Self-Reported Sleep Disturbances over the Menopausal Transition and Fracture Risk: The Study of Women's Health Across the Nation

Sleep disturbances are common and may impact fracture risk directly by influencing bone turnover or indirectly through shared risk factors or mediators. To investigate the association between self-reported sleep disturbances across the menopausal transition (MT) and fractures, we prospectively studied 3101 women enrolled in the Study of Women's Health Across the Nation (SWAN). At each of 14 study visits spaced approximately 18 months apart, a standardized validated scale ascertained trouble falling asleep, waking up several times during the night, and waking up earlier than planned. Two time-varying exposures were modeled: presence of any of the three disturbances at least three times per week and waking up several times during the night at least three times per week. Base models adjusted for fixed (race/ethnicity, study site) and time-varying characteristics (age, body mass index, and MT stage). Fully adjusted models also included time-varying bone beneficial and detrimental medications, smoking, alcohol, physical activity, diabetes, depression and sleep medications, and depressive symptoms. Women who experienced a fracture were more likely to report a greater frequency of having trouble falling asleep, waking up several times, and/or waking up earlier: 35% versus 30% at baseline, p = 0.02. In the base models, women who had any of the three sleep disturbances at least three times per week had a higher risk of any fracture, odds ratio (OR) = 1.23 (95% confidence intervals, 1.02, 1.48) and nontraumatic fracture, OR = 1.36 (1.03, 1.80). These associations were largely attenuated to nonsignificance in the fully adjusted model. Sensitivity analyses limiting our sample to 2315 SWAN women enrolled in the bone mineral density (BMD) centers yielded similar results. Additional adjustment for femoral neck BMD had no effect on our results. In conclusion, self-reported sleep disturbances were associated with an increased risk of fractures, but these associations likely reflect shared risk factors or factors in the causal pathway. © 2023 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Advanced crystallisation methods for small organic molecules

Molecular materials based on small organic molecules often require advanced structural analysis, beyond the capability of spectroscopic techniques, to fully characterise them. In such cases, diffraction methods such as single crystal X-ray diffraction (SCXRD), are one of the most powerful tools available to researchers, providing molecular and structural elucidation at atomic level resolution, including absolute stereochemistry. However SCXRD, and related diffraction methods, are heavily dependent on the availability of suitable, high-quality crystals, thus crystallisation often becomes the major bottleneck in preparing samples. Following a summary of classical methods for the crystallisation of small organic molecules, this review will focus on a number of recently developed advanced methods for crystalline material sample preparation for SCXRD. This review will cover two main areas of modern small organic molecule crystallisation, namely the inclusion of molecules within host complexes (e.g., "crystalline sponge" and tetraaryladamantane based inclusion chaperones) and the use of high-throughput crystallisation, employing "under-oil" approaches (e.g., microbatch under-oil and ENaCt). Representative examples have been included for each technique, together with a discussion of their relative advantages and limitations to aid the reader in selecting the most appropriate technique to overcome a specific analytical challenge.

Distinct genomic landscapes of gastroesophageal adenocarcinoma depending on PD-L1 expression identify mutations in RAS-MAPK pathway and TP53 as potential predictors of immunotherapy efficacy

BACKGROUND

The impact of molecular alterations on programmed death-ligand 1 (PD-L1) combined positive score (CPS) is not well studied in gastroesophageal adenocarcinomas (GEAs). We aimed to characterize genomic features of tumors with different CPSs in GEAs.

PATIENTS AND METHODS

Genomic alterations of 2518 GEAs were compared in three groups (PD-L1 CPS ≥ 10, high; CPS = 1-9, intermediate; CPS < 1, low) using next-generation sequencing. We assessed the impact of gene mutations on the efficacy of immune checkpoint inhibitors (ICIs) and tumor immune environment based on the Memorial Sloan Kettering Cancer Center and The Cancer Genome Atlas databases.

RESULTS

High, intermediate, and low CPSs were seen in 18%, 54% and 28% of GEAs, respectively. PD-L1 positivity was less prevalent in women and in tissues derived from metastatic sites. PD-L1 CPS was positively associated with mismatch repair deficiency/microsatellite instability-high, but independent of tumor mutation burden distribution. Tumors with mutations in KRAS, TP53, and RAS-mitogen-activated protein kinase (MAPK) pathway were associated with higher PD-L1 CPSs in the mismatch repair proficiency and microsatellite stability (pMMR&MSS) subgroup. Patients with RAS-MAPK pathway alterations had longer overall survival (OS) from ICIs compared to wildtype (WT) patients [27 versus 13 months, hazard ratio (HR) = 0.36, 95% confidence interval (CI): 0.19-0.7, P = 0.016] and a similar trend was observed in the MSS subgroup (P = 0.11). In contrast, patients with TP53 mutations had worse OS from ICIs compared to TP53-WT patients in the MSS subgroup (5 versus 21 months, HR = 2.39, 95% CI: 1.24-4.61, P = 0.016).

CONCLUSIONS

This is the largest study to investigate the distinct genomic landscapes of GEAs with different PD-L1 CPSs. Our data may provide novel insights for patient selection using mutations in TP53 and RAS-MAPK pathway and for the development of rational combination immunotherapies in GEAs.

Health-related quality of life in patients with a germline BRCA mutation and metastatic pancreatic cancer receiving maintenance olaparib

BACKGROUND

Patients with metastatic pancreatic cancer often have a detriment in health-related quality of life (HRQoL). In the randomized, double-blind, phase III POLO trial progression-free survival was significantly longer with maintenance olaparib, a poly(ADP-ribose) polymerase inhibitor, than placebo in patients with a germline BRCA1 and/or BRCA2 mutation (gBRCAm) and metastatic pancreatic cancer whose disease had not progressed during first-line platinum-based chemotherapy. The prespecified HRQoL evaluation is reported here.

PATIENTS AND METHODS

Patients were randomized to receive maintenance olaparib (300 mg b.i.d.; tablets) or placebo. HRQoL was assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30-item module at baseline, every 4 weeks until disease progression, at discontinuation, and 30 days after last dose. Scores ranged from 0 to 100; a ≥10-point change or difference between arms was considered clinically meaningful. Adjusted mean change from baseline was analysed using a mixed model for repeated measures. Time to sustained clinically meaningful deterioration (TSCMD) was analysed using a log-rank test.

RESULTS

Of 154 randomized patients, 89 of 92 olaparib-arm and 58 of 62 placebo-arm patients were included in HRQoL analyses. The adjusted mean change in Global Health Status (GHS) score from baseline was <10 points in both arms and there was no significant between-group difference [-2.47; 95% confidence interval (CI) -7.27, 2.33; P = 0.31]. Analysis of physical functioning scores showed a significant between-group difference (-4.45 points; 95% CI -8.75, -0.16; P = 0.04). There was no difference in TSCMD for olaparib versus placebo for GHS [P = 0.25; hazard ratio (HR) 0.72; 95% CI 0.41, 1.27] or physical functioning (P = 0.32; HR 1.38; 95% CI 0.73, 2.63).

CONCLUSIONS

HRQoL was preserved with maintenance olaparib treatment with no clinically meaningful difference compared with placebo. These results support the observed efficacy benefit of maintenance olaparib in patients with a gBRCAm and metastatic pancreatic cancer.

CLINCALTRIALS.GOV NUMBER

NCT02184195.

Abstract P4-03-03: Germline potentially pathogenic variants in breast cancer intrinsic molecular subtypes are not associated with somatic TMB

Background: Breast cancer (BC) is a heterogeneous disease. It is estimated that 5 to 10% of all BC to have a germline genetic predisposition. A 50-gene assay (PAM50) identifies 5 intrinsic molecular subtypes (IMS): Luminal A, Luminal B, HER2-enriched, Basal-like, and Normal-like. Basal-like breast cancers are enriched for BRCA1/2 germline mutations. Deleterious mutations in BRCA1/2 or other DNA-damage repair (DDR) genes may increase tumor mutational burden (TMB), a biomarker for response to checkpoint inhibition therapy. We sought to determine the spectrum of germline mutations in molecular BC subtypes (IMS), and their relation to somatic TMB. Methods: We performed a retrospective analysis of data from NantHealth database. RNAseq was used to classify breast tumors into IMS. Germline variants within putative driver genes (COSMIC v.76) were detected in analysis of 181 whole-genomes and 89 whole-exomes sequenced using Illumina chemistry. Classification of germline variants into potentially pathogenic variants (pPv) was determined using ClinVar database annotation. Patients were categorized as TMB-high by thresholding on &gt;200 non-synonymous exonic somatic mutations as was previously reported. Results: A total of 270 BC patients with comprehensive omics profiling (germline DNAseq, somatic DNAseq, and somatic RNAseq) were available for this analysis. The mean age (±SD) was 56.4 (± 12.5) years (range 20.8-86.5). Forty-six patients (17.0%) were classified TMB-high. The IMS distribution was 40.7% Luminal A, 31.5% Luminal B, 5.9% HER2-enriched, 21.5% Basal-like, and 0.37% Normal-like. Over 200 unique germline variants were detected of which 98 were pPv according to ClinVar annotation. These pPv spanned 21 genes, 7 of which are directly related to DDR. One hundred and four patients had ≥1 pPv (78 had only 1 pPv, and 26 had &gt;1 pPv). The most common pPv were APC (5.9%), BRCA2 (5.2%), TSC2 (4.4%), BRCA1 (3.7%), SDHB (3.3%), SDHD (3.3%), TSC1 (3.0%), PMS2 (3.0%), MUTYH (2.6%), MSH2 (1.5%) and MSH6 (1.5%). BRCA1 and especially BRCA2 pPv were mostly seen in the basal-like patients. Luminal B had distinctly more germline pPv in PMS2, BRCA1 & BRCA2 than Luminal A. TMB-high patients were not significantly enriched for germline pPv (OR 0.73, p=0.41), even when limited to pPv in DDR genes (OR 0.69, p=0.52). TMB-high patients were present in all 4 major IMS types; Her2-enriched 37.5%, Luminal B 23.5%, Basal-like 17.2%, and Luminal A 9.1%. Conclusion: We identified differential distribution of germline pPv in BC IMS. Of the pPv found, APC was the most commonly detected pPv across subtypes, while BRCA1/2 pPv were clustered in Basal-like subtype, and PMS2 in Luminal B subtype. 17% of all patients had a pPv within at least one DDR gene, that potentially may benefit from targeted therapy. Despite IMS types having distinct germline pPv profiles especially in DDR genes, there was no association with subsequent somatic TMB. This suggests that either 1. somatic events are the primary drivers of TMB, or 2. that germline variants with either unknown or benign significance need to be revisited. Future analysis in a larger demographically well-annotated dataset (commercial data, ExAC, other) or via functional studies should be considered.

Citation Format: Obeid E, Reddy SB, Goldstein LJ, Daly MB, Benz SC, Hall MJ, Szeto C. Germline potentially pathogenic variants in breast cancer intrinsic molecular subtypes are not associated with somatic TMB [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-03-03.

Component alignment and clinical outcome following total knee arthroplasty: a randomised controlled trial comparing an intramedullary alignment system with patient-specific instrumentation

AIMS

We conducted a randomised controlled trial to assess the accuracy of positioning and alignment of the components in total knee arthroplasty (TKA), comparing those undertaken using standard intramedullary cutting jigs and those with patient-specific instruments (PSI).

PATIENTS AND METHODS

There were 64 TKAs in the standard group and 69 in the PSI group. The post-operative hip-knee-ankle (HKA) angle and positioning was investigated using CT scans. Deviation of > 3° from the planned position was regarded as an outlier. The operating time, Oxford Knee Scores (OKS) and Short Form-12 (SF-12) scores were recorded.

RESULTS

There were 14 HKA-angle outliers (22%) in the standard group and nine (13%) in the PSI group (p = 0.251). The mean HKA-angle was 0.5° varus in the standard group and 0.2° varus in the PSI group (p = 0.492). The accuracy of alignment in the coronal and axial planes and the proportion of outliers was not different in the two groups. The femoral component was more flexed (p = 0.035) and there were significantly more tibial slope outliers (29% versus 13%) in the PSI group (p = 0.032). Operating time and the median three-month OKS were similar (p = 0.218 and p = 0.472, respectively). Physical and mental SF-12 scores were not significantly different at three months (p = 0.418 and p = 0.267, respectively) or at one year post-operatively (p = 0.114 and p = 0.569). The median one-year Oxford knee score was two points higher in the PSI group (p = 0.049).

CONCLUSION

Compared with standard intramedullary jigs, the use of PSI did not significantly reduce the number of outliers or the mean operating time, nor did it clinically improve the accuracy of alignment or the median Oxford Knee Scores. Our data do not support the routine use of PSI when undertaking TKA. Cite this article: Bone Joint J 2016;98-B:1043-9.

Genetic testing for hereditary cancer predisposition: BRCA1/2, Lynch syndrome, and beyond

Obstetrician/gynecologists and gynecologic oncologists serve an integral role in the care of women at increased hereditary risk of cancer. Their contribution includes initial identification of high risk patients, screening procedures like bimanual exam, trans-vaginal ultrasound and endometrial biopsy, prophylaxis via TAH and/or BSO, and chemoprevention. Further, gynecologists also serve a central role in the management of the secondary repercussions of efforts to mitigate increased cancer risks, including vasomotor symptoms, sexual function, bone health, cardiovascular disease, and mental health. The past several years has seen multiple new high and moderate penetrance genes introduced into the clinical care of women at increased risk of gynecologic malignancy. Awareness of these new genes and the availability of new multi-gene panel tests is critical for providers on the front-line of women's health.

Pharmacology of the glucagon-like peptide-1 analog exenatide extended-release in healthy cats

Exenatide extended-release (ER) is a microencapsulated formulation of the glucagon-like peptide 1-receptor agonist exenatide. It has a protracted pharmacokinetic profile that allows a once-weekly injection with comparable efficacy to insulin with an improved safety profile in type II diabetic people. Here, we studied the pharmacology of exenatide ER in 6 healthy cats. A single subcutaneous injection of exenatide ER (0.13 mg/kg) was administered on day 0. Exenatide concentrations were measured for 12 wk. A hyperglycemic clamp (target = 225 mg/dL) was performed on days -7 (clamp I) and 21 (clamp II) with measurements of insulin and glucagon concentrations. Glucose tolerance was defined as the amount of glucose required to maintain hyperglycemia during the clamp. Continuous glucose monitoring was performed on weeks 0, 2, and 6 after injection. Plasma concentrations of exenatide peaked at 1 h and 4 wk after injection. Comparing clamp I with clamp II, fasting blood glucose decreased (mean ± standard deviation = -11 ± 8 mg/dL, P = 0.02), glucose tolerance improved (median [range] +33% [4%-138%], P = 0.04), insulin concentrations increased (+36.5% [-9.9% to 274.1%], P = 0.02), and glucagon concentrations decreased (-4.7% [0%-12.1%], P = 0.005). Compared with preinjection values on continuous glucose monitoring, glucose concentrations decreased and the frequency of readings <50 mg/dL increased at 2 and 6 wk after injection of exenatide ER. This did not correspond to clinical hypoglycemia. No other side effects were observed throughout the study. Exenatide ER was safe and effective in improving glucose tolerance 3 wk after a single injection. Further evaluation is needed to determine its safety, efficacy, and duration of action in diabetic cats.

Pharmacokinetics and pharmacodynamics of the glucagon-like peptide-1 analog liraglutide in healthy cats

Glucagon-like peptide-1 (GLP-1) is an intestinal hormone that induces glucose-dependent stimulation of insulin secretion while suppressing glucagon secretion. Glucagon-like peptide-1 also increases beta cell mass and satiation while decelerating gastric emptying. Liraglutide is a fatty-acid derivative of GLP-1 with a protracted pharmacokinetic profile that is used in people for treatment of type II diabetes mellitus and obesity. The aim of this study was to determine the pharmacokinetics and pharmacodynamics of liraglutide in healthy cats. Hyperglycemic clamps were performed on days 0 (HGC) and 14 (LgHGC) in 7 healthy cats. Liraglutide was administered subcutaneously (0.6 mg/cat) once daily on days 8 through 14. Compared with the HGC (mean ± standard deviation; 455.5 ± 115.8 ng/L), insulin concentrations during LgHGC were increased (760.8 ± 350.7 ng/L; P = 0.0022), glucagon concentrations decreased (0.66 ± 0.4 pmol/L during HGC vs 0.5 ± 0.4 pmol/L during LgHGC; P = 0.0089), and there was a trend toward an increased total glucose infused (median [range] = 1.61 (1.11-2.54) g/kg and 2.25 (1.64-3.10) g/kg, respectively; P = 0.087). Appetite reduction and decreased body weight (9% ± 3%; P = 0.006) were observed in all cats. Liraglutide has similar effects and pharmacokinetics profile in cats to those reported in people. With a half-life of approximately 12 h, once daily dosing might be feasible; however, significant effects on appetite and weight loss may necessitate dosage or dosing frequency reductions. Further investigation of liraglutide in diabetic cats and overweight cats is warranted.

Genetic counselors' (GC) knowledge, awareness, understanding of clinical next-generation sequencing (NGS) genomic testing

Genomic tests are increasingly complex, less expensive, and more widely available with the advent of next-generation sequencing (NGS). We assessed knowledge and perceptions among genetic counselors pertaining to NGS genomic testing via an online survey. Associations between selected characteristics and perceptions were examined. Recent education on NGS testing was common, but practical experience limited. Perceived understanding of clinical NGS was modest, specifically concerning tumor testing. Greater perceived understanding of clinical NGS testing correlated with more time spent in cancer-related counseling, exposure to NGS testing, and NGS-focused education. Substantial disagreement about the role of counseling for tumor-based testing was seen. Finally, a majority of counselors agreed with the need for more education about clinical NGS testing, supporting this approach to optimizing implementation.

Oxford elbow scores in an asymptomatic population

INTRODUCTION

Patient reported outcome measures (PROMs) are being used increasingly to assess the quality of healthcare delivery in the UK. It is important when using PROMs to know the score of the background population against which any clinical intervention may be benchmarked. The purpose of this study was to measure an elbow specific PROM for the population of the South West Peninsula.

METHODS

A cross-sectional survey was undertaken of patients and healthcare professionals from the South West Peninsula population. Participants were asked to complete a simple demographic questionnaire and an Oxford elbow score for each elbow. Respondents with a history of elbow surgery, elbow injury, chronic elbow problems or an incomplete dataset were excluded from the study.

RESULTS

A total of 1,765 respondents (3,530 elbows) completed the survey but 567 questionnaires were excluded due to incomplete datasets, pre-existing elbow pathology or age criteria, leaving 1,198 individuals (2,396 elbows) for analysis. The median scores for each decade group were 48, with mean scores ranging from 46.74 to 47.94. There was no significant clinical difference in the scores for age, sex or hand dominance.

CONCLUSIONS

When using the Oxford elbow score to assess outcomes after surgery, a normal score should be used as the benchmark. This benchmark is independent of age, sex and hand dominance.

Panton-Valentine leukocidin Staphylococcus aureus osteomyelitis of the adult tibia--a case report

Panton-Valentine leukocidin toxin producing Staphylococcus aureus (PVLSA) is known to be responsible for recurrent soft tissue infections and more serious invasive infections including necrotising pneumonia, pyomyositis, and osteomyelitis. Most reported cases involving musculoskeletal infection in adults are associated with methicillin-resistant S. aureus (MRSA) PVL-producing strains. We present the case of an adult male with PVL toxin-producing methicillin-sensitive S. aureus (MSSA) osteomyelitis of the tibia which has not previously been described in adults and highlight issues of recognition, treatment, and surgical management of PVLSA osteomyelitis.

The psychosocial impact of oral conditions during transition to secondary education

AIM

Transition to secondary education is a significant life event. Little is known about the impact of oro-facial conditions during this time and how concerns may contribute as a risk factor to negative adaptation. The aim of the study was to explore experiences of young people with oro-facial conditions as they undergo the transition to secondary education.

STUDY DESIGN

Qualitative interview and diary study.

METHODS

Participants were children aged 11-12 years with a range of clinical conditions who attended a dental hospital. Participants completed a two-week diary during the transition and were interviewed about the diary and their experiences. The interviews were audio-taped and transcribed verbatim.

RESULTS

Seventeen participants returned the diary and were interviewed; they described both changes in school environment and social interactions. A key finding was the concerns about aspects of themselves that children developed during this time. For some young people these concerns were about their oro-facial condition. No links between gender, severity of condition and experiences of school were apparent.

CONCLUSION

Transition to secondary education affected young people to varying degrees. Timely treatment for those concerned about the condition of their teeth may improve the likelihood of positive adaptation.

Injuries caused by seatbelts

Seatbelts save lives. However, they may cause injury to adjacent structures and when they malfunction can cause injury to the abdominal viscera, bony skeleton and vascular structures. The motor industry has attempted to reduce these injuries by modification of vehicle design and safety equipment. This paper discusses the patterns of injury caused by seatbelts and the methods by which the motor industry attempts to reduce their incidence.

Executive function is less sensitive to estradiol than spatial memory: performance on an analog of the card sorting test in ovariectomized aged rhesus monkeys

Functions supported by the frontal lobes are particularly sensitive to the detrimental effects of aging. Recent studies on postmenopausal women find that estrogen replacement therapy benefits performance on tasks dependent on the frontal lobes. To determine whether estrogen has a similar influence in a rhesus monkey model of menopause, we tested five aged, long-term ovariectomized rhesus monkeys in a modified version of the Wisconsin Card Sort test which had been adapted to the nonhuman primate. In this test, monkeys had to select 3-D objects based either on color (blue, red, yellow) or shape (block, tube, cup) and had to be able to switch their response as a function of reinforcement contingencies. The monkeys were treated with placebo and ethinyl estradiol (EE2, 450 ng/kg/day) in alternation with each successive test. Contrary to our hypothesis, estradiol treatment did not affect performance. Because previous studies in the same monkeys [Neurobiol. Aging 23 (2002) 589] had shown that EE2 improves performance on a spatial memory task dependent on the hippocampus, but not on another task dependent upon the frontal lobes (the delayed response), we conclude that executive processes may be less sensitive to the effects of estradiol than hippocampal-dependent tasks.

Precipitation variability in the Meuse basin in relation to atmospheric circulation

The distribution of precipitation events in the Meuse basin during the past century has been found to reflect the large-scale atmospheric circulation, as characterised by the Grosswetterlagen system. Statistical analysis of the long observation records (1911-2002) for the basin showed that although the annual (November to October) and winter half-year (November to April) frequencies of wet days > or = 1 mm/day) were nearly stable, the associated precipitation amounts have significantly increased since 1980. From 1980 onwards, the very wet days (> or = 10 mm/day) in the winter half-year have become more frequent. No obvious change was identified for the summer half-year (May to October) very wet days. Both the precipitation amounts of wet and very wet days in the winter half-year and the occurrence of associated atmospheric circulation of the types/sub-types west cyclone, southwest cyclone and northwest cyclone showed a significant increase around 1980.

Hypertonic Saline

The optimal fluid for the resuscitation of critically ill and injured patients remains the subject of considerable controversy. Hypertonic crystalloid solutions such as hypertonic saline provide rapid volume expansion, have an acceptable safety profile, and are easy to store and transport. Recent meta-analyses suggest a trend toward increased survival in patients given hypertonic saline, and it has been suggested that they may have particular benefit in certain groups of patients such as hypovolaemic head injury patients. This short review examines the physiological and experimental evidence supporting the use of hypertonic saline in fluid resuscitation.

Use of signal-mediated amplification of RNA technology (SMART) to detect marine cyanophage DNA

Here, we describe the application of an isothermal nucleic acid amplification assay, signal-mediated amplification of RNA technology (SMART), to detect DNA extracted from marine cyanophages known to infect unicellular cyanobacteria from the genus Synechococcus. The SMART assay is based on the target-dependent production of multiple copies of an RNA signal, which is measured by an enzyme-linked oligosorbent assay. SMART was able to detect both synthetic oligonucleotide targets and genomic cyanophage DNA using probes designed against the portal vertex gene (g20). Specific signals were obtained for each cyanophage strain (S-PM2 and S-BnMI). Nonspecific genomic DNA did not produce false signals or inhibit the detection of a specific target. In addition, we found that extensive purification of target DNA may not be required since signals were obtained from crude cyanophage lysates. This is the first report of the SMART assay being used to discriminate between two similar target sequences.

Old World screwworm fly, Chrysomya bezziana, occurs as two geographical races

A morphological and molecular analysis was undertaken with the objective of identifying markers for geographical populations of Old World screwworm flies, Chrysomya bezziana Villeneuve (Diptera: Calliphoridae). The morphological analysis involved 192 adult flies from 14 countries, and the molecular analysis involved 45 larvae or adults from 14 populations in 11 countries. Principal components and cluster analysis of 10 morphological characters indicated that flies from Papua New Guinea (PNG) were a distinct group and most similar to flies from nearby Asian islands (Java, Sabah). There was poor resolution of other geographical regions, but some support for clustering of flies from Africa or India. Cladistic analysis of mitochondrial DNA sequences gave strong support for recognizing two races of Old World screwworm, one from sub-Saharan Africa and the other from the Gulf region and Asia. This latter race could be further divided into two lineages, i.e. one from mainland Asia (from Iraq to the Malay Peninsula) and the other from two islands of PNG.

The role of Joseph Lister in developing the absorbable ligature

Joseph Lister is associated with pioneering work on antisepsis. However an important but less well-known contribution to surgical progress was his work on the absorbable suture. This article details the problems Lister faced in operative surgery, his observations and experiments that lead to his development of an absorbable suture.

Hemodynamic effects of simulated obstructive apneas in humans with and without heart failure

STUDY OBJECTIVES

To determine whether generation of negative intrathoracic pressure during apnea would cause more pronounced and sustained reductions in cardiac output in patients with congestive heart failure (CHF) than in healthy subjects.

DESIGN

Physiologic intervention study.

SETTING

Cardiorespiratory physiology laboratory.

PARTICIPANTS

Nine patients with CHF and nine healthy control subjects matched for age and sex.

INTERVENTIONS

Patients with CHF and healthy subjects generated - 30 cm H(2)O of intrathoracic pressure during 15-s Mueller maneuvers (MMs) to simulate the acute hemodynamic effects and aftereffects of obstructive apneas.

RESULTS

In both groups, MMs caused an immediate rise in left ventricular transmural pressure during systole (LVPtmsys) [p < 0.05], but in CHF patients, this immediate increase was followed by a significant drop in LVPtmsys (p < 0.05), associated with significantly greater reductions in systolic BP and cardiac index than in healthy subjects (- 25 +/- 3 mm Hg vs - 11 +/- 2 mm Hg [p < 0.05] and - 0.53 +/- 0.11 L/min/m(2) vs - 0.15 +/- 0.11 L/min/m(2) [p < 0.05], respectively). Healthy subjects recovered promptly, but in CHF patients, these adverse hemodynamic effects were sustained following release of the MM.

CONCLUSIONS

CHF patients experience more pronounced and sustained reductions in BP and cardiac output both during and following the MM than do healthy subjects. These findings suggest the potential for adverse hemodynamic effects and aftereffects of negative intrathoracic pressure generation during obstructive sleep apnea in patients with CHF.

Trend data on medical encounters: tracking a moving target

The National Health Care Survey (NHCS), conducted by the National Center for Health Statistics, consists of separate data collection activities that can be used to track the number and content of health care encounters in the United States. Tracking even something as simple as the number of encounters, however, is complicated by the fact that the content of these encounters changes over time. Results from the NHCS indicate that the U.S. population has been receiving more drugs, more cardiac procedures, more ambulatory surgery, more therapies in nursing homes, and more home health care over time. Policymakers and researchers who examine health care trends should be wary about judging whether the number of length of encounters is positive or negative without also examining the content of these encounters.

Conceptual sequencing and disordered speech in schizophrenia

This study examined associations between impairments of attention, memory, and conceptual sequencing ability, and specific schizophrenia thought and language symptoms. Speech samples of stable schizophrenia outpatients were assessed for frequencies of six different types of communication failures. The classification of types of failures was based on hypothesized differences in underlying cognitive process. Frequencies of the four types of communication failures believed to involve language structural weaknesses all were significantly and fairly strongly related to conceptual sequencing ability. In addition, regression analyses indicated that each of these four types of communication failures was associated with a unique configuration of attentional, memorial, and conceptual sequencing processes. In contrast, the two types of communication disturbances not suggestive of language structural problems were not positively associated with any of the cognitive weaknesses assessed.

Removal of an airborne low volatility metal under fuel-rich and fuel lean conditions through condensation onto soot and/or sorbent particles

The removal by a sorbent of a low volatility heavy metal, barium, from a combustor exhaust stream was investigated experimentally. The barium was introduced into the gas phase through a combustion process simulating incineration of waste materials. Sorbent- and metal-feed-rate, temperature and air intake were varied to study the impact on the gas-to-particle conversion and the metal condensation process. Peak temperature and subsequent temperature drop were found to be the dominant factors affecting the condensation process. Fuel-rich and fuel-lean conditions result in lower peak temperatures and a more rapid temperature drop relative to stoichiometric conditions. Since the metal vapor saturation pressure falls exponentially with temperature a larger condensation rate was observed, as long as nucleation was suppressed. Fuel-rich conditions promote the formation of soot particles. These particles function as sites for subsequent metal-species condensation. Chlorine was injected into the flow, to study the effect on metal vaporization. Chlorine promoted the volatilization of barium and therefore the subsequent condensation capture was made more effective.

Protection of normal proliferating cells against chemotherapy by staurosporine-mediated, selective, and reversible G(1) arrest

BACKGROUND

A major limiting factor in human cancer chemotherapy is toxicity in normal tissues. Our goal was to determine whether normal proliferating cells could be protected from chemotherapeutic agents by taking advantage of the differential drug sensitivity of cell cycle G(1) checkpoint in normal and cancer cells.

METHODS

Normal mammary epithelial cells and mammary cancer cells were initially treated with staurosporine at a cytostatic (i.e., nonlethal) concentration, which preferentially arrests normal cells in the G(0)/G(1) phase of the cell cycle without affecting the proliferation of tumor cells. After the selective arrest of normal cells in G(0)/G(1), both normal and tumor cells were treated with doxorubicin or camptothecin, two cytotoxic (i.e., lethal) chemotherapeutic agents. Cells were then allowed to recover in drug-free medium for 12 days.

RESULTS

After pretreatment of both normal and tumor cells with staurosporine followed by treatment with doxorubicin or camptothecin, tumor cells were selectively killed by chemotherapeutic agents, whereas normal cells resumed proliferation after the drugs were removed. Pretreatment with staurosporine also protected normal circulating lymphocytes that had been induced to proliferate in vitro with phytohemagglutinin from chemotherapeutic agents. Staurosporine-induced arrest of normal cells in G(0)/G(1) phase was reversible, and arrested cells tolerated doses of camptothecin that were more than 100-fold higher than necessary to eradicate all tumor cells in culture. Staurosporine-mediated G(0)/G(1) arrest targets the retinoblastoma protein (pRb) pathway and was accompanied by a rapid decrease in cyclin-dependent kinase (CDK) 4 protein levels, increased binding of CDK inhibitors p21 and p27 to CDK2, and inhibition of CDK2 activity in normal cells.

CONCLUSIONS

Breast cancer cells with defective checkpoints regulated by the pRb pathway can be targeted specifically with chemotherapeutic agents, following staurosporine-mediated, selective and reversible G(0)/G(1) arrest in normal cells.

Effects of spinal manipulative therapy on autonomic activity and the cardiovascular system: a case study using the electrocardiogram and arterial tonometry

OBJECTIVE

To determine if there is alteration in the autonomic nervous and cardiovascular systems after chiropractic manipulative therapy (CMT). A novel approach was used to quantitatively probe for changes in the activity of the autonomic nervous system, in blood pressure, and in pressure pulse transmission time. This approach uses the electrocardiogram and arterial tonometry equipment.

DESIGN

This case study involves 1 subject treated over a 6-week period (2 visits/week). Respiration, electrocardiogram, and left and right radial artery blood pressures were measured during the baseline (2 visits) and treatment (10 visits) phases. Measurements were obtained before (n = 3) and after (n = 3) a break period (baseline) or before and after CMT. High-velocity, low-amplitude CMT that produced joint cavitation was used.

SETTING

The study was performed at the Parker College Research Institute in a temperature-controlled laboratory.

MAIN OUTCOME MEASURES

Fourier analysis was performed on the electrocardiogram-determined rest-redistribution intervals. The low frequency power between 0.04 to 0.15 Hz and the high frequency power between 0.15 to 0.40 Hz represent the activity of the sympathetic and parasympathetic nervous systems, respectively. The main outcome measure was the sympathovagal index, which is determined from the ratio of low frequency to high frequency. The arterial pressure and the time for pressure pulses to travel from the heart to the radial artery recording sites (pressure pulse transmission time) were studied. Differences (average of 3 measurements after treatment minus measurements before treatment) for each variable were calculated.

RESULTS

After the 1st CMT treatment, the difference between treatment and baseline decreased for both the low frequency/high frequency (-2.804 +/- 1.273) and low frequency power (-0.135 +/- 0.056). These findings indicated that the parasympathetic nervous system predominated the sympathetic nervous system. After the 3rd, 4th, 6th, and 9th treatment, the difference between treatment and baseline increased for low frequency/high frequency (0.908 +/- 0.338, 2.313 +/- 0.300, 2.776 +/- 1.102, and 0. 988 +/- 0.269, respectively) and indicated that the sympathetic nervous system predominated the parasympathetic nervous system. In addition, the difference between treatment and baseline for the pressure pulse transmission time decreased bilaterally after the 4th treatment (left, -13.52 +/- 3.70 ms; right, -9.75 +/- 3.76 ms) and 6th treatment (left, -9.53 +/- 3.60 ms; right, -9.24 +/- 3.50 ms), which indicated that arterial compliance had decreased. Furthermore, after the 6th treatment, the difference between treatment and baseline for the rest-redistribution interval time decreased (-0.084 +/- 0.014 s). The difference between treatment and baseline for the systolic, diastolic, and mean arterial pressure for the above-mentioned treatments was not considered significant.

CONCLUSION

This case study is the first to attempt to use electrocardiogram and arterial tonometry data to study the effects of CMT on the autonomic nervous and cardiovascular systems over an extended period of time. These devices allowed a more in-depth study of the cardiovascular and autonomic changes associated with CMT. Although changes in the autonomic nervous and cardiovascular systems can be detected, further development of a reliable and reproducible experimental protocol is required before validating the effects of CMT on these systems.

Hospitalizations for injury: United States, 1996

OBJECTIVES

This report presents national estimates of the 1996 hospitalizations for injury in the United States. Numbers and rates of discharges are shown within sex, age, and racial groups by type of injury. Average lengths of stay and days of care data by injury type are also included.

METHODS

Estimates are based on medical abstract data collected in the National Hospital Discharge Survey. Diagnoses are coded according to the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Injuries are defined as ICD-9-CM codes 800-999. External causes of injury are defined as codes E800-E999 (E-codes).

RESULTS

In 1996, there were 2.6 million hospitalizations for injury. Fractures resulted in over a million hospitalizations; medical injuries, including adverse effects and complications, were responsible for 666,000 hospitalizations. The medical records for 64 percent of the patients hospitalized for injuries had an external cause-of-injury code (E-code). Elderly people had the largest number and rate of injuries.

CONCLUSIONS

Data on injuries requiring hospitalization and characteristics of patients differentially affected can be used to design and target more effective injury prevention programs. Preventing injuries would decrease the considerable pain, disability, and economic impact associated with these conditions.

Communication disturbances in relatives beyond the age of risk for schizophrenia and their associations with symptoms in patients

This article provides a detailed examination of subclinical disturbances in the natural speech of healthy relatives beyond the age of risk for schizophrenia. Speech samples from 43 stable schizophrenia outpatients, 42 nonschizophrenia parents of patients (pairs only), and 23 control subjects matched to the parents were analyzed for frequencies of six specific types of communication failures. The parents had higher overall communication disturbance ratings than the control subjects. The specific types of failures that occurred more frequently were unclarities caused by (1) language structural breakdown, (2) use of vague, overinclusive words, and (3) use of words with ambiguous meanings. In intrafamilial analyses, higher levels of communication disturbance in parents were associated with greater severity of illness in their patient offspring. These results support the idea that communication disturbances may be one manifestation of a stable genetic vulnerability to schizophrenia. The nature of the failures identified suggests the possible involvement of weaknesses in specific areas of cognitive functioning.

Medicinal maggots: an ancient remedy for some contemporary afflictions

Certain fly larvae can infest corpses or the wounds of live hosts. Those which are least invasive on live hosts have been used therapeutically, to remove dead tissue from wounds, and promote healing. This medicinal use of maggots is increasing around the world, due to its efficacy, safety and simplicity. Given our low cultural esteem for maggots, the increasing use and popularity of maggot therapy is evidence of its utility. Maggot therapy has successfully treated many types of chronic wounds, but much clinical and basic research is needed still. In this review, the biology of myiasis and the history of maggot therapy are presented, the current status of our understanding and clinical use of medicinal maggots is discussed, and opportunities for future research and applications are proposed.

Parent coping styles and schizophrenic patient behavior as predictors of expressed emotion

Several studies have examined relationships between levels of expressed emotion in relatives of individuals with schizophrenia and the coping strategies these relatives employ. In an attempt to elucidate these relationships, 44 parents were assessed using the Camberwell Family Interview and the Strategic Approach to Coping Scale. Associations between these measures were examined. Additionally, interactions between parent coping style and patient aggression were assessed with respect to expressed emotion. The results indicate that scores on the coping scale generally were not directly related to levels of expressed emotion. However, an interaction was found between parent coping style and patient behavior which predicted level of expressed emotion. This finding supports the idea that research into the variables underlying expressed emotion should include the assessment of both parent and patient characteristics and examine the interactions between these variables.

Poisoning by Amanita phalloides ("deathcap") mushrooms in the Australian Capital Territory

Amanita phalloides ("deathcap") mushrooms are widespread in south-eastern Australia. Seven patients presented to hospital in the Australian Capital Territory with poisoning by this mushroom between 1988 and 1998. Three developed hepatoxicity and one died. Because A. phalloides is becoming more widespread, increased community and medical awareness is needed to reduce the frequency and morbidity of poisoning.

1997 summary: National Hospital Discharge Survey

OBJECTIVES

This report presents national estimates of the use of non-Federal short-stay hospitals in the United States during 1997. Numbers and rates of discharges, diagnoses, and procedures are shown by age and sex. Discharges are also shown by geographic region of the hospital. Average lengths of stay are presented for all discharges and for selected diagnostic categories by age and by sex.

METHODS

The estimates are based on medical abstract data collected through the National Hospital Discharge Survey for 1997. The survey has been conducted annually by the National Center for Health Statistics since 1965. Diagnoses and procedures presented are coded according to the International Classification of Diseases, 9th Revision, Clinical Modification, or ICD-9-CM.

Band-integrated infrared absorptance of low-molecular-weight paraffin hydrocarbons at high temperatures

The spectral absorptance of the 3.4-microm band of methane, ethane, propane, and butane has been measured with a Fourier transform infrared spectrometer over a range of temperatures from 296 to 900 K. The measurements were made at a 4-cm(-1) resolution and integrated over the entire band to give the total absorptance. The total absorptance is found to behave in such a way that it can be correlated by a combination of algebraic expressions that depend on the gas temperature and concentration. Average discrepancies between the correlations and the measurements are less than 4%, with maximum differences of no greater than 17%. In addition, the correlations presented here for methane are shown to be in good agreement with established models. Expressions given for the integrated intensity of each gas show an inverse dependence on temperature, reflecting the associated change in density.

Ambulatory and inpatient surgery: national patterns for the elderly

In 1996 the elderly made 13.6 million visits to ambulatory and inpatient settings for surgery. This was 401.0 visits per 1,000 population, which was approximately three and a half times the rate of 114.4 for persons under 65. A total of 25.3 million procedures were performed during these visits. More of the elderly's procedures were performed during inpatient visits (14.5 million procedures) than during ambulatory visits (10.7 million procedures). Three-quarters of the procedures performed on the elderly were in four categories: operations on the eye, cardiovascular operations, operations on the digestive system, and miscellaneous diagnostic and therapeutic procedures. The leading procedures for this age group were extraction of lens, insertion of lens, arteriography and angiocardiography, and endoscopies of small and large intestines. Women who comprised the majority of the elderly population had a larger number of procedures than men, but elderly men had a higher rate per 1,000 population. The 65-74 year-old group had the largest number of procedures, followed by 75-84 year-olds and then the 85 years and older group, reflecting the decreasing population size of these age groups. But the 75-84 year and 85 years and over groups had higher rates of procedures than those aged 65 to 74.

Prevalence of traumatic myiasis in Hungary: a questionnaire survey of veterinarians

Veterinarians in Hungary were asked to complete a questionnaire on traumatic myiasis; of the 664 veterinarians contacted, 247 replied (37.2 per cent) and of these 209 (84.6 per cent) reported myiasis to be a problem among the livestock they treated. Infestation levels of > 10 per cent of animals were reported in sheep, cattle and horses. The myiasis season lasted from March to November with most cases reported in July and August. Significantly more respondents reported that fly larvae were present deep in wounds rather than superficially, consistent with infestations due to the obligate parasite Wohlfahrtia magnifica (Diptera: Sarcophagidae). Frequent inspections and the treatment of infested animals were reported by 64.1 per cent of respondents as contributing to the economic impact of traumatic myiasis, and approximately half of the respondents (51.4 per cent) reported that inspections and treatments were carried out at least weekly during the summer. The most common form of treatment was the manual removal of larvae followed by topical application of insecticides, particularly organophosphates. More than half of the respondents (56.6 per cent) reported that there had been no change in the importance of myiasis over the last five to 10 years, but of those who reported a change, more reported an increase (28.3 per cent) than a decrease (15.2 per cent).

Magnitude and time course of hemodynamic responses to Mueller maneuvers in patients with congestive heart failure

To simulate the immediate hemodynamic effect of negative intrathoracic pressure during obstructive apneas in congestive heart failure (CHF), without inducing confounding factors such as hypoxia and arousals from sleep, eight awake patients performed, at random, 15-s Mueller maneuvers (MM) at target intrathoracic pressures of -20 (MM -20) and -40 cmH2O (MM -40), confirmed by esophageal pressure, and 15-s breath holds, as apneic time controls. Compared with quiet breathing, at baseline, before these interventions, the immediate effects [first 5 cardiac cycles (SD), P values refer to MM -40 compared with breath holds] of apnea, MM -20, and MM -40 were, for left ventricular (LV) systolic transmural pressure (Ptm), 1.0 +/- 1. 9, 7.2 +/- 3.5, and 11.3 +/- 6.8 mmHg (P < 0.01); for systolic blood pressure (SBP), 2.9 +/- 2.6, -5.5 +/- 3.4, and -12.1 +/- 6.8 mmHg (P < 0.01); and for stroke volume (SV) index, 0.4 +/- 2.8, -4.1 +/- 2.8, and -6.9 +/- 2.3 ml/m2 (P < 0.001), respectively. Corresponding values over the last five cardiac cycles were for LVPtm 6.4 +/- 4.4, 5.4 +/- 6.6, and -4.5 +/- 9.1 mmHg (P < 0.01); for SBP 6.9 +/- 4.2, -8.2 +/- 7.7, and -24.2 +/- 6.9 mmHg (P < 0.01); and for SV index -0. 4 +/- 2.1, -5.2 +/- 2.8, and -9.2 +/- 4.8 ml/m2 (P < 0.001), respectively. Thus, in CHF patients, the initial hemodynamic response to the generation of negative intrathoracic pressure includes an immediate increase in LV afterload and an abrupt fall in SV. The magnitude of response is proportional to the intensity of the MM stimulus. By the end of a 15-s MM -40, LVPtm falls below baseline values, yet SV and SBP do not recover. Thus, when -40 cmH2O intrathoracic pressure is sustained, additional mechanisms, such as a drop in LV preload due to ventricular interaction, are engaged, further reducing SV. The net effect of MM -40 was a 33% reduction in SV index (from 27 to 18 ml/min2), and a 21% reduction in SBP (from 121 to 96 mmHg). Obstructive apneas can have adverse effects on systemic and, possibly, coronary perfusion in CHF through dynamic mechanisms that are both stimulus and time dependent.

Ambulatory surgery in the United States, 1996

OBJECTIVES

This report presents estimates of surgical and nonsurgical procedures performed on an ambulatory basis in hospitals and freestanding ambulatory surgery centers in the United States during 1996. Data are presented by types of facilities, age and sex of the patient, and geographic region. Major categories of procedures and diagnoses are shown by age, sex, and region.

METHODS

The estimates are based on data collected by the 1996 National Survey of Ambulatory Surgery conducted by the National Center for Health Statistics. The 1996 data were abstracted from 125,000 medical records in 488 hospitals and freestanding ambulatory surgery centers.

Affective reactivity of speech in schizophrenia patients and their nonschizophrenic relatives

This study compared levels of referential communication disturbance in speech samples from 41 stable schizophrenia outpatients, 46 parents of patients, and 23 nonpsychiatric control participants in affectively positive versus affectively negative conditions. The speech of the patients and parents showed elevated frequencies of reference failures in the affectively positive condition compared with control participants: the speech of the patients became more disordered in the affectively negative condition, whereas the speech of the parents did not. These results support the idea that referential communication disturbances reflect vulnerability, as well as overt illness, but that affective reactivity of these disturbances is associated mainly with the manifest illness. These findings are consistent with biological, cognitive, and psychological theories about the processes underlying stress responsiveness of schizophrenic symptoms more generally.

Use of odour-baited sticky boards to trap tabanid flies and investigate repellents

Tabanid flies were captured in a sheep pasture in Hungary using black plastic boards (30 x 30 cm), coated with an adhesive sheet, which were either unbaited or baited with ethane-ethiol or Swormlure-4. Five species of tabanid were caught, of which Tabanus tergestinus was caught in the greatest number (87% of 192). The sex ratio of T. tergestinus on unbaited boards was not statistically significantly different to equality. However, on baited boards, males were significantly more numerous, probably due to a repellent effect of the odours on female tabanids. Because of the importance of repellents in tabanid control, this result encourages the exploration of a wider range of compounds as tabanid repellents than are used at present. Sticky boards offer a simple technique for trapping both sexes of tabanids, especially males, which are poorly represented in many tabanid traps.