T regulatory cells were significantly decreased in AA patients than controls (P < .01) and were correlated with activated CD8⁺ T cells and with multiple cytokine subsets (P < .05). While Th2 and Tc2 clustered with disease severity, IFN-γ producing cells were linked with AA duration.

CONCLUSIONS

Alopecia areata is accompanied by Th2/Tc2 activation in skin-homing and systemic subsets, correlating with disease severity, while IFN-γ is linked to disease chronicity. These data hint for a possible role of diverse T-cells subsets in disease pathogenesis and emphasize the systemic nature of AA supporting the need for systemic therapeutic strategies in severe patients.

Pneumatic Balloon Dilatation for Achalasia Cardia; Early & late results, a single center study

Objective:

Achalasia Cardia is treated by Pneumatic balloon dilatation, Heller’s Myotomy and recently, by Peroral Esophagaeal Myotomy. This study reports the efficacy of pneumatic balloon dilatation as a non-surgical motility in achieving relief of dysphagia, clinical improvement and recurrence. Long-term complications were reported.

Methods:

Eight hundred ninety two adult achalasia patients of both genders were treated from January 1988 till December 2011, with pneumatic balloon (Rigiflex Microvasive^®) dilatation, under fluoroscopy Barium swallow was obtained prior to and five minutes after dilatation to evaluate for efficacy of dilatation as well as for complications. Patients not responding to 30 mm balloon had repeat dilatation with 35 mm balloon after 8 weeks. All patients were enrolled in regular follow up at one, six months and yearly intervals up to a period of five years. Recurrence was defined as an increase in symptom score at 8 weeks greater than 50% of their baseline value. These patients were treated with 35 mm balloon or referred for surgical intervention.

Results:

Of 892 patients, follow up was obtained in 50% for 5 years, 9.2% for 4-years), 9.3% for 3-years, 10% for 2-years and 21.5% for 1-year of patients. One patient died after repeat dilatation. Eighty-eight patients were excluded from this analysis (20 died due to non-procedure related causes and another 68 were lost during follow up). Statistically significant improvement was noted in reduction in height and width of barium column and symptom score coupled with weight gain during follow up. Forty-eight patients were subjected to repeat dilatation with 35 mm balloon, two of these developed post-procedure perforations with one mortality. Three non-responsive patients required surgical laparoscopic myotomy. No carcinoma of esophagus was reported during follow up. One patient post dilatation, developed esophageal bezoar. A single pneumatic dilatation achieved a remission rate of 93% at four years, 90% at three years, 95% at two years and 92% at one year post dilatation.

Conclusion:

Achalasia of esophagus can be effectively and safely treated with balloon dilatation to achieve adequate short and long-term symptomatic relief with a low complication rate.

AAA Syndrome, Case Report of a Rare Disease

Triple A (Allgrove) syndrome, an autosomal recessive disease is characterized by achalasia, alacrimia and ACTH-resistant adrenal failure with progressive neurological syndrome including central, peripheral and autonomic nervous system impairment, and mild mental retardation. The triple A syndrome gene, designated AAAS, localized on chromosome 12q 13 encodes for a 546 amino acid protein called ALADIN (Alacrimia-Achlasia-Adrenal Insufficiency and Neurologic disorder). This report relates to two sisters, aged 8 and 12 years, who had vomiting, muscle weakness, alacrimia, excessive fatigue and dysphagia. Abdominal sonography, esophago-gastroduodenoscopy, barium swallow, esophageal manometry, CT scan abdomen and brain, biochemical profiles, as well as neurologic and ophthalmic evaluations were consistent with Allgrove's syndrome. Management consisted of pneumatic balloon dilatation for achalasia and initiation of cortisone therapy with successful resolution of dysphagia and other symptoms.

Epidural steroid injections: update on efficacy, safety, and newer medications for injection

The best evidence for epidural injection appears to be in the setting of radicular pain with epidural steroid and non-steroid injections more efficacious than non-epidural injections. Studies showed the efficacy of non-particulate steroid to approach the efficacy of particulate steroid and very limited comparisons demonstrated no significant difference between epidural steroid and epidural non-steroid (local anesthetic) injection. Preliminary studies evaluating epidural injection of disease modifying anti-rheumatic drugs such etanercept and tocilizumab showed conflicting results and had significant limitations. Randomized studies support better efficacy of transforaminal injection due to greater incidence of ventral epidural spread of injectate when compared to interlaminar injection. Thus, the transforaminal approach is recommended when unilateral radicular pain is limited to one nerve root. However, the transforaminal approach is associated with greater incidence of central nervous system injury, including paraplegia, attributed to embolization of the particulate steroid. Recent studies showed that non-particulate steroids potentially last as long as particulate steroids. Therefore non-particulate steroid should be used in initial transforaminal epidural injection. Future studies should look into the role of adjunct diagnostic aids, including digital subtraction angiography, in detecting intravascular injection and the ideal site of needle placement, whether it is the safe triangle or the triangle of Kambin. Finally, the role of epidural disease -modifying antirheumatic drugs in the management of back pain needs to be better elucidated.

Amelogenesis imperfecta: an introduction

Amelogenesis imperfecta (AI) is an inherited disorder that is associated with mutations in five genes (AMEL; ENAM; MMP20; KLK4 and FAM83H) with a wide range of clinical presentations (phenotypes). It affects the structure and appearance of enamel of all teeth, both in the primary and secondary dentition. In this review paper, we look at the epidemiology, classification, aetiology, clinical description and diagnosis of AI. In the following three papers of this series, we aim to describe the role of paediatric dentists, orthodontists and restorative dentists in the clinical management of patients with AI.

Long-range epigenetic silencing of chromosome 5q31 protocadherins is involved in early and late stages of colorectal tumorigenesis through modulation of oncogenic pathways

Loss of tumour suppressor gene function can occur as a result of epigenetic silencing of large chromosomal regions, referred to as long-range epigenetic silencing (LRES), and genome-wide analyses have revealed that LRES is present in many cancer types. Here we utilize Illumina Beadchip methylation array analysis to identify LRES across 800 kb of chromosome 5q31 in colorectal adenomas and carcinomas (n=34) relative to normal colonic epithelial DNA (n=6). This region encompasses 53 individual protocadherin (PCDH) genes divided among three gene clusters. Hypermethylation within these gene clusters is asynchronous; while most PCDH hypermethylation occurs early, and is apparent in adenomas, PCDHGC3 promoter methylation occurs later in the adenoma-carcinoma transition. PCDHGC3 was hypermethylated in 17/28 carcinomas (60.7%) according to methylation array analysis. Quantitative real-time reverse transcription-polymerase chain reaction showed that PCDHGC3 is the highest expressed PCDH in normal colonic epithelium, and that there was a strong reciprocal relationship between PCDHGC3 methylation and expression in carcinomas (R=-0.84). PCDH LRES patterns are reflected in colorectal tumour cell lines; adenoma cell lines are not methylated at PCDHGC3 and show abundant expression at the mRNA and protein level, while the expression is suppressed in hypermethylated carcinoma cell lines (R=-0.73). Short-interfering RNA-mediated reduction of PCDHGC3 led to a decrease of apoptosis in RG/C2 adenoma cells, and overexpression of PCDHGC3 in HCT116 cells resulted in the reduction of colony formation, consistent with tumour suppressor capabilities for PCDHGC3. Further functional analysis showed that PCDHGC3 can suppress Wnt and mammalian target of rapamycin signalling in colorectal cancer cell lines. Taken together, our data suggest that the PCDH LRES is an important tumour suppressor locus in colorectal cancer, and that PCDHGC3 may be a strong marker and driver for the adenoma-carcinoma transition.

Pulsed radiofrequency: a critical review of its efficacy

Pulsed radiofrequency is a growingly popular pain treatment modality. However, its clinical efficacy remains controversial. In this review, the available literature on pulsed radiofrequency is critically analysed to determine its clinical efficacy. Our search of the literature for pulsed radiofrequency yielded 341 citations; after reviewing the abstracts we found 51 relevant articles. There were 4 review articles: 44 articles pertained to the application of pulsed radiofrequency by an electrode placed in the vicinity of a neural structure. Of these only two were randomised controlled trials. Of the remaining 42 articles, one was a non-randomised controlled trial, three were prospective uncontrolled trials: there were six retrospective studies, 11 case reports, eight laboratory studies, two position papers, five editorials and seven items of correspondence, while one publication reported two studies. Three articles pertained to transcutaneous application of pulsed radiofrequency. Of the two randomised controlled trials, one reported efficacy of the pulsed radiofrequency while the other reported it to be ineffective. The majority of the uncontrolled and observational studies reported clinical efficacy of pulsed radiofrequency, however many of these studies had limitations. Further randomised controlled clinical trials are recommended in order for the practising pain physician to clearly understand the role of pulsed radiofrequency in the treatment of various chronic pain syndromes.

Achalasia esophagus; presenting as acute air way obstruction

Acute airway obstruction from mega-esophagus is a rare presentation of achalasia. Mega-esophagus is generally considered when the transverse width of the esophagus is more than 7 cm. A 78 year old lady presented with longstanding history of productive cough and nocturnal dyspnoea. She was seen in the emergency department with acute exacerbation of dyspnoea after a bout of vomiting, containing semi-solid food with foetid smell. Her respiratory status deteriorated rapidly with onset of stridor, and cyanosis. Chest x-ray showed widening of mediastinum due to dilated esophagus with air-fluid level. Prompt, repeated, upper respiratory tract suction was carried out. A wide bore nasogastric tube was introduced, esophagus was decompressed with a gush of air and fluid, relieving the respiratory distress. This case illustrates an unusual presentation of achalasia underscoring the need for urgent, life-saving esophageal decompression. Hypotheses, regarding the mechanism of airway compromise, as well as, treatment options are reviewed.

Treatment of multilevel degenerative disc disease with intradiscal electrothermal therapy

Intradiscal electrothermal therapy is a frequently performed procedure for the pain of internal disc disruption. It is typically performed on one to two discs; the discal treatment is followed by a long period of rest and rehabilitation. In patients with multilevel disc disease, intradiscal electrothermal therapy is either not contemplated or only one to two discs are treated at a time. This approach therefore either denies these patients the potential benefits of intradiscal electrothermal therapy or significantly prolongs the period of pain and disability. A 25-year-old female patient presented with internal disc disruption at four lumbar disc levels, diagnosed by provocative discography and post discography CT scan. All these discs were treated simultaneously by intradiscal electrothermal therapy. The patient tolerated the procedure well and responded favourably with significant and prolonged decrease in her symptoms. She reported sustained reduction in her pain and showed no clinical evidence of early neurological or infectious complications during 18 months of follow-up. This report indicates that intradiscal electrothermal therapy can be performed at multiple levels at a single sitting, compared to intradiscal electrothermal therapy performed at one to two discs at a time, this approach may obviate the need for surgery and may reduce the duration of pain and disability incurred. However, the influence of multilevel intradiscal electrothermal therapy on long-term complications or outcome is not known.

Genotype-phenotype correlation in a family with late onset CMT and an MPZ lys236del mutation

An in frame, lys236 deletion in the intracytoplasmic domain of myelin protein zero (MPZ) has recently been designated as a mutation possibly associated with Charcot-Marie-Tooth disease (CMT) but requiring further documentation. In this report we present a detailed clinical, electrophysiological, and genotype correlation in three generations of a family with the MPZ lys236del mutation and provide further evidence that this mutation is associated with CMT. The MPZ lys236del mutation is associated with an autosomal dominant, adult onset CMT phenotype, with variable penetrance ranging from an asymptomatic state to foot deformities, pedal numbness, and muscle cramps. Nerve conduction studies disclose intermediate range, somewhat non-uniform slowing of motor nerve conduction, which is accentuated in forelimb rather than distal nerve segments. Based on the contrasting finding of entirely normal conduction velocities (CV) in a genetically affected 15 year old in this family, it remains to be established whether CV slowing with this mutation is progressive in life, a pattern that would contrast with CMT1a (PMP22 gene duplication).

The validation of self-reported smoking status by analysing cotinine levels in stimulated and unstimulated saliva, serum and urine

OBJECTIVES

Cotinine, a nicotine metabolite, can be used to measure exposure to tobacco smoke. The aim of this study was to compare cotinine levels in different biological fluids collected from both smokers and non-smokers and to relate the findings to self-reported smoking status. Data were also collected concerning the acceptability of the differing methods of sample collection.

MATERIAL AND METHOD

Patients recruited to the study were asked to provide samples of urine, blood and saliva (both stimulated and unstimulated). Data collected from patients by questionnaire included information on smoking behaviour such as daily number of cigarettes and environmental exposure to smoke. After the sample collection, patients were asked to rate the acceptability of each sampling method. Samples were analysed using enzyme immunoassay (EIA) kits.

RESULTS

In total, 80 patients participated, with 49 being smokers and 31 being non-smokers. There was clear differentiation between smokers and non-smokers (P < 0.001) for all the different samples in terms of cotinine. A significant relationship was seen between cotinine and daily number of cigarettes for both salivas and urine (all P < 0.001) but not for serum. Participants found serum and urine collection methodologies 'very acceptable' (67 and 66%, respectively) whereas 9% found collection of stimulated saliva 'not at all acceptable'.

CONCLUSION

Cotinine, whatever the collection method and analysed by EIA kits, shows good differentiation between smokers and non-smokers. Salivary samples have the advantage of being non-invasive, although collection methodology is important, as cotinine levels may vary.

The new RENT family of repetitive elements in Nicotiana species harbors gene regulatory elements related to the tCUP cryptic promoter

The tCUP cryptic constitutive promoter was discovered in the tobacco genome by T-DNA (transfer DNA) tagging with a promoterless GUS-nos gene. Here, we show that the portion of the tCUP sequence containing a variety of cryptic gene regulatory elements is related to a new family of moderately repetitive sequences (10(2) copies), the RENT (repetitive element from Nicotiana tabacum) family. The RENT family is found only in certain Nicotiana species. Five RENT elements were cloned and sequenced. The RENT elements are a minimum of 5 kb in length and share 80-90% sequence similarity throughout their length. The 5' termini are the same in the isolated RENT family members and are characterized by a conserved border sequence (TGTTGA(T or C)ACCCAATTTT(T or C)). The 3' ends of RENT sequence similarity vary in location and sequence. The tCUP cryptic promoter originated from a unique truncated RENT element that interrupts a phytochelatin synthase-like gene that may have undergone rearrangements prior to or resulting from T-DNA insertion. No evidence was found for expressed coding regions within the RENT elements; however, like the cryptic gene regulatory elements within the tCUP sequence, the isolated RENT elements possess promoter activity and translational enhancer activity.

Wilms' tumor: a paradigm for the new genetics

Carcinogenesis can be triggered by a diverse range of molecular lesions, a variety of which can be illustrated by Wilm's tumor (WT), a pediatric kidney cancer. Molecular defects observed in WTs include several independent targets and mechanisms best exemplified by changes on the short arm of chromosome 11. This article will review the molecular pathology of WT and emphasize the broader ramifications for cancer genetics. Consideration will be given to carcinogenic pathways, novel cellular molecules, and technologies that will assist in the rapid interpretation and assimilation of DNA sequence data arising from the sequencing of the human genome.

A constitutive gene expression system derived from the tCUP cryptic promoter elements

A limited number of constitutive promoters have been used to direct transgene expression in plants and they are often derived from non-plant sources. Here, we describe novel gene-regulatory elements which are associated with a cryptic constitutive promoter from tobacco, tCUP, and modifications that were made to create a strong gene-expression system that is effective across all living cell types from a wide range of plant species, including several important crops ( Arabidopsis, canola, flax, alfalfa, tobacco). The tCUP 5' untranslated region was mutated to eliminate translational interference by upstream ATGs, and the influence of the Kozak consensus sequence on the levels of a beta-glucuronidase (GUS) reporter gene activity was demonstrated. These modifications resulted in expression that was greatly enhanced in all organs. A TATA consensus sequence was added to the core promoter to complement an existing Initiator (Inr) sequence. Although this addition was known to elevate core promoter activity by 3-fold the additive effect on the overall gene-expression system was marginal in all of the transgenic plants tested. Two transcriptional enhancers were identified and the region containing them were oligomerized, yielding a significant increase in marker gene-expression in some but not all plant species. In general, the enhanced tCUP gene-expression system generated levels of GUS activity which exceeded that of the 35S promoter in most plant species and the elevation in activity occurred uniformly among the various plant organs. The potential benefit of cryptic elements for the construction of gene-expression systems for crop species is discussed

Ectopic expression of an Arabidopsis calmodulin-like domain protein kinase-enhanced NADPH oxidase activity and oxidative burst in tomato protoplasts

Among plant defense responses to pathogen attack, the release of active oxygen species (AOS), termed the oxidative burst, may affect the attacking pathogen and the host plant cells at the infection site, thereby limiting the spread of the pathogen. Plasma membrane-associated NADPH oxidase represents a key enzyme in mediating the oxidative burst. The mechanisms of NADPH oxidase activation, however, remains unclear. Ectopic expression of AK1-6H, an Arabidopsis calmodulin-like domain protein kinase (CDPK) in tomato protoplasts enhanced plasma membrane-associated NADPH oxidase activity. Arabidopsis protein phosphatase 2A abolished this enhancement, whereas Arabidopsis dual-specificity protein tyrosine phosphatase 1 or maize protein phosphatase 1 had no effect tMEK2MUT, a constitutively activated, mitogen-activated protein kinase kinase from tomato, did not enhance NADPH oxidase activity when overexpressed. In a cell-free system, AK1-6H moderately stimulated the NADPH oxidase activity on plasma membrane. AK1-6H, but not tMEK2MUT, also enhanced production of AOS in intact protoplasts. Our results show that ectopic expression of a heterologous CDPK can enhance NADPH oxidase activity and stimulate an oxidative burst in tomato protoplasts.

Influence of age and height on nerve conduction

Previous studies demonstrated age- and height-related slowing of nerve conduction velocity (NCV) and reduction in nerve response amplitude. Unfortunately, many studies examined discontinuous populations, preventing regression analysis. The correlation coefficients of available studies vary widely, preventing clear conclusions. We retrospectively examined 3969 clinically normal subjects ranging in age from 20 to 95 years from a total of 22,420 electrodiagnostic studies done between 1986 and 1998. The correlation of NCV with height was stronger than with age. Regression equations using both factors account for 12--27% of the variance. Responses were seen in the majority of patients aged 70 years and older, but the percentage of normals who had no response increased with advancing age. Age was strongly inversely correlated with the amplitudes of both sensory and motor responses, accounting for 7--16% of the variance. Regression equations using both height and age improved this correlation, accounting for 7--22% of the variance. Therefore, both height and age must be taken into consideration when normal values are developed.

Enhancers and core promoter elements are essential for the activity of a cryptic gene activation sequence from tobacco, tCUP

Cryptic gene regulatory elements are sequences that are inactive at their native locations in the genome but have the ability to become functional when positioned adjacent to genes. We have recently isolated such a cryptic sequence from tobacco, tCUP, that can act as a promoter. A 135-bp fragment spanning extending from position -197 to -62, relative to the transcription start site, was found to promote GUS expression in all of the major organs of transgenic Arabidopsis plants. Furthermore, this 135-bp fragment complemented the -46 minimal promoter of CaMV 35S and conferred constitutive expression on transgenic Arabidopsis plants. An electrophoretic mobility-shift assay showed that nuclear proteins prepared from tobacco leaves interact with the 135-bp fragment. tCUP has a core promoter that lacks the TATA consensus sequence but addition of a TATA-box sequence increased the core promoter activity by three-fold. The sequence surrounding the transcription start site of tCUP has sequence similarity with the initiator element (Inr), and deletion of this sequence significantly reduced promoter activity, suggesting that an essential Inr element may exist in the tCUP core promoter. Fusion of the GCC-box enhancer element from pathogenesis-related genes to the core promoter elevated tCUP core promoter activity. Our study indicates that cryptic promoters are similar in composition and organization to promoters associated with expressed genes and that their promoter elements can be combined to create composite promoters that are fully functional. This data provides direct evidence that the expression pattern of plant genes can be influenced by cryptic gene regulatory elements when they are brought into juxtaposition with genes through DNA rearrangements.

Retrograde carbon monoxide is required for induction of long-term potentiation in rat superior cervical ganglion

Carbon monoxide (CO), produced in the body by the enzyme heme oxygenase (HO), has been suggested as a retrograde synaptic messenger with a prominent role in the long-term potentiation (LTP) of certain areas of the brain. LTP of sympathetic ganglia is 5-HT(3) receptor-dependent and has been shown to require nitric oxide for the maintenance, but not for the induction, phase. We investigated the possibility of CO being required for the induction of ganglionic LTP. Pretreatment of rat isolated superior cervical ganglia with oxyhemoglobin (25-100 microm) completely blocked LTP. In the same ganglia, prolonged washout of oxyhemoglobin did not uncover any potentiation of the compound action potential. Oxyhemoglobin had no significant effect on the maintenance phase in ganglia with established LTP. Pretreatment of ganglia with the HO inhibitor zinc protoporphyrin-IX (ZnPP) (10 microm) completely and irreversibly prevented the expression of tetanus-evoked LTP. However, in the same ganglia, after superfusion of CO in the presence of ZnPP, tetanic stimulation readily evoked LTP. No effect was seen on the maintenance phase when ZnPP was superfused on ganglia with established LTP. Pretreatment of ganglia with the 5-HT(3) receptor antagonist ondansetron (0.4 microm) alone completely and irreversibly blocked LTP. However, in the presence of CO, ondansetron did not block LTP. These results suggest that activation of 5-HT(3) receptors may be involved in the production of CO. The results also suggest that CO, probably originating outside the presynaptic nerve terminal, is involved in the induction of LTP.

Activation of tomato PR and wound-related genes by a mutagenized tomato MAP kinase kinase through divergent pathways

A mitogen-activated protein kinase kinase (MAPKK) gene, tMEK2, was isolated from tomato cv. Bonny Best. By mutagenesis, a permanently active variant, tMEK2MUT, was created. Both wild-type tMEK2 and mutant tMEK2MUT were driven by a newly described strong plant constitutive promoter, tCUP, in a tomato protoplast transient gene expression system. Pathogenesis-related genes, PRlb1, PR3 and Twi1, and a wound-inducible gene, ER5, were activated by tMEK2MUT. Specific inhibitors of p38 class MAPK inhibited tMEK2MUT-induced activation of PR3 and ER5 genes but not that of the PRlb1 or Twi1 gene. Arabidopsis dual-specificity protein tyrosine phosphatase 1 (DsPTP1) and maize protein phosphatase 1 (PP1) inhibited tMEK2MUT-induced activation of the ER5 gene and the Twi1 gene, respectively, whereas PRlb1 and PR3 were not affected by either AtDsPTP1, or maize PP1, or Arabidopsis protein phosphatase 2A (PP2A). We have demonstrated for the first time that a single MAPKK activates an array of PR and wound-related genes. Our observation indicates that the activation of the genes downstream of tMEK2 occurs through divergent pathways and that tMEK2 may play an important role in the interaction of signal transduction pathways that mediate responses to both biotic (e.g. disease) and abiotic stresses (e.g. wound responsiveness).