Successful Confirmation of Dual Genital Herpes Co-Infection with Herpes Simplex Virus 1 and Herpes Simplex Virus 2 Using Unbiased Metagenomic Next-Generation Sequencing

Dual co-infection with both HSV-1 and HSV-2 is rare, with few cases reported in the literature. In this case report, we describe the successful use of unbiased metagenomic next-generation sequencing (mNGS) as a rapid and alternative method for confirming dual genital herpes co-infection. Our case involves a 74-year-old woman who presented with genital lesions and initially tested positive for both HSV-1 and HSV-2 via the Luminex ARIES HSV 1&2 assay. The entire mNGS process, from nucleic acid extraction to result analysis, was completed in less than 48 h. Using mNGS, we identified mapped reads specific to either HSV-1 or HSV-2 and screened the sequences to rule out mis-genotyping by the Luminex ARIES assay. Notably, the generated sequences can reveal sequence variations within multiple gene regions, demonstrating the potential of mNGS for identifying novel HSV-1 and HSV-2 variants. Our findings suggest that mNGS can serve as a rapid and reliable alternative confirmatory method for dual genital herpes infections, providing valuable information to guide appropriate treatment options for patients. By eliminating the need for prior knowledge of causative agents, mNGS offers an unbiased approach for detecting and characterizing viral co-infections.

Effect of the use of earplugs and eye masks on the quality of sleep after major abdominal surgery: a randomised controlled trial

Significant sleep disturbance can occur following major abdominal surgery. We aimed to evaluate the effectiveness of earplugs and eye masks in improving sleep quality and patient satisfaction, reducing nursing demands and in the incidence of delirium in patients after major abdominal surgery. We conducted a randomised controlled trial in 100 patients undergoing major abdominal surgery. We randomly allocated participants to sleep with or without earplugs and eye masks on postoperative days 1-3. The primary outcome measure was sleep quality as measured by the Richards-Campbell Sleep Questionnaire. Secondary outcomes were patient satisfaction, frequency of nursing demand and incidence of delirium measured by the Neelon and Champagne Confusion Scale. Median (IQR [range]) sleep scores were 64 (38-74 [0-100] and 60 (44-82 [18-100]) for the control and intervention groups, respectively (p = 0.310). Age and Pittsburgh Sleep Quality Index scores were found to be significant factors affecting sleep quality. There were no differences in patient satisfaction, reduction in frequency of nursing demands or incidence of delirium on postoperative days 1-3 after major abdominal surgery. The compliance rate in the intervention group was 60-65%. This study has demonstrated that the use of earplugs and eye masks did not contribute to improvements in sleep quality. Of note, sleep quality was moderate, with higher age and worse baseline sleep quality contributing to worse sleep scores. More studies are needed to investigate interventions to improve sleep quality after major abdominal surgery.

Tunability of Acoustic and Mechanical Behaviors in Breast Tissue Mimicking Materials

In radiology practices, the ultrasound-guided breast biopsy is among the most commonly performed minimally invasive procedures. However, many radiology residents in their graduate residencies are found with little or no hands-on experience with ultrasound-guided breast procedures. To enhance safety, the problem can be solved by the use of anthropomorphic training phantoms which can provide the resident with realistic ultrasound imaging and needle insertion haptic feedback. Stiffness and acoustic properties of breast tissues vary between different people. The training breast phantom should be able to possess different acoustic and mechanical properties which conform the inconsistencies found in real tissues among people. Therefore, this paper investigates the tunability of acoustic and mechanical behaviors in breast tissue mimicking materials (TMMs). Experiments of central composite design (CCD) with a center point, four corner points, and an additional four axis points were used to fit the non-linear regression model of the speed of sound. The same design of experiment approach was then used to fit the second-order response surface of the attenuation coefficient. Suitable series of tissue mimicking materials for the glandular tissue and malignant lesion were suggested. Latin hypercube design method was conducted to evaluate the main factors that affected the mechanical property (Young's modulus) of tissue mimicking materials. The results showed that the recipe of tissue mimicking materials could be customized to possess different acoustic and mechanical properties which conform the inconsistencies found in real breast tissues.

An accidental laboratory exposure to Brucella melitensis: the prospective post-exposure management and a detailed investigation into the nature of the exposure

Our aim was to prospectively manage 22 Brucella-exposed individuals and identify the lapses in laboratory practices that lead to the exposure. The exposed individuals were risk-stratified, assessed for post-exposure prophylaxis (PEP), counselled to self-monitor symptoms and followed-up with three serology tests. Staff laboratory practices were recorded. Ten out of 13 high-risk individuals received PEP within 48 h of exposure. Compliance with PEP and serology monitoring was 90 and 96 %, respectively. No brucellosis cases were documented. A single handler manipulated the Brucella isolate on the open bench. Movement of the isolate was tracked in detail, highlighting various points of laboratory non-conformance. Early PEP intervention is effective in preventing acquired brucellosis. Our pragmatic post-exposure management achieved high PEP and serology compliance. We experience first-hand how regular staff engagement motivated PEP adherence and interval blood sampling attendance. The enforcement of practical strategies and safety practices was also implemented without compromising our laboratory processing times.

Comparison of the AMBU® Laryngeal Mask and the LMA Classic in Anaesthetised, Spontaneously Breathing Patients

There may be a role for single-use laryngeal mask airways with concerns about inability to adequately sterilise laryngeal mask airways to eradicate prion proteins. A single-blinded prospective randomised controlled trial was conducted to compare the clinical performance of the single-use AMBU®LMA with the reuseable LMA Classic. There was no difference in time to insertion, successful insertion at first attempt, oropharyngeal leak pressure, haemodynamic response to insertion or complications of placement. The AMBU®LMA was easier to insert. There was a suggestion of reduced postoperative sore throat and pharyngeal trauma for the AMBU® LMA group. The AMBU®LMA is a viable alternative to the LMA Classic for airway management in spontaneously breathing patients.

Evaluation of the Luminex ARIES HSV 1&2 Assay and Comparison with the FTD Neuro 9 and In-house Real-Time PCR Assays for Detecting Herpes Simplex Viruses

Background

Human herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) are responsible for a plethora of human diseases, of which cutaneous and mucocutaneous infections are the most prevalent. In its most severe form, HSV infection can cause meningitis/encephalitis. We compared the Luminex ARIES HSV 1&2 assay (Luminex Corp., Austin, TX, USA), an automated sample-to-result molecular solution, to two non-automated HSV DNA assays.

Methods

A total of 116 artificial controls were used to determine the analytical performance of the ARIES assay. Controls were prepared by spiking universal transport medium (UTM) and cerebrospinal fluid (CSF) samples from patients who tested negative for HSV by an in-house HSV-1 and -2 DNA assay with reference materials (SeraCare Life Sciences, MA, USA; ZeptoMetrix Corp., MA, USA). Another 117 clinical samples were then used to compare the clinical performance of the ARIES assay with those of an in-house assay and the FTD Neuro 9 assay (Fast Track Diagnostics, Junglinster, Luxembourg).

Results

The analytical sensitivity (95% limit of detection) of the ARIES assay was 318 copies/mL (UTM samples) and 935 copies/mL (CSF samples) for HSV-1 strain 96 and 253 copies/mL (UTM samples) and 821 copies/mL (CSF samples) for HSV-2 strain 09. No cross-reactivity was observed in samples spiked with 14 non-HSV microorganisms. Compared with the reference result (agreement between the in-house and FTD Neuro 9 results), the ARIES assay had overall concordance rates of 98.2% (111/113) and 100% (113/113) for HSV-1 and HSV-2, respectively.

Conclusions

The ARIES assay appears to be an excellent alternative for rapid detection and differentiation of HSV in skin and genital infections, meningitis, and encephalitis.

Nurse Performed Ultrasonography in Confirming the Position of Nasogastric Tube in the Emergency Department: A Prospective Single Group Diagnostic Test Study

Introduction

Emergency nurses often encounter patients with nasogastric tube (NGT) dislodgements who require reinsertion. Empirical evidence supporting the use of ultrasonography in verifying the position of NGT in local accident and emergency departments (AED) is scanty. There is also a lack of validation of nurse performed ultrasonography in Hong Kong. With the support from hospitals and medical personnel, a prospective, single group diagnostic test study was conducted to review the possibility of nurse performed ultrasonography in verifying the position of NGT in AED.

Methods

This study was conducted in the AED of three local hospitals. Investigators with specific ultrasound training performed ultrasonography scans to the subjects in addition to conventional pH test and “whoosh” test. Results were compared with chest or abdominal X-ray for evaluation of accuracies.

Results

This study confirmed a high sensitivity and specificity of nurse performed ultrasonography in confirming the position of NGT in the AED. The high positive predictive value and positive likelihood ratio supported the confirmation of NGT position by bedside ultrasound. The high specificities and minimal negative likelihood ratios of ultrasonography tests also suggested the application of bedside ultrasound in ruling out patients with misplaced NGTs.

Conclusions

Nurse performed ultrasonography allows immediate bedside confirmation of the position of NGT in the overcrowded AED. Considered the limitations of conventional methods, nurse performed ultrasonography can be incorporated into daily practice for providing extra evidence for the confirmation of NGT position.

Dynapenic obesity and the risk of incident Type 2 diabetes: the English Longitudinal Study of Ageing

AIM

Obesity is a well-established risk factor for developing Type 2 diabetes. Evidence suggests that sarcopenia, the age-related decline in muscle mass and strength, may exacerbate diabetes risk in obese individuals. The aim of this study was to determine the combined effect of obesity and low muscle strength, dynapenia, on the risk of incident Type 2 diabetes in older adults.

METHODS

Participants were 5953 (1670 obese) men and women from the English Longitudinal Study of Ageing without known Type 2 diabetes at baseline and for whom handgrip strength, biochemical and other clinical data were collected. A diagnosis of Type 2 diabetes was recorded from self-reported physician diagnosis over 6 years.

RESULTS

For each unit increase in grip strength, there was a reduction in diabetes risk (age-, sex- and BMI adjusted HR; 0.98; 95% CI 0.96-0.99). The risk of Type 2 diabetes was elevated in all obese participants, but was greatest in those with low handgrip strength (HR = 4.93, 95% CI 2.85, 8.53) compared with non-obese individuals with high handgrip strength. Eleven per cent of the sample met the threshold for weakness (handgrip strength: men < 26 kg; women < 16 kg) that was associated with elevated Type 2 diabetes risk in obese (HR = 3.57, 95% CI 2.04, 6.24) but not in non-obese (HR = 0.86, 95% CI, 0.44, 1.68) compared with normal/non-obese participants.

CONCLUSION

Dynapenic obesity, determined by high BMI and low handgrip strength, is associated with increased risk of incident Type 2 diabetes in older people.

Temporal bone squamous cell carcinoma - Penang experience

Temporal bone squamous cell carcinoma (TBSCC) is rare and poses difficulties in diagnosing, staging and management. We describe a case series with six patients who were diagnosed TBSCC, from January 2009 to June 2014, with median age of 62 years old. All patients presented with blood-stain discharge and external auditory canal mass, showing that these findings should highly alert the diagnosis of TBSCC. Three patients staged T3 and another three with T4 disease. High-resolution CT (HRCT) temporal findings were noted to be different from intraoperative findings and therefore we conclude that MRI should be done to look for middle ear involvement or other soft tissue invasion for more accurate staging. Lateral temporal bone resection (LTBR) and parotidectomy was done for four patients with or without neck dissection. Patients with positive margin, perineural invasion or parotid and glenoid involvement carry poorer prognosis and postoperative radiotherapy may improve the survival rate. One patient had successful tumor resection via piecemeal removal approach in contrast with the recommended en bloc resection shows that with negative margin achieved, piecemeal removal approach can be a good option for patients with T2-3 disease. In general, T4 tumor has dismal outcome regardless of surgery or radiotherapy given.

Bracing Scoliosis - State of the Art

Spinal bracing is indicated in moderate to severe curves during growth. Brace effectiveness in halting progression of adolescent idiopathic scolisosis has been shown in a Cochrane review and in a randomized controlled trial (RCT). The outcome of brace treatment is dependent on the extent of in-brace correction and compliance. We have reviewed the literature on bracing to determine the types of brace that offer the best in-brace correction.

MATERIALS AND METHODS

The literature has been searched for papers on bracing with documented in-brace corrections and long-term results .

RESULTS

The in-brace percentage of correction of asymmetric braces is generally higher than that of the symmetric braces. According to the literature found in our search, long-term corrections are possible when starting treatment early, at an immature stage and with asymmetric braces of recent standards.

CONCLUSIONS

Bracing today is supported by high quality evidence (Level I). Asymmetric braces have led to better corrections than that described for symmetric braces . An improvement of the average corrective effect has been described due to the latest CAD / CAM development. Long-term corrections are possible when starting brace treatment early, at an immature stage and with asymmetric braces of recent standards.

What Do Mothers know about Neonatal Jaundice? Knowledge, Attitude and Practice of Mothers in Malaysia

No abstract available.

Design and preliminary recruitment results of the Cluster randomised triAl of PSA testing for Prostate cancer (CAP)

BACKGROUND

Screening for prostate cancer continues to generate controversy because of concerns about over-diagnosis and unnecessary treatment. We describe the rationale, design and recruitment of the Cluster randomised triAl of PSA testing for Prostate cancer (CAP) trial, a UK-wide cluster randomised controlled trial investigating the effectiveness and cost-effectiveness of prostate-specific antigen (PSA) testing.

METHODS

Seven hundred and eighty-five general practitioner (GP) practices in England and Wales were randomised to a population-based PSA testing or standard care and then approached for consent to participate. In the intervention arm, men aged 50-69 years were invited to undergo PSA testing, and those diagnosed with localised prostate cancer were invited into a treatment trial. Control arm practices undertook standard UK management. All men were flagged with the Health and Social Care Information Centre for deaths and cancer registrations. The primary outcome is prostate cancer mortality at a median 10-year-follow-up.

RESULTS

Among randomised practices, 271 (68%) in the intervention arm (198,114 men) and 302 (78%) in the control arm (221,929 men) consented to participate, meeting pre-specified power requirements. There was little evidence of differences between trial arms in measured baseline characteristics of the consenting GP practices (or men within those practices).

CONCLUSIONS

The CAP trial successfully met its recruitment targets and will make an important contribution to international understanding of PSA-based prostate cancer screening.

A comparison between bitewing radiographs taken with rectangular and circular collimators in UK military dental practices: a retrospective study

OBJECTIVES

The aim of this study was to determine any increase in the incidence of cone cut errors that adversely affected diagnostic yield resulting in more retakes using rectangular collimation with film holders in bitewing radiography. Comparisons were also made with other positioning errors that occurred when bitewings were taken with circular collimation, with and without film holders.

METHODS

A preliminary questionnaire was used to determine the year that rectangular collimation was adopted by military dental practice. 3 time-framed subsets, each of 1000 bitewing radiographs, were identified: subset 1, films taken with circular collimators without film holders; subset 2, films taken with circular collimators with film holders; and subset 3, films taken with rectangular collimators with film holders. Each subset was assessed for positioning errors of cone cut, horizontal overlap, vertical distortion and film centring. The χ(2) test was used to test significant differences amongst the three subsets.

RESULTS

The use of film holders with circular collimation significantly reduced the incidence of cone cut errors from 21.7% to 3.3%. There was an increase in the incidence of cone cut errors from 3.3% to 20.9% when rectangular collimation was used, but the actual number considered "rejects" was very small, only 0.1% (1 in 1000 films) in subset 2 and 0.3% (3 of 1000 films) in subset 3, when assessed for diagnostic yield.

CONCLUSIONS

This study provides evidence that rectangular collimation did not significantly affect the diagnostic yield of bitewing radiographs despite the presence of cone cut. Therefore, all practitioners should adopt rectangular collimation.

UGT1A1 haplotype mutation among Asians in Singapore

BACKGROUND

The uridine diphosphate glucuronosyltransferase 1A1 (UGT1A1) enzyme is responsible for conjugation of the bilirubin in the liver as well as for drug metabolism. Some of the polymorphisms have been associated with an increased risk of neonatal hyperbilirubinemia which may explain the increased incidence of jaundice in an Asian population as well as exaggerated irinotecan-induced leukopenia.

OBJECTIVE

The local Asian incidence of hypomorphic haplotypes, defined as gene mutations known to have a reduced function, has not been described. Clinical correlation between the mutations and the need for phototherapy for hyperbilirubinemia was carried out.

METHODS

A cohort of 241 consecutive term infants delivered in the National University Hospital, Singapore, was recruited with parental consent. Cord blood was collected, and the promoter and coding regions of the UGT1A1 gene were sequenced.

RESULTS

Six known haplotypes and 2 novel haplotypes were identified: 1 wild type, 5 with reduced function, while the 2 novel ones were predicted to have decreased function. The frequency of these hypomorphic haplotypes was high. Among the 241 infants screened, 35% had 1 hypomorphic haplotype and 12% had 2 hypomorphic haplotypes. The frequency was also different among ethnic groups, with 48% Chinese, 64% Indian and 31% Malay infants having at least 1 hypomorphic haplotype (chi(2) test, p < 0.05). There was a trend seen between the number of G71R mutations and the need for phototherapy (chi2 test for trend, p < 0.05).

CONCLUSIONS

The local Asian incidence of hypomorphic haplotypes was high and there was a trend between the number of G71R mutations and the need for phototherapy. The G71R mutation may account for the increased incidence of neonatal jaundice seen in Asian populations.

Use of Block Copolymers of Poly(Ortho Esters) and Poly (Ethylene Glycol) Micellar Carriers as Potential Tumour Targeting Systems

Amphiphilic AB and ABA block copolymers have been prepared from poly (ortho esters) and poly (ethylene glycol). Such block copolymers readily form micellar dispersions in water, or buffers. The CMC is in the range of 3 x 10(-4)-5 x 10(-4) g/l which is a value low enough to assure retention of micelle integrity upon intravenous injection. The size, as determined by dynamic light scattering was in the 40-70 nm range. The micelles can be stored in lyophilized form for at lest 8 months and easily reconstituted to the original properties. The micelles are stable in PBS at pH 7.4 and 37 degrees C for 3 days and in a citrate buffer at pH 5.5 and 37 degrees C for 2 h. Stability in the presence of bovine serum albumin depends on the structure of the block copolymer and especially the length of the POE block.

Detection of plasmid-mediated AmpC in Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis

AIMS

This study investigated the prevalence of plasmid-mediated AmpC production in selected clinical isolates of Escherichia coli, Klebsiella species and Proteus mirabilis, and compared the results of boronic acid disc screening with conventional susceptibility testing for the detection of AmpC-positive isolates.

METHODS

E coli, Klebsiella species and P mirabilis with reduced susceptibility to amoxycillin-clavulanate, cefuroxime and cephalexin, but without phenotypic evidence of extended-spectrum beta-lactamases were screened for AmpC activity using enzyme-extraction methods. The presence of plasmid-mediated ampC was determined by multiplex PCR. Antibiotic susceptibilities were determined using both disc and dilution-based methods. A disc-based screening method for detection of AmpC-producing strains was evaluated using boronic acid as an inhibitor of AmpC, and cefoxitin as the antibiotic substrate.

RESULTS

Plasmid-mediated ampC was present in 26% of study isolates, with CMY-like enzymes detected predominantly in E coli and DHA-like enzymes predominantly in Klebsiella pneumoniae. Current susceptibility methods failed to detect a significant proportion of plasmid-mediated AmpC-producing isolates, with 33% of such strains interpreted as susceptible to third-generation cephalosporins using current Clinical Laboratory Standards Institute breakpoints. The boronic acid disc method showed sensitivity and specificity of 90% and 98% respectively in detecting AmpC-positive isolates.

CONCLUSION

The prevalence of plasmid-mediated ampC was high in the study population, and may be missed by conventional susceptibility testing methods. Inhibitor-based screening methods would improve detection of this emerging resistance phenotype.

Salivary duct strictures: nature and incidence in benign salivary obstruction

OBJECTIVES

The aim of this study was to establish the incidence and character of salivary duct strictures by carrying out a 10 year retrospective review. Salivary gland obstruction is most commonly caused either by salivary calculi or duct strictures. These strictures or stenoses develop secondarily to inflammation in the duct wall and may be single or multiple.

METHODS

All reports of sialographic examinations performed on patients referred to the Dental Radiology Department in a London Dental Hospital between 1995 and 2004 were reviewed and those patients with symptoms of salivary obstruction identified. In total, 1362 sialograms using the conventional hand injection technique with water-soluble contrast media were performed on 1349 patients with obstructive symptoms during the 10-year period.

RESULTS

Of the 1362 sialograms performed, the reports revealed that 877 (64.4%) showed evidence of benign intraductal obstruction. The remaining 485 (35.6%) were normal. 642 of the cases (73.2%) revealing obstruction were reported to be due to salivary calculi, 198 due to duct strictures (22.6%) and the remaining 37 (4.2%) were considered to be due to mucous plugs. Detailed analysis of the patients with strictures showed they were more common in women with a mean age of 52 years. Single strictures were evident in 66.7% of cases while 33.3% showed multiple stenoses. Strictures were more common in the parotid duct (75.3%). 7% of patients presented with bilateral stenoses.

CONCLUSION

This is the largest review of duct strictures to be reported. It has shown that ductal stricture formation accounts for almost 25% of cases of benign salivary obstruction and appears to have been an under-recognized condition. Strictures more commonly affect parotid ducts and are typically found in the fourth, fifth or sixth decades, particularly in women.

Comparison of Etest, Vitek and agar dilution for susceptibility testing of colistin

In total, 172 isolates of Enterobacteriaceae, Acinetobacter spp., Pseudomonas aeruginosa and Stenotrophomonas maltophilia were tested for susceptibility to colistin by agar dilution, Etest and the Vitek 2 system. Isolates with a colistin MIC < or =2 mg/L were considered to be susceptible. Fifty-four (31%) Gram-negative isolates were resistant to colistin. Categorical agreement between agar dilution and Etest was 87%, and between agar dilution and Vitek 2 was 82%. Based on the data obtained, the Vitek 2 system was unreliable for detecting colistin resistance, and results obtained by Etest may require confirmation by a standard MIC susceptibility testing method.

Comparison of ultrasound, digital and conventional radiography in differentiating periapical lesions

OBJECTIVES

To carry out an in vivo comparative pilot study to evaluate the efficacy of ultrasound, digital (DR) and conventional plain film-based imaging (PF) in the differential diagnosis of periapical lesions.

METHODS

Fifteen patients aged between 13 years and 40 years with periapical lesions associated with anterior maxillary or mandibular teeth requiring endodontic surgery were selected and consented for the study. Pre-operative periapical radiographs (PF) and charge coupled device (CCD) DR were obtained. Measurements and provisional diagnoses of the apical areas were made by three specialist observers (two dental radiologists and one endodontist) on three separate occasions. Pre-operative ultrasound examinations were then performed and the images assessed by two specialist observers (ultrasonographer and endodontist) for the size, contents, vascular supply and a provisional diagnosis made as to whether the lesion was a cyst or granuloma. Endodontic surgery was performed including curettage of the apical tissues to enable histopathological investigation, which provided the gold standard diagnosis. All measurements and findings were compared and statistically analysed.

RESULTS

On PF and DR the periapical lesions were readily identified but observers were unable to differentiate granuloma from cyst using either modality. Dimensional measurements were subject to greater interobserver variation on DR than on PF. Where sufficient buccal cortical bone had been resorbed, ultrasound imaging was straightforward but underestimated the size of the lesions compared with PF and DR. In all 15 cases, the ultrasound diagnosis agreed with the histopathological gold standard.

CONCLUSIONS

PF and DR enable diagnosis of periapical disease existence, but not of its nature; while ultrasound underestimates the extent of disease, but can provide accurate information on the pathological nature of the lesion.

The in-vitro activity of colistin in gram-negative bacteria

INTRODUCTION

Colistin is a polypeptide antibiotic belonging to the polymyxins, and has been increasingly used for the treatment of multiresistant gram-negative infections. There is little current available data on the susceptibility of gram-negative bacilli to colistin, in part because susceptibility testing for colistin remains problematic, and also because the use of colistin is not widespread. This study tested clinical isolates of gram-negative bacilli for susceptibility to colistin using the reference susceptibility testing method of agar dilution.

METHODS

102 strains of gram-negative bacilli were collected over a one-year period. Antibiotic susceptibility profiles were derived from disc susceptibility testing, and organisms were identified by standard microbiological methods. Isolates were selected for inclusion in the study using susceptibility profiles and epidemiological data. Minimum inhibitory concentrations to colistin were obtained by performing agar dilution according to a standardised method.

RESULTS

30 percent of tested isolates were resistant to colistin. All Acinetobacter spp. and Escherichia coli were susceptible to colistin. Colistin resistance was detected predominantly in Stenotrophomonas maltophilia and Pseudomonas aeruginosa, but was also present in Enterobacter spp. and Klebsiella spp.

CONCLUSION

Colistin resistance is uncommon in the Enterobacteriaceae, but present in a significant proportion of S. maltophilia and P. aeruginosa isolates. From the results of this study, we recommend that susceptibility testing be performed whenever the clinical use of the polymyxins is considered.

Observation of tumour thickness and resection margin at surgical excision of primary oral squamous cell carcinoma—assessment by ultrasound

Tumour thickness and the status of resection margins are of prognostic significance in the treatment of oral cancer. In a single blind prospective study, 14 patients with biopsy proven oral squamous cell carcinoma had intraoral ultrasound imaging done preoperatively to measure tumour thickness, and intraoperatively to measure the deep surgical margin half way during resection. The cut surface was demonstrated on ultrasound by placing a metal, ultrasound-reflective, retractor into the surgical cut. The ultrasound measurements were compared to the subsequent histological measurements. Using the threshold of 5mm as indicator of margin clearance, there was agreement in 10 out of 14 cases between ultrasound and histology. Ultrasound detection of close surgical margins had a sensitivity of 83% and a specificity of 63%. For preoperative tumour thickness measurement, ultrasound imaging showed a high degree of correlation with histology (Pearson correlation coefficient=0.95, P<0.01). This original paper demonstrates that high resolution ultrasound imaging applied intraorally is a reliable tool in objectively assessing both the tumour thickness and the surgical margin clearance at the time of surgery.

Tensile testing of a single ultrafine polymeric fiber

Due to the difficulty in handling micro and nanoscale fibers and measuring the small load required for deformation, mechanical properties of these fibers have not been widely characterized. In this study, tensile test of a single-strand polycaprolactone electrospun ultrafine fiber was performed using a nano tensile tester. The tested fiber exhibited the characteristic low strength and low modulus but high extensibility at room temperature. The mechanical properties were also found to be dependent on fiber diameter. Fibers with smaller diameter had higher strength but lower ductility due to the higher 'draw ratio' that was applied during the electrospinning process.

Diagnostic difficulties of complex root morphology: case study of a lower wisdom tooth

We did a panoramic radiographic examination of a symptomatic lower third molar for surgical planning and risk assessment. This showed a close association with the inferior dental canal, in addition to uncertain root morphology. A periapical radiograph showed evidence of additional smaller curved roots. Axial computed tomography (CT) with coronal reformats did not provide further information about the morphology of the root. After removal of the tooth, its root form was compared with the diagnostic images. The periapical radiograph provided the most information about the morphology of the additional roots. The axial and reformatted coronal CT showed accurately the position and tortuous course of the inferior dental canal.

Ultrasound imaging in the preoperative estimation of the size of tracheostomy tube required in specialised operations in children

BACKGROUND

Some children are dependent on a tracheostomy for many years. As they grow, larger tracheostomy tubes may be required. Although tables of sizes of tracheas exist for different age groups, they are estimations of normal and may not be accurate for atypical cases. Chest radiographs and computed tomograms (CT) have been used experimentally to estimate tracheal sizes, but are not in regular use.

METHOD

High-resolution diagnostic ultrasound imaging was used to estimate the internal and external transverse tracheal diameter, and the depth of the trachea from the skin surface. This allowed selection of the correct standard pattern tracheostomy tube, or the construction of a custom-made tube preoperatively.

RESULTS

Four children with various abnormalities who were being considered for replacement tracheostomies were scanned. In one, diagnostic ultrasound confirmed that a new larger fenestrated tube could be placed, which subsequently improved vocalisation and respiration. In the other three, the scan showed there was no space to allow a larger tube to be placed. The standard tables were not suitable for any of these patients.

CONCLUSION

High-resolution ultrasound has a role in the non-invasive measurement of the size of the tube needed for specialised operations in children.

A new approach using intraoperative ultrasound imaging for the localization and removal of multiple foreign bodies in the neck

An innovative method of using ultrasound imaging intraoperatively is reported. Multiple radiopaque and radiolucent foreign bodies within soft tissues were localized in theatre using high resolution ultrasonography. Depth of injury and vessel status were also ultrasonically assessed. Surgical removal of all foreign bodies was aided by intraoperative ultrasound guidance. In addition, this new approach of using intraoperative ultrasonography was pivotal in confirming the removal of all foreign bodies from the wound at the time of the operation.

Decreased access to health care and social isolation among young adults with cerebral palsy after leaving school

OBJECTIVE

To examine if leaving special schools has a negative impact on the health care and social isolation of young adults with cerebral palsy.

METHODS

Young adults with cerebral palsy, aged between 15 and 22 years, were divided into 2 cohorts: current students, who were still receiving services from special schools, and school-leavers, who had since been discharged from care. A questionnaire and physical examination were administered to assess the extent of disability, health care received by, and social isolation of these young adults.

RESULTS

School-leavers had a greater degree of dissability than did students, although the results were not statistically significant. Health care exposure to specialists, general practitioners, therapists physiotherapists, occupational therapists, and/or speech therapists), and medical social workers decreased after leaving school; with the exception of contact with general practitioners, these results were significant (p<0.05). The entire cohort was more socially isolated than a control cohort. School-leavers participated in fewer activities outside their homes, but showed less concern about their disability than did current students.

CONCLUSIONS

Young adults with cerebral palsy continue to have health care and lifestyle needs after leaving school, which are currently not being adequately met.

Interpretation of skull radiographs for facial fractures by medical staff working in UK emergency departments: a pilot study

OBJECTIVES

This was a pilot study to determine the ability of hospital doctors (1) to assess the technical quality of occipitomental (OM) radiographs and (2) to identify facial fractures.

METHOD

Twenty-two doctors from four UK Accident and Emergency (A&E) departments participated in a two part study: Part A was a postal questionnaire containing questions on demographic data, educational background, selection criteria, assessing radiographs and radiation protection; and Part B was a clinical viewing session to interpret 20 randomized OM radiographs divided into four groups; technically good and poor without fractures, and technically good and poor with fractures.

RESULTS

Study participants ranged from junior house officers to senior consultants. There was considerable variation in educational background and radiographic interpretation instruction at undergraduate and postgraduate level. OM radiographs constituted 10% of all skull radiographs examined per week, yet only 40% of the doctors felt confident when assessing technical quality. The majority of participants had only a limited knowledge of radiation protection legislation. During the viewing session, only 50% of the participants correctly identified those radiographs with fractures and those with technique errors. There was no significant difference between house officers and other grades of staff. A higher level of seniority did not equate with greater interpretative ability. Subjective confidence in assessing film quality did not correlate with the actual film viewing.

CONCLUSION

Only half of the A&E doctors taking part in the study were able to correctly assess film quality and identify facial fractures on OM radiographs. If the pilot sample is representative, then the findings are of considerable concern.

Development and applications of injectable poly(ortho esters) for pain control and periodontal treatment

Poly(ortho esters) with a low glass transition temperature are semi-solid materials so that therapeutic agents can be incorporated at room temperature, without the use of solvents, by a simple mixing procedure. When molecular weights are limited to < 5 kDa, such materials are directly injectable using a needle size no larger than 22 gauge. Somewhat hydrophilic polymers can be produced by using the diketene acetal 3,9-diethylidene-2,4,8,10-tetraoxaspiro[5.5]undecane and triethylene glycol (TEG), while hydrophobic materials can be produced by using the diketene acetal and 1,10-decanediol. Molecular weight can be reproducibly controlled by using an excess of the diol, or by use of an alcohol that acts as a chain-stopper. Erosion rates can be controlled by varying the amount of latent acid incorporated into the polymer backbone. Toxicology studies using the TEG polymer have been completed and have shown that the polymer is non-toxic. Toxicology studies using the decanediol polymer are underway. Development studies using the TEG polymer aimed at providing a sustained delivery of an analgesic agent to control post-surgical pain are under development and human clinical trials using the decanediol polymer for the treatment of periodontitis are also underway.

A retrospective survey of attitudes toward acceptance of peritoneal dialysis in Chinese end-stage renal failure patients in Hong Kong--from a cultural point of view

OBJECTIVE

We undertook to study the attitudes toward dialysis of patients approaching end-stage renal failure and to analyze those attitudes from a cultural perspective.

SETTING

The study was performed in the pre-dialysis clinic of a tertiary referral renal center.

PATIENTS

All patients of Chinese ethnic origin seen in the pre-dialysis clinic from 1995 to 2000 for assessment of dialysis therapy were included.

METHOD

We performed a retrospective analysis of patient records with regard to attitudes of the patients toward dialysis, reasons for those attitudes, and factors that could lead to a subsequent change in attitude.

RESULTS

We assessed 462 patients over the 6-year period. Their mean age was 65.5 +/- 13.3 years, and 43.9% of the patients had diabetes. Peritoneal dialysis (PD) was offered to 74% of the patients, and hemodialysis (HD) to 3.9%. Among the patients offered PD, only 44% accepted dialysis. After counselling, 54% of the patients who originally declined PD ultimately accepted it. The major reasons for refusing PD were the ideas of "having lived long enough" and "lack of family support." Most other reasons could be overcome by counselling. Only a minority of patients demanded hemodialysis.

CONCLUSIONS

Declining an offer of dialysis was common. Counselling helped patients to accept PD. Certain cultural elements that hindered acceptance of dialysis were involved in the ideas of "having lived long enough" and "lack of family support." Those cultural elements should be tackled more specifically during counselling.

Intraoperative ultrasound imaging to aid abscess drainage--a technical note

Diagnostic ultrasound is used widely to identify the presence of fluid collections preoperatively. Although its role in other parts of the body is well established, this report describes the technique of using diagnostic ultrasound intraoperatively to aid drainage of a large fascial space abscess in the head and neck. Following previously inadequate drainage of a large superficial abscess from a blindly placed drain, a second procedure was carried out, using ultrasound imaging to locate the persisting abscess. Furthermore, ultrasound demonstrated the adequacy of drainage and helped the surgeon to position the drain in the correct tissue space. We consider that intraoperative use of ultrasound has a role as a guidance tool to drain superficial fascial space abscesses in the head and neck region.

Immune mediated chorea encephalopathy syndrome in childhood

We report four previously healthy female children, aged between 3 and 8 years, who presented with encephalopathy and an extrapyramidal movement disorder (chorea n=4, rigidity n=2, oculogyric crisis n=2). In addition, an acute behavioural disturbance occurred in two patients and mutism in two others. Seizures heralded the onset of the illness in three patients. Acute MRI was either normal or initially normal with later generalized cerebral atrophy. All infective (including streptococcus), biochemical, and metabolic investigations were normal, although all four patients had oligoclonal bands in the (CSF) but not the serum, indicating intrathecal immunoglobulin synthesis. All four children made an apparently full recovery within four months of the onset. We suggest that these patients represent an immune-mediated movement disorder and encephalopathy syndrome.

Intraoperative ultrasound-guided retrieval of an airgun pellet from the tongue: a case report

Real-time intraoperative ultrasonography was used to detect and facilitate removal of an airgun pellet from the tongue of a 14-year-old boy. Diagnostic ultrasound was crucial in clarifying the positional relation between the foreign body and the instrument used, enabling safe, precise and rapid retrieval during a potentially hazardous surgical operation.

Ultrasound features of osteosarcoma of the mandible--a first report

Ultrasound imaging is becoming widely used in the head and neck region as a first-line investigation to assess soft tissue swellings. Clinicians should be aware of the potential of diagnostic ultrasound to identify important signs of malignant disease involving bone. Involvement of the mandible by osteosarcoma is uncommon. A young adult patient presented with facial swelling and an apparently infected lower third molar extraction socket. Subtle signs were missed on dental radiographs. Diagnostic ultrasound investigation was pivotal in identifying sinister signs: namely, soft tissue mass associated with bone thinning, erosion, expansion, and the "sunray" appearance of the buccal cortex, which were suggestive of osteosarcoma. These findings enabled priority to be given to subsequent investigations using other modalities. We present a first report of the ultrasound features of osteosarcoma of the mandible and consider this to be a useful modality in an initial investigation.

Metachronous bilateral primary adenocarcinoma of the submandibular glands

A young woman developed an unusual adenocarcinoma in each submandibular salivary gland at an interval of 30 months. This presentation has not been described previously. The possible etiology for this and treatment options are discussed. The choice of diagnostic imaging (ultrasound versus magnetic resonance imaging) is highlighted. As a result of regular follow-ups using diagnostic ultrasound, a second tumor was observed to reach a dimension of 8 mm in less than 6 months. This is probably the first report documenting the extent of initial growth of this rare tumor.

Release of BSA from poly(ortho ester) extruded thin strands

A solventless procedure was used where powdered polymer and micronized protein were intimately mixed and then extruded into 1 mm strands that were cut to the desired length. The polymers used were poly(ortho esters) specifically designed to allow extrusion in the neighborhood of 70 degrees C. At these temperatures many proteins maintain activity in the dry state. In vitro erosion and BSA release results indicate that after a fairly long lag-time, BSA release and polymer erosion occur concomitantly indicating an erosion-controlled process. The lag-time could be eliminated by the addition to the mixture prior to extrusion between 1 and 5 wt% poly(ethylene glycol) or its methoxy derivatives. The lag-time could also be eliminated by using an AB-block copolymer where A is poly(ortho ester) and B is poly(ethylene glycol).

Ultrasound-guided retrieval of labial minor salivary gland sialoliths

We report a case of minor salivary gland sialolithiasis presenting as acute, painful swelling of the upper lip. Conventional, unguided, incision and drainage removed three of the sialoliths. Diagnostic ultrasound identified two further sialoliths which were successfully removed with real-time, ultrasound-guided, needle localization. This technique of sialolith retrieval has not been previously reported.

Poly(ortho esters) - their development and some recent applications

Poly(ortho esters) have been under development since the early 1970s and four families of such polymers have been described. Of most interest are poly(ortho ester) III and poly(ortho ester) IV. Poly(ortho ester) III is a semisolid material that has been shown to be highly biocompatible and is currently being investigated as an adjunct to glaucoma filtering surgery and other ocular applications. However, the polymerization is difficult to control and is not readily scaled up. Poly(ortho ester) IV can be easily prepared in a highly reproducible manner, is very stable provided moisture is rigorously excluded and has also been shown to be highly biocompatible. It is currently under development for a variety of applications, such as ocular delivery, protein release, post-operative pain treatment and post-operative cancer treatment.

Extensive temporal bone pneumatization: incidental finding in a patient with TMJ dysfunction

An 18-year-old male presented with symptoms of temporomandibular joint dysfunction. A panoramic radiograph revealed slight erosion of the condylar heads, and an incidental finding of multilocular radiolucencies in the zygomatic processes of the right and left temporal bones. CT scans were undertaken to exclude any sinister cause. The radiolucencies were shown to be extensive bilateral pneumatization of the temporal bones. Conservative management relieved the symptoms of TMJ dysfunction.

Development of a poly(ortho ester) prototype with a latent acid in the polymer backbone for 5-fluorouracil delivery

A study has been carried out to determine whether the latest family of poly(ortho esters) can be converted into a practical delivery system. This polymer differs from the previously described polymers in that it incorporates a short segment of a latent acid in the polymer backbone. The following issues were specifically addressed: (a) can the erosion and drug release be reproducibly controlled to yield the desired drug release kinetics and erosion rates? (b) Is the polymer stable during radiation sterilization, on storage and on fabrication? (c) Can the polymer be prepared reproducibly at the desired molecular weights and molecular weight distribution? (d) Is the polymer safe for its intended application and does the in vivo erosion proceed to completion? (e) Can the polymer be easily fabricated into desired configurations? Studies have shown that if the synthesis is carefully controlled, the desired molecular weights can be reproducibly prepared, that the polymer is reasonably stable after irradiation at 24 kGy and during storage at room temperature under anhydrous conditions, and that it can be safely thermally fabricated at temperatures in the neighborhood of 120 degrees C. When polymer devices were implanted intraperitoneally in rats the polymer eroded to completion without any overt toxicity as determined by the measured parameters.

Hair calcium and magnesium levels in patients with fibromyalgia: a case center study

BACKGROUND

Fibromyalgia is not an uncommon condition. Because its cause has yet to be identified. treatment of the condition has been empirical; frequently, outcomes are unsatisfactory. Some patients with fibromyalgia were observed to have high hair calcium and magnesium levels compared with healthy subjects. Because of this and because supplementing calcium with magnesium to fibromyalgia subjects reduced the number of tender points detected by digital palpation, it is worth investigating if patients with fibromyalgia have significantly higher hair calcium and magnesium levels than their healthy counterparts.

OBJECTIVES

To determine the degree of difference between the hair calcium and magnesium levels in patients with fibromyalgia and in healthy subjects.

METHODS

The study was retrospective and of paired design. Twelve patients who had hair analysis performed and met the criteria of fibromyalgia defined by American College of Rheumatology (1990) were selected consecutively from clinical files. These patients were then matched by age and sex to 12 healthy subjects selected consecutively from the same patient files who had hair analysis performed for checkup purposes. Nonparametric Wilcoxon rank sum tests were used to determine if the hair calcium and magnesium levels in patients with fibromyalgia were significantly higher than that of the control subjects.

RESULTS

Wilcoxon rank sum tests showed that patients with fibromyalgia had significantly higher calcium and magnesium levels than the control subjects at alpha = .025 and .05, respectively.

CONCLUSION

In the presence of high hair calcium and magnesium levels, calcium and magnesium supplements may be indicated as an adjunctive treatment of fibromyalgia.

A case of Castleman's disease mimicking a multicystic ovarian tumour

We report on a case of solitary Castleman's disease that had an unusual presentation. A 29-year-old Filipino woman who had a history of intermittent right lower abdominal pain for several years was admitted to the Princess Margaret Hospital because of a sudden exacerbation of the abdominal pain. Ultrasonography had previously detected a multilocular right ovarian cyst of approximately 6.5 cm in diameter. Intra-operative findings, however, revealed a retroperitoneal presacral cystic tumour of approximately 7 cm in diameter, which was unrelated to the ovaries. The tumour was removed and found to be well defined and measure 7 x 5 x 4 cm. The cut surface revealed homogenous light-brown tissue at the periphery. The central part showed cystic spaces of 1- to 3-cm diameter. Histological examination of the tumour led to the diagnosis of hyaline vascular-type Castleman's disease. Cystic spaces were visible within the infarcted tissue; extensive cystic changes in Castleman's disease are unusual and may have caused the diagnostic difficulty.

In vitro drug release from self-catalyzed poly(ortho ester): case study of 5-fluorouracil

Self-catalyzed poly(ortho esters) are a new variation of linear poly(ortho esters) prepared by the addition of diols to the diketene acetal 3,9-diethylidene-2,4,8,10-tetraoxaspiro[5,5]undecane where dimer segments of lactic acid or glycolic acid are built into the polymer backbone. By varying the concentration of these segments, polymer erosion rate can be controlled. The present investigation describes the in vitro drug release characteristics from these new polymers. Because poly(ortho esters) have potential applications for the delivery of antifibroblastic agents for example after glaucoma-filtering surgery, the in vitro release studies were evaluated using 5-fluorouracil as the active compound. It was shown that a mole ratio of 90/10 or 80/20 diol/diol-lactate incorporated into the polymer lead to a release of 5-fluorouracil by an erosion process. Smaller amounts of diol-lactate lead to a concomitant drug release by diffusion and erosion. It was also shown that the release rate depends on the alkyl chain length of the diol in the polymer backbone but it does not depend on the drug loading.

Pseudomonas exit-site infections in CAPD patients: evolution and outcome of treatment

OBJECTIVE

To examine the natural history of Pseudomonas aeruginosa (PSA) exit-site infections (ESI) in patients treated with antibiotics with or without surgical interventions.

DESIGN

Retrospective record review from May 1994 to April 1997.

SETTING

A single dialysis unit in a district hospital.

PATIENTS

The review included 353 patients who had undergone continuous ambulatory peritoneal dialysis (CAPD).

OUTCOME MEASURES

The prevalence and etiology of ESI, the treatment regimen for PSA ESI, and the outcome of treatment.

RESULTS

The prevalence of ESI was 55%. A total of 131 episodes (range 1-5) of PSA ESI occurred in 78 (40.2%) of the 194 patients who experienced ESI. Among these 78 patients, 4 groups with different outcomes were identified. In group I, 35 patients (44.9%) were treated successfully with antibiotic therapy alone. Among these 35 patients, 4 developed PSA peritonitis at a mean of 5 months (range 2-10 mth) after apparent clinical resolution of PSA ESI. Two of the 4 patients switched to long-term hemodialysis (HD) because of peritoneal failure. In group II, 8 patients (10.3%) responded to a combination of antibiotics and shaving of the external cuff. In group III, 21 patients (26.9%) with recurrent ESI underwent elective Tenckhoff catheter removal and reinsertion. One of the 21 patients had relapse of PSA ESI 14 months after the operation. In group IV, 14 patients (17.9%) had recurrent PSA ESI that failed to respond to multiple courses of antibiotics and shaving of the external cuff. Consent for Tenckhoff catheter removal was not obtained and 4 of these 14 patients subsequently developed PSA peritonitis. One of the 4 patients changed to permanent HD due to peritoneal failure.

CONCLUSIONS

Considering the increased risk and the poor outcome of PSA peritonitis in patients with persistent PSA ESI, early Tenckhoff catheter removal is recommended if the patient fails to respond to antibiotics with or without externalization of the external cuff.

Death-effector filaments: novel cytoplasmic structures that recruit caspases and trigger apoptosis

The death-effector domain (DED) is a critical protein interaction domain that recruits caspases into complexes with members of the TNF-receptor superfamily. Apoptosis can also be induced by expressing certain DED-containing proteins without surface receptor cross-linking. Using Green Fluorescent Protein to examine DED-containing proteins in living cells, we show that these proteins cause apoptosis by forming novel cytoplasmic filaments that recruit and activate pro-caspase zymogens. Formation of these filaments, which we term death-effector filaments, was blocked by coexpression of viral antiapoptotic DED-containing proteins, but not by bcl-2 family proteins. Thus, formation of death-effector filaments allows a regulated intracellular assembly of apoptosis-signaling complexes that can initiate or amplify apoptotic stimuli independently of receptors at the plasma membrane.

Synthesis and characterization of self-catalyzed poly(ortho ester)

Poly(ortho esters) are currently under investigation as a carrier system for an antiproliferative agent in glaucoma filtering surgery. The present investigation illustrates the development of a series of self-catalyzed poly(ortho ester). These polymers contain short dimer segments of alpha-hydroxy acids in their backbone and are prepared by the addition of different polyols to the diketene acetal 3,9-diethylidene-2,4,8,10-tetra-oxaspiro-[5.5]-undecane. The structures were confirmed by NMR- and FT-IR-spectroscopy. The polymers were characterized by determination of the molecular weight, the glass transition temperature and the rheological behavior. The amount of residual solvents was also analyzed. The characteristics of the polymer can be varied by the type of polyol incorporated in its backbone. Since poly(ortho ester) is susceptible to acid-catalyzed degradation, the polymer hydrolysis can be controlled by the amount of incorporated portion of alpha-hydroxy acid. Due to the high hydrophobicity of the polymer structure, the ester bonds are more susceptible to hydrolysis than the ortho ester bonds in the polymer backbone. The hydrolysis proceeds via initial protonation of the exocyclic alkoxy group to yield pentaerythritol dipropionate and the free diol. In a next step, the pentaerythritol dipropionate hydrolysis to pentaerythritol and propionic acid. The molecular weight decrease, weight loss and the pH profile of the polymer in aqueous medium were monitored during the degradation.

Intra-oral ultrasound imaging of a submandibular duct calculus

A case is presented showing the first reported use of a small, digitally-guided, intra-oral ultrasound probe to image a calculus in a submandibular salivary duct. This use of intra-oral ultrasound is discussed in the context of the overall current status of intra-oral and extra-oral ultrasound imaging. It is proposed that using a combination of intra-oral and extra-oral probes, the whole of the salivary apparatus may now be examined sonographically for the presence of calculi.

CD28-costimulation activates cyclic AMP-responsive element-binding protein in T lymphocytes

Cyclic AMP-responsive element binding protein (CREB) mediates gene expression in response to cAMP stimulation. The transcriptional activity of CREB depends on both the phosphorylation of Ser133 and the recruitment of cofactor for assembly of transcriptional complex. Extensive Ser133 phosphorylation of CREB was induced during T cell activation. This phosphorylation event is essential for IL-2 gene expression. However, phosphorylation of CREB at Ser133 was not sufficient for transcriptional activity by CREB. The presence of a second signal from CD28, a potent costimulatory molecule on T cells, stimulated CREB-mediated gene expression. CD28, an effective costimulator of T cell activation and IL-2 gene expression, is shown to induce CREB activation in the presence of anti-CD3 or O-tetradecanoylphorbol 13-acetate. These two signals together stimulated a CRE-dependent reporter gene, the proliferating cell nuclear Ag promoter, and transactivation by the GAL4-CREB fusion protein. Thus optimal induction of CREB, similar to the full activation of T lymphocytes, may be mediated by two distinct signal transductions. Using the specific kinase inhibitor, one of the two pathways appeared to involve mitogen-activated protein kinase kinase but not protein kinase C, protein kinase A, or p70 S6 kinase.