CARD 2023: expanded curation, support for machine learning, and resistome prediction at the Comprehensive Antibiotic Resistance Database

The Comprehensive Antibiotic Resistance Database (CARD; card.mcmaster.ca) combines the Antibiotic Resistance Ontology (ARO) with curated AMR gene (ARG) sequences and resistance-conferring mutations to provide an informatics framework for annotation and interpretation of resistomes. As of version 3.2.4, CARD encompasses 6627 ontology terms, 5010 reference sequences, 1933 mutations, 3004 publications, and 5057 AMR detection models that can be used by the accompanying Resistance Gene Identifier (RGI) software to annotate genomic or metagenomic sequences. Focused curation enhancements since 2020 include expanded β-lactamase curation, incorporation of likelihood-based AMR mutations for Mycobacterium tuberculosis, addition of disinfectants and antiseptics plus their associated ARGs, and systematic curation of resistance-modifying agents. This expanded curation includes 180 new AMR gene families, 15 new drug classes, 1 new resistance mechanism, and two new ontological relationships: evolutionary_variant_of and is_small_molecule_inhibitor. In silico prediction of resistomes and prevalence statistics of ARGs has been expanded to 377 pathogens, 21,079 chromosomes, 2,662 genomic islands, 41,828 plasmids and 155,606 whole-genome shotgun assemblies, resulting in collation of 322,710 unique ARG allele sequences. New features include the CARD:Live collection of community submitted isolate resistome data and the introduction of standardized 15 character CARD Short Names for ARGs to support machine learning efforts.

P-112 PRE-OPERATIVE PAIN AND REDUCED QUALITY OF LIFE SCORES IN PATIENTS THAT REPORT PERSISTENT PAIN AT 365 DAYS FOLLOWING LAPAROSCOPIC INCISIONAL HERNIA REPAIR

Background

​The use of patient reported outcome measures (PROMs) for incisional hernia has been established. This study aims to explore relationships between persistent pain at Day365 post laparoscopic-IPOM repair and other clinical and patient-reported data for patients within the TACKoMESH randomised trial.

Methods

Clinical, operative and PROMs data were collected pre-operatively and at four post-operative time points up to one year. Pain scores were measured using a visual analogue scale (VAS). Quality of life (QoL) data were measured using the short-form 36 (SF-36) and Carolina Comfort Score (CCS). Patients reporting pain ‘at rest’ at Day365 were compared with those reporting no pain. Statistical analysis was undertaken in R studio.

Results

54/63 trial participants attended followed up at Day365; 36 were male, and mean age was 59.1.

10 patients reported persistent pain at Day365 ranging from 1–9 on VAS. Patients were found to have reported higher pre-operative pain scores ‘at rest’ (5 [2–7] vs 0 [0–3] p=0.0181) and ‘on activity’ (8.5 [5–10] vs 4 [2–8] p=0.0181). They reported lower QoL scores in every domain on the SF-36, with significantly lower score for social function (50 [31–50] vs 75 [63–100] p=0.006).

Those reporting persistent pain at Day365 were more likely to have developed hernia recurrence (4 vs 3 p=0.0171). There were no significant differences in baseline characteristics, operative variables, and other complication rates between the groups.

Conclusion

Patients that report persistent pain at Day365 following laparoscopic-IPOM repair are more likely to have reported higher pain and lower QoL scores at pre-operative assessment.

Diagnostic efficacy of cone beam computed tomography in paediatric dentistry: a systematic review

Purpose

To determine in which clinical situations it is indicated or contra-indicated to prescribe cone beam computed tomography (CBCT) for paediatric patients.

Methods

Systematic review of in vivo paediatric research studies of diagnostic efficacy using CBCT, with supplementary searches for guideline documents on CBCT and for systematic reviews permitting inclusion of ex vivo and adult studies.

Results

After screening, 190 publications were included, mostly case studies. No systematic reviews were found of in vivo paediatric research. Fourteen studies of diagnostic efficacy were identified. The supplementary searches found 18 guideline documents relevant to the review and 26 systematic reviews. The diagnostic efficacy evidence on CBCT was diverse and often of limited quality. There was ex vivo evidence for diagnostic accuracy being greater using CBCT than radiographs for root fractures. The multiplanar capabilities of CBCT are advantageous when localising dental structures for surgical planning. Patient movement during scanning is more common in children which could reduce diagnostic efficacy.

Conclusions

No strong recommendations on CBCT are possible, except that it should not be used as a primary diagnostic tool for caries. Guidelines on use of CBCT in the paediatric age group should be developed cautiously, taking into account the greater radiation risk and the higher economic costs compared with radiography. CBCT should only be used when adequate conventional radiographic examination has not answered the question for which imaging was required. Clinical research in paediatric patients is required at the higher levels of diagnostic efficacy of CBCT.

Electronic supplementary material

The online version of this article (10.1007/s40368-019-00504-x) contains supplementary material, which is available to authorized users.

Household air pollution and lung function in Indian adults: a cross-sectional study

Exposure to air pollution produced by cooking is common in developing countries, and represents a potentially avoidable cause of lung disease. Cross-sectional data were collected by the World Health Organization's Study on Global AGEing and Adult Health conducted in India between 2007 and 2010. Exposure to biomass cooking was also associated with a decrease in forced expiratory volume in 1 s (FEV1) (-70 ml, 95%CI -111 to -30) and FEV1/FVC (forced vital capacity) ratio (-0.025, 95%CI -0.035 to -0.015) compared to those who were not exposed. These associations were predominantly observed in males (P < 0.05 for interaction analyses). Intervention studies using non-biomass fuels in India are required to ascertain potential respiratory health benefits.

Patients with Essential Thrombocythaemia have an Increased Prevalence of Antiphospholipid Antibodies which may be associated with Thrombosis

A significant proportion of patients with Essential Thrombocythaemia (ET) have thrombotic complications which have an important impact upon the quality, and duration of their life. We performed a retrospective cross sectional study of the prevalence of antiphospholipid antibodies (APA) in 68 ET patients. Compared to 200 “elderly” controls (> 50 years) there was a significant increase in anticardiolipin IgM (p < 0.0001) and anti β2 glycoprotein I (anti-β2GPI) IgM (p < 0.0001) antibodies in ET. Thrombosis occurred in 10/20 with APA and 12/48 without, p = 0.04, relative risk 2.0 (95% confidence intervals 1.03–3.86); these patients did not differ in terms of other clinical features. The prevalence of thrombosis in patients with dual APA (6/7) was significant when compared to those with single APA (p = 0.02) and the remaining patients (p < 0.0002). Also anti-β2GP1 IgM antibodies either alone, or in combination with another APA, were associated with thrombosis (p = 0.02). These results suggest that the prevalence of APA in ET and their influence upon thrombotic risk merit investigation in a larger study.

Oxidative photoreactivity of mono-transition-metal functionalized lacunary Keggin anions

The photooxidative activity of mono-transition-metal functionalized lacunary silicotungstate Keggin anions is reported together with preliminary mechanistic insight into the photoreactivity.

Neurological soft signs in children with attention deficit hyperactivity disorder

CONTEXT

Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder with wide repercussions. Since it is etiologically related to delayed maturation, neurological soft signs (NSS) could be a tool to assess this. Further the correlation of NSS with severity and type of ADHD and presence of Specific Learning Disability (SLD) would give further insight into it.

AIMS

To study neurological soft signs and risk factors (type, mode of delivery, and milestones) in children with ADHD and to correlate NSS with type and severity of ADHD and with co-morbid Specific Learning Disability.

SETTINGS AND DESIGN

The study was carried out in Child care services of a tertiary teaching urban hospital. It was a cross-sectional single interview study.

MATERIALS AND METHODS

52 consecutive children diagnosed as having ADHD were assessed for the presence of neurological soft signs using Revised Physical and Neurological Examination soft Signs scale (PANESS). The ADHD was rated by parents using ADHD parent rating scale.

STATISTICAL ANALYSIS

The data was analyzed using the chi-squared test and Pearson's co-relational analysis.

RESULTS AND CONCLUSIONS

Neurological soft signs are present in 84% of children. They are equally present in both the inattentive-hyperactive and impulsive-hyperactive types of ADHD. The presence of neurological soft signs in ADHD are independent of the presence of co-morbid SLD. Dysrrhythmias and overflow with gait were typically seen for impulsive-hyperactive type and higher severity of ADHD is related to more errors.

[Intraosseous infusion in the pediatric emergency medical service. Analysis of emergency medical missions 1990-2009]

BACKGROUND

Timely establishment of venous access in infants and toddlers during emergency medical care can be a particularly challenging task. Alternative routes for drug and fluid administration, such as endobronchial, intramuscular, central venous or venous cut-down do not offer reliable solutions. Intraosseous infusion (IOI) has become established as an effective alternative intravascular access for rapid and efficient drug delivery. IOI was introduced in our local emergency medical service (EMS) in 1993 and was assigned a high priority in international guidelines for pediatric emergency medical care in 2000 and 2005. The aim of this study was to review the impact of the introduction of IOI on drug administration routes during prehospital emergency treatment of critically ill or severely injured pediatric patients (NACA index V-VII) in our tertiary medical care centre over a period of 20 years.

METHODS

Pediatric prehospital emergency medical protocols from 1990 to 2009 were analyzed with respect to the administration routes for fluids and medications in severely injured or critically ill children with NACA severity scores V-VII. The frequency and mode of vascular access during prehospital treatment including IOI, endobronchial administration, central venous catheterization (CVC) and intramuscular administration as well as prehospital treatment and transportation without vascular access were analyzed. Two groups were compared: the introduction phase of IOI between 1990 and 1999 and the phase of growing IOI routine after introducing guidelines and regular staff IOI technique training between 2000 and 2009. Demographic data and drug administration routes in the two different time periods were analyzed using the Mann-Whitney-u test and t-test or χ(2)-test, respectively. A p-value <0.05 was regarded as significant.

RESULTS

A total of 5,279 pediatric prehospital emergency charts were analyzed and 401 patients (7.6%) were scored as NACA V-VII. At the emergency scene 299 patients (75%) received a peripheral intravenous access, 3 (0.7%) a central venous line access, 77 (19%) an intraosseous needle and in 22 (5.4%) no vascular or intraosseous access was used during the course of prehospital treatment (NACA VII - 13 patients, NACA VI - 2 patients, NACA V - 7 patients). Of the NACA VII patients 3 were transported under continuous cardiopulmonary resuscitation without vascular access. After 2002 all patients with NACA index VII were treated with vascular or intraosseous access. In 48 patients (12%) at least initial medication was given by the endobronchial or alternative route but within the last 3 years endobronchial drug administration was no longer reported. Thus, in 124 critically ill patients (31%) routine peripheral venous access could not be established initially or until the end of treatment (77 times IOI, 22 times no access over the course of treatment, 3 times CVC and 22 times initial endobronchial followed by peripheral venous access). Over the reviewed period the use of IOI increased significantly (p<0.001), while the incidence of lacking vascular access (p<0.05) and alternative drug administration routes (p<0.001) continuously decreased.

CONCLUSION

The IOI technique has not only been assigned a high priority in the guidelines for pediatric emergency care of critically ill children with difficult or failed venous access but has also significantly influenced current prehospital care. The introduction of the IOI technique in our prehospital pediatric emergency system has markedly reduced the number of critically ill or severely injured pediatric patients without vascular access or with less reliable alternative administration routes in the last 20 years.

Personalizing Stem Cell Research and Therapy: The Arduous Road Ahead or Missed Opportunity?

The euphoria of stem cell therapy has diminished, allowing scientists, clinicians and the general public to seriously re-examine how and what types of stem cells would effectively repair damaged tissue, prevent further tissue damage and/or replace lost cells. Importantly, there is a growing recognition that there are substantial person-to-person differences in the outcome of stem cell therapy. Even though the small molecule pharmaceuticals have long remained a primary focus of the personalized medicine research, individualized or targeted use of stem cells to suit a particular individual could help forecast potential failures of the therapy or identify, early on, the individuals who might benefit from stem cell interventions. This would however demand collaboration among several specialties such as pharmacology, immunology, genomics and transplantation medicine. Such transdisciplinary work could also inform how best to achieve efficient and predictable stem cell migration to sites of tissue damage, thereby facilitating tissue repair. This paper discusses the possibility of polarizing immune responses to rationalize and individualize therapy with stem cell interventions, since generalized "one-size-fits-all" therapy is difficult to achieve in the face of the diverse complexities posed by stem cell biology. We also present the challenges to stem cell delivery in the context of the host related factors. Although we focus on the mesenchymal stem cells in this paper, the overarching rationale can be extrapolated to other types of stem cells as well. Hence, the broader purpose of this paper is to initiate a dialogue within the personalized medicine community by expanding the scope of inquiry in the field from pharmaceuticals to stem cells and related cell-based health interventions.

Beneficial effects of yoga lifestyle on reversibility of ischaemic heart disease: caring heart project of International Board of Yoga

OBJECTIVES

Yoga based lifestyle modifications have been earlier shown to be beneficial in coronary artery disease in a small number of patients. We evaluated the role of lifestyle modification based on Yoga techniques, stress management and dietary modifications in retardation of coronary artery disease.

METHODS

This prospective, controlled, open trial included angiographically proven coronary artery disease patients (71 patients in study group and 42 patients in control group). They were assessed clinically, by biochemical parameters, stress myocardial perfusion and function studies and coronary angiography and on psychological parameters. The study group patients were given a family based Yoga Programme which included, control of risk factors, dietary modifications and stress management for a period of one year. The patients were assessed at baseline, at frequent intervals and at the end of one year.

RESULTS

At the end of one year of yoga training, statistical significant changes (P<0.05) were found in serum total cholesterol (reduction by 23.3% in study group patients as compared to 4.4% in controls); serum LDL cholesterol (reduction of 26% in study group patients as compared to 2.6% in the control group), regression of disease (43.7% of study group patients v/s 31% control group on MPI and 70.4% of study group v/s 28% of control group on angiography) arrest of progression (46.5% study group v/s 33.3% control group on MPI) and progression (9.9% of study group vs 35.7% of controls on MPI, 29.6% of study group v/s 60.0% of controls on angiography). At the end of the study improvement in anxiety scores was concordant with the improvement seen in the MPI. No untoward effects of the therapy were observed.

CONCLUSION

Yoga based lifestyle modifications help in regression of coronary lesions and in improving myocardial perfusion. This is translated into clinical benefits and symptomatic improvement.

Mounier-Kuhn syndrome

A variant of Mounier-Kuhn syndrome is reported where the patient had bronchiectasis with tracheo-bronchomegaly. The patient also had facial anomalies and asthenozoospermia. This combination has not been reported so far in the literature.

Patients with essential thrombocythaemia have an increased prevalence of antiphospholipid antibodies which may be associated with thrombosis

A significant proportion of patients with Essential Thrombocythaemia (ET) have thrombotic complications which have an important impact upon the quality, and duration of their life. We performed a retrospective cross sectional study of the prevalence of antiphospholipid antibodies (APA) in 68 ET patients. Compared to 200 "elderly" controls (>50 years) there was a significant increase in anticardiolipin IgM (p < 0.0001) and anti beta2 glycoprotein I (anti-beta2GPI) IgM (p < 0.0001) antibodies in ET. Thrombosis occurred in 10/20 with APA and 12/48 without, p = 0.04, relative risk 2.0 (95% confidence intervals 1.03-3.86): these patients did not differ in terms of other clinical features. The prevalence of thrombosis in patients with dual APA (6/7) was significant when compared to those with single APA (p = 0.02) and the remaining patients (p < 0.0002). Also anti-beta2GP1 IgM antibodies either alone, or in combination with another APA, were associated with thrombosis (p = 0.02). These results suggest that the prevalence of APA in ET and their influence upon thrombotic risk merit investigation in a larger study.

Reversal of autocrine and paracrine effects of interleukin 1 (IL-1) in human arthritis by type II IL-1 decoy receptor. Potential for pharmacological intervention

Interleukin 1 (IL-1), produced by both synovial cells and chondrocytes, plays a pivotal role in the pathogenesis of cartilage destruction in osteoarthritis (OA). We examined the specific expression and function of IL-1 receptor family-related genes in human joint tissues. Gene array analysis of human normal and OA-affected cartilage showed mRNA expression of IL-1 receptor accessory protein (IL-1RAcp) and IL-1 type I receptor (IL-1RI), but not IL-1 antagonist (IL-1ra) and IL-1 type II decoy receptor (IL-1RII). Similarly, human synovial and epithelial cells showed an absence of IL-1RII mRNA. Functional genomic analyses showed that soluble (s) IL-1RII, at picomolar concentrations, but not soluble TNF receptor:Fc, significantly inhibited IL-1beta-induced nitric oxide (NO) and/or prostaglandin E(2) production in chondrocytes, synovial and epithelial cells. In OA-affected cartilage, the IC(50) for inhibition of NO production by sIL-1RII was 2 log orders lower than that for sIL-1RI. Human chondrocytes that overexpressed IL-1RII were resistant to IL-1-induced IL-1beta mRNA accumulation and inhibition of proteoglycan synthesis. In osteoarthritis, deficient expression by chondrocytes of innate regulators or antagonists of IL-1 such as IL-1ra and IL-1RII (soluble or membrane form) may allow the catabolic effects of IL-1 to proceed unopposed. The sensitivity of IL-1 action to inhibition by sIL-1RII has therapeutic implications that could be directed toward correcting this unfavorable tissue(s) dependent imbalance.

COX-2, NO, and cartilage damage and repair

The production of nitric oxide (NO) and prostaglandin E2 (PGE(2)) is increased in human osteoarthritis-affected cartilage. These and other inflammatory mediators are spontaneously released by OA cartilage explants ex vivo. The excessive production of nitric oxide inhibits matrix synthesis, and promotes its degradation. Furthermore, by reacting with oxidants such as superoxide anion, nitric oxide promotes cellular injury, and renders the chondrocyte susceptible to cytokine-induced apoptosis. PGE(2) exerts both anabolic and catabolic effects on chondrocytes, depending on the microenvironment and physiological condition. Thus, NO and PGE(2), produced by activated chondrocytes in diseased cartilage, may modulate disease rogression in osteoarthritis, and should therefore be considered potential targets for therapeutic intervention

A comparative study of psychological factors in patients with normal and abnormal angiographic findings

Chest pain is one of the most common symptoms in psychiatric and primary care practice and a frequent reason for extensive diagnostic work-up. Despite extensive investigations no recognizable medical cause to account for these symptoms is detected in many patients with chest pain. Studies of patients with non-cardiac chest pain have revealed that many continue to report symptoms and disability despite medical reassurances.The aims of the study were to evaluate the prevalence of psychiatric morbidity, personality profile and stressors along with functional impairment in patients with chest pain and normal angiographic findings and compare the same with patients who have chest pain but abnormal angiographic findings and a diagnosis of ischemic heart disease.The study included 30 consecutive patients in each group. The scales used were SCID-I of DSM-III-R, 16-PF, semi structured questionnaire for assessment of type A behaviour, PSLES and GAF scale of DSM-III-R.Panic disorder and depression were highly prevalent in patients with atypical chest pain. These patients had lower prevalence of type A behaviour, a unique 16-PF profile, experienced more stresses at any given point in time and significant impairment in day-day and in socio-occupational functioning.

Beta2-agonist abuse in food producing animals: use of in vitro liver preparations to assess biotransformation and potential target residues for surveillance

1. The biotransformation of [3H]clenbuterol, [3H]salbutamol, [14C]salmeterol and 7-ethoxycoumarin by bovine liver was investigated by incubation with freshly prepared microsomes, suspension and monolayer cultures of isolated hepatocytes, precision-cut (250 microm) and chopped (600 microm) tissue slices. 2. Radio-HPLC analysis indicated that the saligenin beta2-agonists salmeterol and salbutamol were extensively metabolized by all intact cell preparations. A single major product (SmM1) was evident for salmeterol and two unresolved products for salbutamol (SbM1 and SbM2). Differential enzyme hydrolysis studies with Helix pomatia beta-glucuronidase/aryl sulphatase indicated that the main metabolites were glucuronide conjugates. Consistent with this, analysis of metabolites by liquid chromatography-mass spectrometry showed molecular ions ([M+H]+) at m/z 592 for Sm1 and 416 for both Sb1 and Sb2. 3. Comparable studies with clenbuterol revealed three minor metabolites. Prolonged incubations generated products representing, at maximum, 27% biotransformation. Two of the products have been identified as a glucuronide ([M+H]+, m/z 453) and hydroxyclenbuterol ([M+H]+, m/z 293). 4. These findings indicate that in vitro studies provide simple and cost-effective means of evaluating xenobiotic metabolism, and thus of identifying potential target residues to enable surveillance of use of unlicensed veterinary drugs, or prohibited substances in farm animals.

Regulation of cytosolic COX-2 and prostaglandin E2 production by nitric oxide in activated murine macrophages

Murine macrophages (RAW 264.7) when stimulated with LPS show 90% distribution of cyclooxygenase-2 (COX-2) in the nuclear fraction and approximately 10% in the cytosolic fraction. Further analysis of this cytosolic fraction at 100,000 x g indicates that the COX-2 is distributed both in the 100,000 x g soluble fraction and membrane fraction. Stimulation of RAW 264.7 cells with LPS in the presence of inducible nitric oxide synthase inhibitor L-NMMA at concentrations that inhibit nitrite accumulation by </=80% is inadequate to augment PGE2 production. However, inhibition of nitrite accumulation by >/=85% with higher concentrations of L-NMMA shows 1) up-regulation of PGE2 production, 2) accumulation of COX-2 protein in the 100,000 x g soluble and membrane fractions of the cytosolic fraction, and 3) with no significant effects on the accumulation of COX-2 mRNA. These experiments suggest that low concentrations of nitric oxide (10-15% of the total) attenuate PGE2 production in response to LPS in RAW 264.7 cells. This inhibition is, in part, due to decreased expression of cytosolic COX-2 protein.

Performance on the Rey-Osterrieth Complex Figure Test in Alzheimer disease and vascular dementia

BACKGROUND

Alzheimer disease (AD) and vascular dementia (VaD) are the two most common age-associated dementias. Neuropsychologic studies have demonstrated visuoconstructional impairment in AD and in VaD.

OBJECTIVE

This study used the Rey-Osterrieth Complex Figure to assess and compare specific aspects of visuoconstructional deficits in patients with AD, patients with VaD, and normal age-matched subjects.

METHOD

Thirteen normal controls, 20 patients with AD, and 20 patients with VaD were given a neuropsychologic battery as part of a comprehensive evaluation for dementia. The groups were similar in age and education, and the VaD and AD groups had comparable levels of dementia. Based on their previous research on visual deficits in AD, the authors devised a new scoring system that divided the Rey-Osterrieth Complex Figure into six perceptual categories: right, left, upper, lower, basic gestalt, and inner detail.

RESULTS

Patients with AD and patients with VaD had significant deficits in all six Rey-Osterrieth Complex Figure scoring categories compared with normal controls. Patients with AD exhibited a pattern of deficits similar to that of patients with VaD, with one significant exception: The patients with AD had increased left-sided errors or inattention.

CONCLUSIONS

These results suggest that left hemispatial inattention contributes to impaired performance on visuoconstructional tasks in AD.

Determination of oestrogen concentrations in bovine plasma by a recombinant oestrogen receptor-reporter gene yeast bioassay

A recombinant cell yeast bioassay (RCBA) was applied to the generic measurement of bovine plasma oestrogen concentration. Samples were prepared by diethyl ether extraction of plasma following addition of [3H]17 beta-oestradiol as internal standard; organic and aqueous phases were separated by freezing (recovery 97.1 +/- 0.7%) and dried extract reconstituted in culture medium (recovery 31.4 +/- 4.5%). Plasma oestrogen concentrations were measured by incubation of extracts with yeast containing a stable human oestrogen receptor (hER) and a reporter construct comprising an hER response element regulating beta-galactosidase expression. The linearity of response for the analysis of spiked plasma samples using the RCBA, following corrections, is described by y = 0.8994x - 0.111 (r2 = 0.9776, P < 0.0001). Inter-assay variation for endogenous oestrogen was 11.5% for > 1 pg ml-1. Plasma oestrogen concentrations for intact (n = 5) and castrated (n = 3) males were < 0.5 pg ml-1, and 3.7 +/- 2.6 pg ml-1 for luteal phase females (n = 10). Analysis by RCBA of sequential samples from heifers during the reproductive cycle failed to detect the pre-ovulatory increase in plasma 17 beta-oestradiol as determined by radioimmunoassay (RIA) (maximal concentrations 2.09 +/- 2.1 pg ml-1 and 32.6 +/- 14.6 pg ml-1, respectively). Interestingly, when samples were hydrolysed using Helix pomatia glucuronidase the RCBA gave concentrations (29.5 +/- 8.9 pg ml-1) not significantly different to those obtained by RIA. These preliminary findings suggest that a substantial proportion of plasma oestrogen during the pre-ovulatory period may be conjugated. These data indicate the potential of the RCBA to measure biologically active and physiological levels of plasma oestrogens in cattle. One potentially valuable application of this generic oestrogen assay could be in surveillance programmes to detect illegal use of anabolic oestrogens in live-stock where the identity of the analyte may be unknown.

Clenbuterol plasma pharmacokinetics in cattle

The pharmacokinetics of clenbuterol (Cb) were investigated to determine the extent to which analysis of plasma concentration can be used to discriminate between therapeutic and illicit growth promoting treatment of cattle. Analysis of plasma concentration enabled assessment of the extent of differences in pharmacokinetics between such dosing regimens. Cattle were treated with Cb using either a therapeutic (20 calves, 0.8 microgram Cb kg-1, twice daily in feed for 10 days), or growth promoting (30 calves, 10 micrograms Cb kg-1, twice daily by drench for 20 days) dosing regimens. Blood samples were collected by jugular venepuncture, and plasma Cb concentrations determined by direct enzyme immunoassay. To determine plasma pharmacokinetics, use of a two compartment model was applied to the data and revealed that steady state kinetics were reached after 3 and 5 days following initiation of therapeutic and growth promoting dosing regimens, respectively. Tolerance limit analysis of concentrations during the therapeutic regimen indicated that a plasma Cb concentration greater than 1.63 ng ml-1 would be indicative (p < 0.01) of a growth promoting dose.

Analysis of di-n-butylphthalate biotransformation in cattle by liquid chromatography/ion trap mass spectrometry/mass spectrometry

The nature of products of contamination intake were investigated in cattle dosed with [14C]di-n-butylphthalate (DBP). Radio-labelled metabolites were extracted from bile, faeces, plasma and urine onto solid-phase media, fractionated by ion-exchange chromatography, separated by reverse phase HPLC and analysed by negative ion atmospheric pressure chemical ionization mass spectrometry(n) (LCQ, Finnigan). All matrices contained a common major metabolite [deprotonated molecular ion (M-H)- m/z 221] which coeluted with and had an identical daughter ion spectrum to reference monobutylphthalate (MBP). MBP was metabolised to a beta-glucuronidase sensitive compound (M-H)- m/z 397 whose spectrum contained daughter ions (m/z 175 and 221) consistent with the parent glucuronide. A further three beta-glucuronidase resistant radio-labelled metabolites were also produced (M-H- m/z 165, 193 and 237); comparison of daughter ion spectra with those of reference MBP and phthalic acid indicated identity with phthalic acid, monoethylphthalate (MEP) and monohydroxybutylphthalate (MHBP) respectively. The presence of a benzoate daughter ion (m/z 121) in all spectra was indicative of side chain biotransformation. Both MBP and MEP contained a phthalate daughter ion (m/z 165) indicating loss of a butyl and ethyl side chain respectively. A daughter ion of m/z 89 derived from the side chain provided evidence that the third metabolite was MHBP. Incubation of DBP with isolated bovine hepatocytes produced the same metabolites and provided relatively clean samples for LC/MSn analysis. Detection of these DBP metabolites in meat or dairy food products will provide evidence for environmental exposure and biotransformation in vivo, whereas the presence of the parent compound would suggest contamination during food processing and packaging.

Biotransformation, tissue distribution, and persistence of 4-nonylphenol residues in juvenile rainbow trout (Oncorhynchus mykiss)

Alkylphenols are weak oestrogenic environmental contaminants and have been implicated in the disruption of endocrine function in wildlife. The influence of biotransformation, tissue distribution, and elimination on biological activity was investigated in juvenile rainbow trout following a single iv dose of [3H]4-nonylphenol. Distribution and elimination of [3H]4-nonylphenol residues in tissues sampled 1, 2, 4, 24, 48, 72, and 144 hr after dosing was determined by sample combustion and liquid scintillation counting (LSC). Total 3H-labeled residue concentrations in trout 144 hr after dosing were in order: bile >> faeces >> liver > pyloric caecae > kidney > brain, gill, gonad, heart, plasma, skeletal muscle, and skin. The depletion kinetics of [3H]residues from tissues and plasma was biphasic with prolonged beta-phase half-lives in muscle and liver of 99 hr. Radio-HPLC analysis of metabolites in bile, liver, pyloric caecae, and faeces samples demonstrated similar profiles and contrasted with muscle where only parent compound was found. The predominant metabolite in bile was a glucuronide conjugate of 4-nonylphenol. Other metabolites included glucuronide conjugates of ring or side chain hydroxylated 4-nonylphenol. Liver contained a low level (1.7%) of covalently bound residues. Metabolism studies using isolated trout hepatocytes produced a similar range of metabolites and a sulfate conjugate of hydroxylated 4-nonylphenol. Despite rapid metabolism and excretion, a substantial depot of parent compound remained in muscle which will have implications for the maintenance of 4-nonylphenol residues and associated biological activity.

Evaluation of a recombinant yeast cell estrogen screening assay

A wide range of chemicals with diverse structures derived from plant and environmental origins are reported to have hormonal activity. The potential for appreciable exposure of humans to such substances prompts the need to develop sensitive screening methods to quantitate and evaluate the risk to the public. Yeast cells transformed with plasmids encoding the human estrogen receptor and an estrogen responsive promoter linked to a reporter gene were evaluated for screening compounds for estrogenic activity. Relative sensitivity to estrogens was evaluated by reference to 17 beta-estradiol (E2) calibration curves derived using the recombinant yeast cells, MCF-7 human breast cancer cells, and a prepubertal mouse uterotrophic bioassay. The recombinant yeast cell bioassay (RCBA) was approximately two and five orders of magnitude more sensitive to E2 than MCF-7 cells and the uterotrophic assay, respectively. The estrogenic potency of 53 chemicals, including steroid hormones, synthetic estrogens, environmental pollutants, and phytoestrogens, was measured using the RCBA. Potency values produced with the RCBA relative to E2 (100) included estrone (9.6), diethylstilbestrol (74.3), tamoxifen (0.0047), alpha-zearalanol (1.3), equol (0.085), 4-nonylphenol (0.005), and butylbenzyl phathalate (0.0004), which were similar to literature values but generally higher than those produced by the uterotrophic assay. Exquisite sensitivity, absence of test compound biotransformation, ease of use, and the possibility of measuring antiestrogenic activity are important attributes that argue for the suitability of the RCBA in screening for potential xenoestrogens to evaluate risk to humans, wildlife, and the environment.

Randomised controlled trial of aspirin and aspirin plus heparin in pregnant women with recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies)

OBJECTIVE

To determine whether treatment with low dose aspirin and heparin leads to a higher rate of live births than that achieved with low dose aspirin alone in women with a history of recurrent miscarriage associated with phospholipid antibodies (or antiphospholipid antibodies), lupus anticoagulant, and cardiolipin antibodies (or anticardiolipin antibodies).

DESIGN

Randomised controlled trial.

SETTING

Specialist clinic for recurrent miscarriages.

SUBJECTS

90 women (median age 33 (range 22-43)) with a history of recurrent miscarriage (median number 4 (range 3-15)) and persistently positive results for phospholipid antibodies.

INTERVENTION

Either low dose aspirin (75 mg daily) or low dose aspirin and 5000 U of unfractionated heparin subcutaneously 12 hourly. All women started treatment with low dose aspirin when they had a positive urine pregnancy test. Women were randomly allocated an intervention when fetal heart activity was seen on ultrasonography. Treatment was stopped at the time of miscarriage or at 34 weeks' gestation.

MAIN OUTCOME MEASURES

Rate of live births with the two treatments.

RESULTS

There was no significant difference in the two groups in age or the number and gestation of previous miscarriages. The rate of live births with low dose aspirin and heparin was 71% (32/45 pregnancies) and 42% (19/45 pregnancies) with low dose aspirin alone (odds ratio 3.37 (95% confidence interval 1.40 to 8.10)). More than 90% of miscarriages occurred in the first trimester. There was no difference in outcome between the two treatments in pregnancies that advanced beyond 13 weeks' gestation. Twelve of the 51 successful pregnancies (24%) were delivered before 37 weeks' gestation. Women randomly allocated aspirin and heparin had a median decrease in lumbar spine bone density of 5.4% (range -8.6% to 1.7%).

CONCLUSION

Treatment with aspirin and heparin leads to a significantly higher rate of live births in women with a history of recurrent miscarriage associated with phospholipid antibodies than that achieved with aspirin alone.

Subxiphoid pericardial window for pericardial effusion in end-stage renal disease

Fifty-seven patients with end-stage renal disease who were on maintenance dialysis underwent pericardial fluid drainage surgically between January 1980 and December 1991. All patients had echocardiographically proven pericardial effusion of more than 300 to 500 mL. Seven patients had pericardiectomy by left thoracotomy under general anesthesia in the first 2 years. Subsequently, 50 patients underwent a subxiphoid pericardial window by a left subcostal incision. A pericardial drainage tube was inserted at surgery and removed after 4 to 5 days. All but five patients undergoing subxiphoid pericardial window surgery received local anesthesia. The xiphoid process was not resected during surgery and steroids were not instilled in the pericardial cavity. There were minimal complications, no surgery-related deaths, and no recurrence of fluid in patients after pericardial window surgery. With our present experience, we advise a subxiphoid pericardial window with pericardial drainage under local anesthesia for all end-stage renal disease patients on dialysis who have a symptomatic or large pericardial effusion of more than 300 to 500 mL. Steroid instillation is not necessary for the prevention of recurrence of effusion.

Second-trimester pregnancy loss is associated with activated C resistance

We have investigated whether activated protein C resistance (APCR) is associated with second-trimester miscarriage. The prevalence of APCR was significantly higher amongst women with a history of second-trimester miscarriage (10/50; 20%) compared with either women with a history of first-trimester miscarriages only (4/70; 5.7%) or a control group of parous women with no previous history of pregnancy losses (3/70; 4.3%) (P < 0.02). These results suggest that APCR may be an important mechanism of second-trimester pregnancy loss, possibly related to the increase in intravascular coagulation that occurs during pregnancy.

Hypophosphatemia in end stage renal disease

A case of hypophosphatemia in a 55-year-old black female on maintenance hemodialysis is described. She developed multiple bone fractures and congestive heart failure during her 10-year period on hemodialysis. Iliac crest bone biopsy revealed osteomalacia with absent aluminium stores. Management was difficult due to her noncompliance secondary to severe depression. Though osteomalacia and cardiomyopathy due to hypophosphatemia are described in patients with end stage renal disease on dialysis, it is an uncommon entity.

Antiphospholipid antibodies and beta 2-glycoprotein-I in 500 women with recurrent miscarriage: results of a comprehensive screening approach

Five hundred consecutive women (median age 33 years; range 19-45) with a history of recurrent miscarriage (median 4; range 3-16) were screened for the presence of antiphospholipid antibodies (APA)-lupus anticoagulant (LA) and/or anticardiolipin antibodies (ACA). The prevalence of persistently positive tests for LA was 9.6% and for immunoglobulin G (IgG) and immunoglobulin M (IgM) ACA was 3.3 and 2.2% respectively. Only seven women (1.4%) were LA and ACA positive. Repeat testing, after an interval of at least 8 weeks, demonstrated that only 65.7% of LA positive, 36.6% IgG ACA positive and 36.0% IgM ACA positive women on initial testing had a second positive test result. The dilute Russell's viper venom time detected the LA significantly more often than either the activated partial thromboplastin time or the kaolin clotting time (P < 0.001). There was no difference in the gestation of previous miscarriages between APA positive and APA negative women. There was no difference in the plasma beta 2-glycoprotein-I concentrations between APA positive and APA negative women with miscarriages and normal women. All women with a history of recurrent miscarriage should be tested for the presence of both LA and ACA. A second confirmatory test should be performed in those with an initial positive test result.

Imidocarb residues in edible bovine tissues and in vitro assessment of imidocarb metabolism and cytotoxicity

Imidocarb residues in liver and muscle were measured by HPLC after a single therapeutic dose to cattle (3 mg imidocarb dipropionate kg-1). Imidocarb and 7-ethoxycoumarin metabolism were compared in three different in vitro systems prepared from bovine liver: cultures of hepatocyte monolayers, precision-cut liver slices, and microsomes. The potential hepatotoxicity of imidocarb residues was tested on hepatocyte monolayers and assessed using the neutral red and lactate dehydrogenase leakage assays. The concentration of imidocarb (mean +/- SD) decreased between days 14 and 224 after treatment from 5.40 +/- 0.61 to 0.12 +/- 0.01 and from 1.05 +/- 0.31 to 0.06 +/- 0.02 microgram g-1 in liver and muscle, respectively. The depletion kinetics of imidocarb fitted a two-compartment model with alpha- and beta-phase half-lives of 31.7 and 48.5 days in liver and 34.9 and 120.7 days in muscle, respectively. Imidocarb metabolites were not detected in any in vitro system. 7-Ethoxycoumarin metabolism was found in all in vitro systems; the predominant metabolite produced by hepatocyte and liver slice cultures was umbelliferone glucuronide. Cytotoxicity of imidocarb (100 microM) to hepatocyte monolayers was maximal after 72 hr treatment and dose-dependent above 10 microM imidocarb. It is most likely that the hepatotoxicity of imidocarb is caused by the parent compound, because no evidence for imidocarb metabolism was found.