Totally endoscopic cartilage tympanoplasty: a hierarchical task analysis

BACKGROUND

Totally endoscopic ear surgery is a novel method of conducting otological surgery. Hierarchical task analysis and the systematic human error reduction and prediction approach ('SHERPA') are valuable tools that can effectively deconstruct the technical and non-technical skills required to successfully complete a surgical procedure.

METHODS

Twenty-five endoscopic tragal cartilage tympanoplasties were observed, to identify the tasks and subtasks required for completion of totally endoscopic tragal cartilage tympanoplasty. The systematic human error reduction and prediction approach was used to identify the potential risks and methods, to reduce or remediate these risks.

RESULTS

A hierarchical task analysis was performed, identifying 8 tasks and 50 subtasks for a safe approach to completing totally endoscopic tragal cartilage tympanoplasty. A risk score for each subtask was calculated to produce a systematic human error reduction and prediction approach and to highlight potential errors.

CONCLUSION

This hierarchical task analysis allowed for quick reference to a correct method of endoscopic tympanoplasty. The systematic human error reduction and prediction approach was employed to reduce the risks associated with undergoing endoscopic tympanoplasty, to improve patient safety.

907 Reduction of Nasal Fractures During COVID-19: A Single-Centre Experience

Introduction

The utilization of local or regional anaesthesia for manipulation of nasal fractures (MNF) avoids the need for general anaesthetic (GA), and the risk associated with instrumentation of the airway during the COVID-19 pandemic. Furthermore, MNF under local anaesthetic (LA) provides similar results with regards to cosmesis and patient satisfaction. We present our experience of performing MNF under LA during the COVID-19 pandemic.

Method

A single-centre, prospective study of all patients undergoing MNF under LA was conducted (13th July/20–11thSeptember/20). Following reduction, pain scores and patient satisfaction surveys were administered.

Results

A total of 25 patients (M/F:16/9, median age, 25.6yr (14-52yr)) were enrolled. The majority of patients received either one or two instillations of LA (n = 19, 76%). Pain reported during the MNF procedure was 4.4/10, whilst pain during LA administration was reported as 3.2/10. 80% of patients felt instillation of LA was less painful than expected. 88% of respondents tolerated the LA well, and only 8% would have opted for general anaesthetic. 24 (96%) participants were happy with the cosmetic result.

Discussion

MNF under LA is a safe and effective alternative to MNF under GA. More literature is needed to define the best method of administering LA prior to performing MNF.

Improving peri-operative psychosocial interventions for children with autism spectrum disorder undergoing ENT procedures

OBJECTIVES

Children with autism spectrum disorder face a broad range of communication and sensory challenges. Many of these children also have chronic ENT issues. This study aims to better understand these challenges and improve our services for children with autism spectrum disorder.

METHODS

Questionnaires and semi-structured interviews were carried out with parents of children with autism spectrum disorder.

RESULTS

Thirty-four individuals participated, comprising 9 caregivers and 25 staff members. All parents recognised their critical roles in understanding their children's special needs and sensitivities. Parents and staff stressed the importance of a partnership role that inquired about unique needs, leading to environmental modifications for individual children.

CONCLUSION

The importance of listening to and involving caregivers is a fundamental tenet; parents must be recognised as the experts. Uncertainty must be kept to a minimum, with clear communication in a structured, low-arousal environment for these children. We have listened to parents and staff, and developed a social story.

Whole-exome sequencing points to considerable genetic heterogeneity of cerebral palsy

Cerebral palsy (CP) is a common, clinically heterogeneous group of disorders affecting movement and posture. Its prevalence has changed little in 50 years and the causes remain largely unknown. The genetic contribution to CP causation has been predicted to be ~2%. We performed whole-exome sequencing of 183 cases with CP including both parents (98 cases) or one parent (67 cases) and 18 singleton cases (no parental DNA). We identified and validated 61 de novo protein-altering variants in 43 out of 98 (44%) case-parent trios. Initial prioritization of variants for causality was by mutation type, whether they were known or predicted to be deleterious and whether they occurred in known disease genes whose clinical spectrum overlaps CP. Further, prioritization used two multidimensional frameworks-the Residual Variation Intolerance Score and the Combined Annotation-dependent Depletion score. Ten de novo mutations in three previously identified disease genes (TUBA1A (n=2), SCN8A (n=1) and KDM5C (n=1)) and in six novel candidate CP genes (AGAP1, JHDM1D, MAST1, NAA35, RFX2 and WIPI2) were predicted to be potentially pathogenic for CP. In addition, we identified four predicted pathogenic, hemizygous variants on chromosome X in two known disease genes, L1CAM and PAK3, and in two novel candidate CP genes, CD99L2 and TENM1. In total, 14% of CP cases, by strict criteria, had a potentially disease-causing gene variant. Half were in novel genes. The genetic heterogeneity highlights the complexity of the genetic contribution to CP. Function and pathway studies are required to establish the causative role of these putative pathogenic CP genes.

Two rare cases of Epstein-Barr virus-associated lymphoproliferative disorders in inflammatory bowel disease patients on thiopurines and other immunosuppressive medications

The setting of chronic immunosuppression in inflammatory bowel disease (IBD) may promote the proliferation of Epstein-Barr virus-positive neoplastic clones. We report two rare cases of Epstein-Barr virus-associated lymphoproliferative disorder in IBD patients: one resembled lymphomatoid granulomatosis, and the other was a lymphoma resembling Hodgkin lymphoma. There are currently no guidelines for the prevention of lymphoproliferative disorder in IBD patients on immunosuppressive therapy.

Cognitive exposure versus avoidance in patients with chronic pain: adherence matters

BACKGROUND

Behavioural exposure methods can reduce pain-avoidance behaviours, but outcomes vary. One possible explanation is that patients employ cognitive (experiential) avoidance during behavioural exposure. If so, reducing cognitive avoidance during behavioural exposure should help. One option is interoceptive exposure (IE), which involves sustained exposure (via attention) to pain sensations. In order to test if IE could improve outcomes from behavioural exposure, this study with mixed chronic pain patients compared outcomes from a cognitive behavioural therapy (CBT) pain management programme incorporating either IE or distraction from pain.

METHODS

One hundred forty chronic pain patients were randomly assigned to CBT + IE or CBT + distraction. Outcome measures included pain, disability, depression and medication. Measures reflecting degree of threat of pain were also employed (catastrophizing, fear-avoidance, pain self-efficacy and pain acceptance). An intention-to-treat approach, using mixed-effects model repeated measures, as well as conventional inferential statistical tests, effect sizes and reliable change indices were employed to evaluate the outcomes up to 1-year post-treatment.

RESULTS

Significant improvements were achieved by both treatment conditions on all outcome measures and on measures reflecting the threatening nature of pain, with no differences between treatment conditions.

CONCLUSIONS

The addition of IE to behavioural exposure did not improve outcomes. However, higher adherence to either attentional strategy was associated with larger effect sizes on all measures, suggesting factors shared by the two treatments could have contributed to the outcomes. Taken as a whole, the results suggest that increasing adherence to treatment strategies, possibly by motivational measures, would improve the overall outcomes of these interventions.

Adjunctive colposcopy technologies for examination of the uterine cervix--DySIS, LuViva Advanced Cervical Scan and Niris Imaging System: a systematic review and economic evaluation

BACKGROUND

Women in England (aged 25-64 years) are invited for cervical screening every 3-5 years to assess for cervical intraepithelial neoplasia (CIN) or cancer. CIN is a term describing abnormal changes in the cells of the cervix, ranging from CIN1 to CIN3, which is precancerous. Colposcopy is used to visualise the cervix. Three adjunctive colposcopy technologies for examination of the cervix have been included in this assessment: Dynamic Spectral Imaging System (DySIS), the LuViva Advanced Cervical Scan and the Niris Imaging System.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of adjunctive colposcopy technologies for examination of the uterine cervix for patients referred for colposcopy through the NHS Cervical Screening Programme.

DATA SOURCES

Sixteen electronic databases [Allied and Complementary Medicine Database (AMED), BIOSIS Previews, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Database of Abstracts of Reviews of Effects (DARE), EMBASE, Health Management Information Consortium (HMIC), Health Technology Assessment (HTA) database; Inspec, Inside Conferences, MEDLINE, NHS Economic Evaluation Database (NHS EED), PASCAL, Science Citation Index Expanded (SCIE) and Science Citation Index (SCI) - Conference Proceedings], and two clinical trial registries [ClinicalTrials.gov and Current Controlled Trials (CCT)] were searched to September-October 2011.

REVIEW METHODS

Studies comparing DySIS, LuViva or Niris with conventional colposcopy were sought; a narrative synthesis was undertaken. A decision-analytic model was developed, which measured outcomes in terms of quality-adjusted life-years (QALYs) and costs were evaluated from the perspective of the NHS and Personal Social Services with a time horizon of 50 years.

RESULTS

Six studies were included: two studies of DySIS, one study of LuViva and three studies of Niris. The DySIS studies were well reported and had a low risk of bias; they found higher sensitivity with DySIS (both the DySISmap alone and in combination with colposcopy) than colposcopy alone for identifying CIN2+ disease, although specificity was lower with DySIS. The studies of LuViva and Niris were poorly reported and had limitations, which indicated that their results were subject to a high risk of bias; the results of these studies cannot be considered reliable. The base-case cost-effectiveness analysis suggests that both DySIS treatment options are less costly and more effective than colposcopy alone in the overall weighted population; these results were robust to the ranges tested in the sensitivity analysis. DySISmap alone was more costly and more effective in several of the referral groups but the incremental cost-effectiveness ratio (ICER) was never higher than £1687 per QALY. DySIS plus colposcopy was less costly and more effective in all reasons for referral. Only indicative analyses were carried out on Niris and LuViva and no conclusions could be made on their cost-effectiveness.

LIMITATIONS

The assessment is limited by the available evidence on the new technologies, natural history of the disease area and current treatment patterns.

CONCLUSIONS

DySIS, particularly in combination with colposcopy, has higher sensitivity than colposcopy alone. There is no reliable evidence on the clinical effectiveness of LuViva and Niris. DySIS plus colposcopy appears to be less costly and more effective than both the DySISmap alone and colposcopy alone; these results were robust to the sensitivity analyses undertaken. Given the lack of reliable evidence on LuViva and Niris, no conclusions on their potential cost-effectiveness can be drawn. There is some uncertainty about how generalisable these findings will be to the population of women referred for colposcopy in the future, owing to the introduction of the human papillomavirus (HPV) triage test and uptake of the HPV vaccine.

A systematic review of photodynamic therapy in the treatment of pre-cancerous skin conditions, Barrett's oesophagus and cancers of the biliary tract, brain, head and neck, lung, oesophagus and skin

BACKGROUND

Photodynamic therapy (PDT) is the use of a light-sensitive drug, in combination with light of a visible wavelength, to destroy target cells. PDT is used either as a primary treatment or as an adjunctive treatment. It is fairly well accepted in clinical practice for some types of skin cancer but has yet to be fully explored as a treatment for other forms of cancer.

OBJECTIVE

To systematically review the clinical effectiveness and safety of PDT in the treatment of Barrett's oesophagus, pre-cancerous skin conditions and the following cancers: biliary tract, brain, head and neck, lung, oesophageal and skin.

DATA SOURCES

The search strategy included searching electronic databases (between August and October 2008), followed by update searches in May 2009, along with relevant bibliographies, existing reviews, conference abstracts and contact with experts in the field.

STUDY DESIGNS

Randomised controlled trials (RCTs) in skin conditions and Barrett's oesophagus, non-randomised trials for all other sites.

PARTICIPANTS

People with Barrett's oesophagus, pre-cancerous skin conditions or primary cancer in the following sites: biliary tract, brain, head and neck, lung, oesophageal and skin.

INTERVENTION

Any type of PDT for either curative or palliative treatment.

COMPARATORS

Any comparator including differing applications of PDT treatments (relevant comparators varied according to the condition).

MAIN OUTCOMES

The outcomes measured were mortality, morbidity, quality of life, adverse events and resource use.

REVIEW METHODS

A standardised data extraction form was used. The quality of RCTs and non-randomised controlled studies was assessed using standard checklists. Data extracted from the studies were tabulated and discussed in a narrative synthesis, and the influence of study quality on results was discussed. Meta-analysis was used to estimate a summary measure of effect on relevant outcomes, with assessment of both clinical and statistical heterogeneity. Two reviewers independently screened all titles and abstracts, and data extracted and quality assessed the trials, with discrepancies resolved by discussion or referral to a third reviewer. A scoping review was also undertaken.

RESULTS

Overall, 88 trials reported in 141 publications were included, with some trials covering more than one condition. For actinic keratosis (AK), the only clear evidence of effectiveness was that PDT appeared to be superior to placebo. For Bowen's disease, better outcomes with PDT were suggested when compared with cryotherapy or fluorouracil. For basal cell carcinoma (BCC), PDT may result in similar lesion response rates to surgery or cryotherapy but with better cosmetic outcomes. For nodular lesions, PDT appeared to be superior to placebo and less effective than surgery but suggestive of better cosmetic outcome. For Barrett's oesophagus, PDT in addition to omeprazole appeared to be more effective than omeprazole alone at long-term ablation of high-grade dysplasia and slowing/preventing progression to cancer. No firm conclusions could be drawn for PDT in oesophageal cancer. Further research into the role of PDT in lung cancer is needed. For cholangiocarcinoma, PDT may improve survival when compared with stenting alone. There was limited evidence on PDT for brain cancer and cancers of the head and neck. A wide variety of photosensitisers were used and, overall, no serious adverse effects were linked to PDT.

LIMITATIONS

There were few well-conducted, adequately powered RCTs, and quality of life (QoL) and resource outcomes were under-reported. Problems were identified with reporting of key study features and quality parameters, making the reliability of some studies uncertain. Methodological limitations and gaps in the evidence base made it difficult to draw firm conclusions.

CONCLUSIONS

Evidence of effectiveness was found for PDT in the treatment of AK and nodular BCC in relation to placebo, and possibly for treating Barrett's oesophagus. However, the effectiveness of PDT in relation to other treatments is not yet apparent. High-quality trials are needed to compare PDT with relevant comparators for all meaningful outcomes, including QoL and adverse effects. Further research is also needed on patient experience of PDT, as well as on the cost-effectiveness of PDT.

Identifying predictors of medically-attended injuries to young children: do child or parent behavioural attributes matter?

OBJECTIVE

To investigate whether one can differentiate injured and uninjured young children based on child behavioural attributes or indices of caregiver supervision.

METHOD

A matched case-control design was used in which case participants were children presenting to an emergency department for treatment for an injury and age/sex matched control participants presented for illness-related reasons. During structured phone interviews about supervision parents reported on general supervisory practices (standardised questionnaire) and specific practices corresponding to time of injury (cases) or the last time their child engaged in the activity that incited their match's injury (controls). Parents also reported on child behavioural attributes that have been linked to child risk taking in prior research (inhibitory control, sensation seeking).

RESULTS

Results revealed no group differences in child behavioural attributes; however, the control group received more supervision both in general (OR = 4.82, 95% CI 1.89 to 12.33) and during the specified activity that led to injury in cases (OR = 5.38, 95% CI 2.13 to 13.58).

CONCLUSION

These findings confirm past speculation that caregiver supervision influences children's risk of medically-attended injury and highlight the importance of targeting supervision in child-injury prevention interventions.

Prevalence of anaemia in patients with diabetes mellitus

BACKGROUND

Anaemia is an increasingly recognised entity in patients with diabetes mellitus.

AIMS

We aimed to determine the prevalence of anaemia in our population of patients with diabetes, and to examine the factors associated with anaemia.

METHODS

The haemoglobin (Hb) levels in a consecutive series of patients attending for annual review of their diabetes over a three-month period were measured. Patients were classified as anaemic as per the WHO criteria.

RESULTS

During the period of study, 270 patients attended for review. Eleven per cent of males and 16% of females were anaemic. Seventy four per cent of anaemic patients had a serum creatinine <110micromol/l and 72% of anaemic patients had a calculated creatinine clearance of >60ml/min.

CONCLUSIONS

Anaemia was relatively common in patients attending for routine outpatient diabetes clinic review. The high prevalence of anaemia supports the routine screening for anaemia in the diabetes out-patient clinic, including in those without overt nephropathy.

The Parent Supervision Attributes Profile Questionnaire: a measure of supervision relevant to children's risk of unintentional injury

OBJECTIVE

To further establish the psychometric properties of the Parent Supervision Attributes Profile Questionnaire (PSAPQ), a questionnaire measure of parent supervision that is relevant to understanding risk of unintentional injury among children 2 through 5 years of age.

METHODS

To assess test-retest reliability, parents completed the PSAPQ twice, with a one month interval. Internal consistency estimates for the PSAPQ were also computed. Confirmatory factor analyses were applied to the data to assess the four factor structure of the instrument by assessing the convergent and divergent validity of the subscales and their respective items.

RESULTS

Test-retest reliability and internal consistency scores were good, exceeding 0.70 for all subscales. Factor analyses confirmed the hypothesized model--namely that the 29 item questionnaire comprised four unique factors: protectiveness, supervision beliefs, risk tolerance, and fate influences on child safety.

CONCLUSIONS

Previous tests comparing the PSAPQ with indices of actual supervision and children's injury history scores revealed good criterion validity. The present assessment of the PSAPQ revealed good reliability (test-retest reliability, internal consistency) and established the convergent and divergent validity of the four factors. Thus, the PSAPQ has proven to have strong psychometric properties, making it a unique and useful measure for researchers interested in studying links between supervision and young children's risks of unintentional injury.

Target blood pressure for patients with type 2 diabetes is difficult to achieve in the setting of a busy diabetes clinic

BACKGROUND

Target blood pressure control in patients with type 2 diabetes should be 130/85 mmHg or less; however, it is not clear how achievable this target is in clinical practice.

AIM

To assess the adequacy of blood pressure control in patients with type 2 diabetes attending a busy outpatient clinic.

METHODS

One hundred and eight patients with type 2 diabetes were assessed for the presence of hypertension using a cut-off value of 130/85 mmHg. Antihypertensive treatment and diabetic complications were evaluated.

RESULTS

Hypertension was present in 67% of patients, in whom 90% were receiving anti-hypertensive treatment. Forty-nine per cent of the treated patients achieved target blood pressure. Of the undertreated patients, 55% were on one antihypertensive agent, 30% were on two agents and 15% were on three or more agents. The corresponding figures for the adequately treated patients were 28%, 31% and 41%, respectively (p=0.03).

CONCLUSION

Adequate blood pressure control was underachieved in this patient group underlying the difficulty in treating blood pressure to target values in patients with type 2 diabetes in the setting of outpatient diabetes clinics. A more aggressive strategy, in particular the use of multiple antihypertensive agents should be adopted.

Malnutrition: trials and triumphs

Severe malnutrition is uncommon but often fatal, particularly in very young infants or when oedema is present. Another major contributor to mortality is undiagnosed infection. Three pilot studies have recently been performed in severely malnourished patients in therapeutic feeding centres in sub-Saharan Africa. In each, a practical management problem was addressed and a potential solution tested. Three conclusions were reached: young breastfeeding infants were best managed using a supplemented suckling technique; routine antibiotics from admission reduced mortality; and in adults with oedematous malnutrition, therapeutic diets with a lower-than-usual protein:energy ratio were effective in reducing mortality and permitting catch-up weight gain.

Amino-terminal processing of chemokine ENA-78 regulates biological activity

Epithelial cell-derived neutrophil-activating protein-78 (ENA-78) is a potent stimulator of neutrophils, inducing a variety of biological responses such as chemotaxis, enzyme release, up-regulation of surface receptors, and intracellular calcium mobilization. Proteolysis of ENA-78 with cathepsin G and chymotrypsin yielded a time-dependent increase in elastase-releasing activity, predicting the formation of truncation products with higher potency than native ENA-78. To investigate the biological implications of progressive truncation of ENA-78, the N-terminal variants ENA(5-78), ENA(9-78), and ENA(10-78) were cloned and expressed in E. coli. When tested in the neutrophil elastase release assay, the variants ENA(5-78) and ENA(9-78) had a 2-3-fold higher potency than full-length ENA-78, while ENA(10-78) was 3-fold less potent. In the chemotaxis assay, the variant ENA(5-78) exhibited an 8-fold and ENA(9-78) a 2-fold higher potency than native ENA-78. ENA(10-78), conversely, was 10-fold less potent, but reached a comparable efficacy to ENA-78 at 10(-)7 M concentration. In summary, the rank order in potency with respect to elastase release was ENA(9-78) > ENA(5-78) > ENA-78 > ENA(10-78), while for chemotaxis it was ENA(5-78) > ENA(9-78) > ENA-78 > ENA(10-78). Variant ENA(5-78) had a higher overall potency and efficiency for chemotaxis than interleukin-8 (IL-8), while ENA(9-78) exhibited a higher efficiency at concentrations of 1-100 nM. The fact that neutrophil cathepsin G produces the stable ENA(9-78) variant in vitro strongly suggests a role for this N-terminal proteolysis during inflammatory processes in vivo.

Cutaneous squamoproliferative lesions in renal transplant recipients. Differentiation from lesions in immunocompetent patients

Of 291 immunosuppressed renal transplant recipients (RTRs) with surviving allografts attending the Royal London Hospital, 171 patients (59%) were found to have warty keratoses. On histological analysis, the lesions in 50 patients (17%) showed partial-thickness dysplasia, and 34 (12%) had one or more invasive squamous cell carcinoma (SCC) and/or one or more in situ SCC or full-thickness dysplasia. We examined the claim that squamoproliferative lesions in RTRs possess distinctive histopathological features that differ from those of similar lesions occurring sporadically in the nonimmunosuppressed population. We compared 40 squamoproliferative lesions from RTRs with 40 matched squamoproliferative lesions from nonimmunosuppressed patients; lesions were coded and their source was unknown to the assessors. Two dermatopathologists independently assessed the cases and gave scores for 11 histological features that have been reported to be characteristic of such lesions in the immunosuppressed population. These included a warty architecture, koilocytes, and multinucleate giant cells. Using these criteria, it was not possible to distinguish lesions of immunosuppressed patients from those of immunocompetent people.

A computer tomographic classification system for the displaced intraarticular fracture of the os calcis

The treatment of the displaced intraarticular fracture of the os calcis continues to be controversial. One of the reasons for this is the lack of a workable classification system which would allow comparison among different treatment modalities. Plain radiographs are unable to depict the complex three-dimensional pathology of this fracture. Computed tomography (CT) scanning, however, has the potential to quite accurately depict all components of this injury. At our hospital, a five-part, CT-based classification system has been utilized. This system suggests which fractures will do well with conservative care, and which fractures are amenable to operative stabilization.

Polymorphic light eruption: prevalence in Australia and England

The prevalence and clinical characteristics of polymorphic light eruption were assessed by a questionnaire survey of 172, 196 and 182 subjects in Perth, Ballarat and London, respectively. The prevalence was 5.2% in Perth (latitude 32 degrees), 3.6% in Ballarat (37.5 degrees) and 14.8% in London (51.5 degrees). The age distribution (mostly first three decades) and male:female ratio (1:3) was similar for affected individuals in all three areas. Development of tolerance during the summer was more common in Perth (66.7%) and Ballarat (71.4%) than in London (40.7%).

Nystagmus and joint position sensation: their importance in posterior occipitocervical fusion in rheumatoid arthritis

It is widely believed that brain stem dysfunction and cranial nerve palsies in patients with rheumatoid arthritis (RA) are common and related to the vertical translocation of the odontoid process. In our database of 235 patients with seropositive RA and craniocervical junction involvement, we have found a very low incidence of such problems. Long tract signs were common, but loss of proprioception (joint position sensation) as the sole neurologic deficit was rare. Nystagmus was found to be associated with the tonsillar herniation of a Chiari 1 malformation and loss of joint position sensation with severe compression of the posterior aspect of the spinal cord at the craniocervical junction. The implications for posterior occipitocervical fusion, particularly by sublaminar wiring, are discussed.

Anti-myeloperoxidase antibodies in patients with rheumatoid arthritis: prevalence, clinical correlates, and IgG subclass

OBJECTIVES

To determine the prevalence and clinical associations of autoantibodies to myeloperoxidase (MPO) in an unselected series of well-characterised outpatients with rheumatoid arthritis (RA) and to compare the distribution of IgG subclasses of anti-MPO antibodies in these patients with that in patients with systemic vasculitis.

PATIENTS AND METHODS

A study was made of 97 patients with RA, who have been seen regularly in this department for up to 20 years, and 29 patients with anti-neutrophil cytoplasmic antibody (ANCA) positive systemic vasculitis. Anti-MPO antibodies were detected using a direct-binding enzyme-linked immunosorbent assay (ELISA) with MPO from human granulocytes as antigen. The IgG subclass of anti-MPO antibodies was determined by ELISA using isotype specific monoclonal antibodies.

RESULTS

Anti-MPO antibodies were detected in 12% of patients with RA. Six sera contained IgG anti-MPO antibodies only, 1 IgM only and 5 antibodies of both classes. In the patients with RA the predominant subclasses were IgG1 and IgG3: only 2 sera contained detectable IgG4 antibodies. This was in contrast to patients with vasculitis, in whom most sera contained IgG1, IgG3 and IgG4 anti-MPO antibodies. Anti-MPO antibodies in sera from both patient groups bound only to the native protein. None of the patients studied with RA had evidence of vasculitis affecting the nerves or kidney: three patients (1 positive for anti-MPO antibodies and 2 negative) had cutaneous vasculitis. In the patients with RA, positivity for anti-MPO antibodies was associated with nodules and number of active joints. Three patients with anti-MPO antibodies, and none without, had pulmonary fibrosis.

CONCLUSIONS

Twelve per cent of a group of unselected outpatients with RA, but without evidence of major systemic vasculitis, had anti-MPO antibodies in their serum. Positivity for anti-MPO antibodies was more common in patients with nodular disease and lung involvement but not in patients with cutaneous vasculitis. IgG4 sub-class anti-MPO antibodies were present in 90% of sera from patients with ANCA-positive vasculitis and only 2/11 (18%) of anti-MPO antibody containing sera from patients with RA.

Purification and partial amino acid sequence of a mu opioid receptor from rat brain

A rat brain opioid receptor protein was isolated by binding [epsilon-biotinyl-Lys32] beta-endorphin to membranes, solubilizing the receptor-ligand (R.L) complex with deoxycholate-lysophosphatidylcholine and purifying on immobilized streptavidin and wheat germ agglutinin. The purified glycoprotein had a molecular mass of 60-70 kDa. Recovery of this protein was blocked by the nonselective opioid antagonist naloxone and the highly mu-selective agonist [D-Ala2,N-methyl-Phe4,Glyol5]-enkephalin but not by the highly delta-selective agonist [D-Pen2,4'-Cl-Phe4,D-Pen5]enkephalin when these compounds were added as competitors at the binding step. The 60-70-kDa receptor protein co-purified through the streptavidin column with 40-kDa protein recognized by anti-Gi alpha antibodies. GTP and Na+ influenced dissociation of the solubilized R.125I-L complex and elution of the receptor and G protein from streptavidin in fashions consistent with the pharmacology of mu-opioid receptors. A 23-amino acid residue sequence from the purified receptor differs at 4 positions from a similar sequence in the murine delta-opioid receptor and is encoded within a novel rat brain cDNA isolated by polymerase chain reaction with oligonucleotide primers related to the murine delta-opioid receptor gene.

Surgical management of exertional compartment syndrome of the lower leg. Long-term followup

Forty-six limbs in 28 patients were surgically treated for exertional compartment syndrome. One group of 16 patients (26 limbs) underwent a fasciotomy for exertional anterior compartment syndrome (Group 1). A second group of 12 patients (20 limbs) underwent a fasciotomy for exertional deep posterior compartment syndrome (Group 2). Patients in Group 2 experienced symptoms for a significantly longer time than those in Group 1:16 versus 6.8 months (P < 0.01). All three of the pressure measurements used in this study (resting pressure, 1 minute after exercise, and 5 minutes after exercise) were significantly higher in both groups than in normal controls (P < 0.01). The 1 minute after exercise values were significantly higher in Group 1 (mean, 36.5) than in Group 2 (mean, 29.1) (P < 0.01). In Group 1, 25 of 26 limbs (96%) had excellent results. In Group 2, 13 of 20 limbs (65%) had satisfactory results (5 excellent and 8 good) and 7 (35%) had unsatisfactory results (4 fair and 3 poor). Those patients who had an unsatisfactory outcome did so within 6 months. Patients in Group 1 had a significantly higher rate of satisfactory results than those in Group 2 (P < 0.05).

Factors predicting death, survival and functional outcome in a prospective study of early rheumatoid disease over fifteen years

Sixty-four survivors from a prospective study of early rheumatoid disease were assessed again at a mean of 15.2 years from presentation and their status compared with 29 patients who had died. Eleven of the dead and only two of the survivors had been treated with steroids. There was a small increase in mortality due to the disease itself but only one death was directly caused by it. As might be expected, those who died were older. In the first year of disease, they had lower haemoglobin levels, a lower body mass, higher sedimentation rates and higher levels of blood urea. One-fifth at entry to the study and two-fifths by the time of death, had poor functional capacity. Of 64 survivors, six had poor functional capacity at entry and nine after 15 years. Discriminant analysis was performed to identify the most powerful combination of early features predicting a poor functional outcome. A combination including early erosive change, seropositivity, poor grip strength and cervical subluxation predicted the outcome correctly in 73% of survivors. Almost 60% of survivors remained with or improved to normal function at 15 years suggesting that morbidity is not as bad as has been suggested in the past.

Radiological progression in rheumatoid arthritis: how many patients are required in a treatment trial to test disease modification?

OBJECTIVE

To determine whether the number of patients required in a therapeutic trial that uses progression of radiological abnormalities as the outcome measure would be similar for multiple centres.

METHODS

The progression of radiological damage to the fingers and wrists of patients with rheumatoid arthritis in five centres, three in North America and two in Europe, was examined. The reproducibility of repeated readings by the same and multiple observers was examined. The number of patients required in a two group trial was calculated for several combinations of power and significance.

RESULTS

Scoring progression of radiological abnormalities in sequential films taken between 0.5 and 2.1 years was found to be highly reproducible. When the scores of a single reader were used the rate of change of radiological scores was similar in all centres. Based on the mean progression rate for all centres it was estimated that 153 patients in each group would be required to assure 90% power for detecting a 50% slowing of radiological progression at a significance of 0.05. Review of the experience in three trials showed a large variability in the radiological progression rates.

CONCLUSION

The progression of scores for radiological damage in rheumatoid arthritis is relatively uniform in North America and Europe and thus the number of patients required in a trial would be similar. Experience in three trials showed that patient selection is of paramount importance in setting up a successful study.

The rat SSTR2 somatostatin receptor subtype is coupled to inhibition of cyclic AMP accumulation

The rat somatostatin receptor SSTR2 subtype has been cloned and expressed in Chinese Hamster Ovary (CHO) cells. Four different radioligands were used to determine the pharmacological properties of this somatostatin receptor subtype. [125ITyr11]S-14, [125ITyr25]S-28, and cyclo (D-Trp-Lys-Abu-Phe-MeAla-[125ITyr]) displayed comparable affinities for the SSTR2 subtype (approximately 100 pM). The affinity of a fourth radioligand, D-beta Nal-cyclo (Cys-[125ITyr]-DTrp-Lys-Val-Cys)-Thr-H2N, was approximately 10-fold lower (approximately 1000 pM) than the three other radioligands. Competition of [125I]S-14 with either S-14 or S-28 also revealed comparable IC50 values (250 pM). In CHO cells transfected with the SSTR2 cDNA, S-14 inhibited forskolin-stimulated cAMP accumulation by 75% in a dose-dependent fashion (EC50 = 350 pM).

Impact of short-term oral steroid use upon children's school achievement and behavior

Physicians need clarification of whether the temporary use of adrenal corticosteroids to abort acute asthma can adversely effect school achievement and behavior problems. Nineteen nonsteroid-dependent asthmatic children were given prednisone orally while all other medications were kept constant. Five days later, when they were seen in the physician's office, an academic achievement test was administered to the child; and the child, a parent, and a teacher completed behavior rating surveys. After 2 weeks off the steroids the child returned to the physician's office and the achievement test and rating scales were completed again. There was no significant difference between the achievement test scores and behavior ratings in school or at home under the two conditions. Short-term use of oral steroids does not impair children's basic academic skills nor their behavior at school or home.

Purification of a pituitary receptor for somatostatin. The utility of biotinylated somatostatin analogs

A somatostatin (SRIF) receptor and its associated Gi regulatory proteins was purified from GH4C1 rat pituitary cells by: 1) saturation of the membrane-bound receptor with biotinyl-NH-[Leu8,D-Trp22,Tyr25] SRIF28 (bio-S28); 2) solubilization of receptor-ligand (R.L) complex with deoxycholate-lysophosphatidylcholine (D.L); 3) adsorption of solubilized receptor-ligand complex to immobilized streptavidin; and 4) elution of receptor and G-protein by GTP. The receptor, a glycoprotein with an average M(r) of 85,000, was then purified to substantial homogeneity on immobilized wheat germ agglutinin. The 85-kDa glycoprotein was identified as a SRIF receptor by several criteria. (a) It had the same size as the chemically cross-linked R.[125I]L complex. (b) Yield of the purified protein increased and plateaued in the same range of bio-S28 concentrations where specific high affinity binding reached saturation. (c) It was copurified with appropriate G-protein subunits. The 85-kDa receptor and two other proteins with M(r) values of 35,000 and 40,000, the sizes of G beta and G alpha, did not appear in eluates from control streptavidin columns done with SRIF receptors loaded with nonbiotinylated S14. The 40-kDa protein was identified as a Gi alpha by ADP-ribosylation from [32P]NAD catalyzed by pertussis toxin. (d) Both the chemically cross-linked R.[125I]L complex and SRIF receptor purified from [35S]methionine-labeled GH4C1 cells were reduced in size to about 38 kDa by endoglycosidase F. (e) Amino acid sequence from the purified receptor was nearly identical with that of a recently cloned SRIF receptor subtype.

Partial amino acid sequence of a somatostatin receptor isolated from GH4C1 pituitary cells

A somatostatin receptor isolated from GH4C1 rat pituitary tumor-derived cells was cleaved with cyanogen bromide or cyanogen bromide+trypsin to obtain sequenceable fragments. Five unique amino acid sequences ranging from 6 to 27 amino acid residues were obtained. The sequence was identical to sequence recently reported for one of two somatostatin receptors cloned from human pancreas [Yamada et al., (1992) Proc. Natl. Acad. Sci. U.S.A. 89, 251-255] except for a single valine to isoleucine substitution. This is the first report of amino acid sequence from a purified somatostatin receptor.

Magnetic resonance imaging evaluation of calcaneal fat pads in patients with os calcis fractures

Destruction of the calcaneal fat pad has been implicated as a source of chronic pain following fractures of the os calcis. Several investigators postulate that the initial trauma that produces a calcaneal fracture also results in destruction of the U-shaped fibrous septa that maintain the piston-like organization of the fat columns. Fibrosis and loss of the protective cushioning provided by the fat pad may eventually occur. The authors report on the largest series of magnetic resonance images of the calcaneal fat pad in the heels of patients with calcaneal fractures. A prospective consecutive study utilizing magnetic resonance imaging was performed on 22 heels with calcaneal fractures. Ten contralateral heels without calcaneal fracture and the heels of five normal subjects were scanned as controls. No signal changes suggestive of increased fat pad edema, fibrosis, or fatty release were detected. In addition, the vertical septa were well visualized and found to be intact in all cases. The height of the fat pad was measured, with no changes noted as compared with the contralateral heel. In those patients with acute fractures, signal changes suggestive of hematoma were well visualized in the soft tissue surrounding the calcaneus. In two of these cases, there was extension beneath the plantar fascia, but no penetration into the fat columns. Magnetic resonance imaging allows excellent detailed visualization of the calcaneal fat pad and surrounding structures. No evidence is found to support the hypothesis that marked damage to the gross structure of the fat pad occurs at the time of injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Synthesis and Tubulin-Binding Properties of Some AC- and ABC-Ring Analogs of Allocolchicine

Fourteen analogues [compounds (8), (9) and (11)-(22)] of the powerful antimitotic agent allocolchicine (5) have been prepared and evaluated for their ability to prevent tubulin polymerization. The X-ray structure of one of the more active compounds, tricycle (20), is reported.