Nontraumatic spinal cord lesions: a prospective study of medical complications during in-patient rehabilitation

STUDY DESIGN

Prospective study between 1st Jan 1995 and 31st Dec 1999.

OBJECTIVE

To document medical complications among subjects with Nontraumatic Spinal Cord Lesions (NTSCL) during in-patient rehabilitation.

SETTING

Bangalore, India.

METHODS

Persons with NTSCL admitted for in-patient rehabilitation were included in the study. Clinical evaluation was carried out according to The International Standards for Neurological and Functional classification of Spinal Cord Injury. Disability was quantified using Barthel index. All medical complications were documented.

RESULTS

A total of 297 subjects (154 men and 143 women) with NTSCL were included. The number of medical complications in each patient varied from 0 to 17 (mean=6.1+/-3.7). Common complications seen were urinary tract infections (184), spasticity (169), pain (149), urinary incontinence (147), depression (114), respiratory tract infections (101), constipation (92), pressure ulcers (89), contractures (52) and sleep disturbance (43). The number of medical complications correlated positively with duration of stay (Pearson's correlation coefficient r=0.5, P<0.01) and negatively with Barthel Index at admission (r=-0.2, P<0.05) and at discharge (r=-0.2, P<0.05). Complications were more frequent among people with tetraplegia than those with paraplegia (P<0.001).

CONCLUSIONS

Medical complications are frequent among subjects undergoing rehabilitation for NTSCL. Patients with severe disability at admission have more complications during rehabilitation. Conversely, individuals with more complications have greater disability at discharge.

Capecitabine and mitomycin C as third-line therapy for patients with metastatic colorectal cancer resistant to fluorouracil and irinotecan

Protracted venous infusion 5-fluorouracil (5FU) combined with mitomycin C (MMC) has demonstrated significant activity against metastatic colorectal cancer. Owing to potential synergy based upon upregulation of thymidine phosphorylase by MMC, the combination of capecitabine and MMC may improve outcomes in irinotecan-refractory disease. Eligible patients with progressive disease during or within 6 months of second-line chemotherapy were treated with capecitabine (1250 mg m⁻² twice daily) days 1–14 every 3 weeks and MMC (7 mg m⁻² IV bolus) once every 6 weeks. A total of 36 patients were recruited, with a median age of 64 years (range 40–77), and 23 patients (78%) were performance status 0–1. The objective response rate was 15.2%. In all, 48.5% of patients had stable disease. Median failure-free survival was 5.4 months (95% CI 4.6–6.2). Median overall survival was 9.3 months (95% CI: 6.9–11.7). Grade 3 toxicities were palmar-plantar erythema 16.7%, vomiting 8.3%, diarrhoea 2.8%, anaemia 8.3%, and neutropenia 2.8%. No patients developed haemolytic uraemic syndrome. Symptomatic improvement occurred for pain, bowel symptoms, and dyspnoea. Capecitabine in combination with MMC is an effective regimen for metastatic colorectal cancer resistant to 5FU and irinotecan with an acceptable toxicity profile and a convenient administration schedule.

Rapid assessment of maternal activity among rural Indian mothers (Pune Maternal Nutrition Study)

OBJECTIVE

To develop an activity questionnaire for objective and rapid assessment of maternal habitual physical activity with the aim of describing its relationship with birth size.

DESIGN

Prospective observational study.

SETTING

Six villages near Pune, Maharashtra, India.

SUBJECTS

Seven hundred and ninety-seven rural Indian mothers were studied after excluding abortions and termination of pregnancies, foetal anomalies, etc.

METHOD

Principal components analysis (PCA) was used to identify a few leading questions from an elaborate questionnaire involving 36 questions related to 14 typical maternal activities.

RESULTS

On the basis of high loading (>0.8), PCA identified three activities, i.e. farming, fetching water and washing clothes. Questions and sub-questions related to these activities only were considered for defining an activity score for rapid assessment. Validation of this new activity score, with the score based on the elaborate questionnaire, showed 70% sensitivity as well as specificity. New activity scores showed strong inverse relationships similar to those observed using the elaborate questionnaire, at early as well as late gestation, with neonatal head circumference (P=0.001 and 0.055) and mid-arm circumference (P=0.02 and 0.03).

CONCLUSIONS

Simple questionnaires, based on leading activities identified by PCA, can be as informative as longer and detailed questionnaires. This method has potential for adaptation, especially in rural communities in developing countries.

Report of two protocol planned interim analyses in a randomised multicentre phase III study comparing capecitabine with fluorouracil and oxaliplatin with cisplatin in patients with advanced oesophagogastric cancer receiving ECF

The purpose of the study was to establish the optimal dose of capecitabine (X) to be used within a multicentre, randomised study evaluating the potential roles of oxaliplatin (O) and X in chemonaive patients (pts) with advanced oesophagogastric cancer. Two by two design was used, and pts were randomised to one of four regimens and stratified for extent of disease, performance status (PS) and centre. The treatment regimens are epirubicin, cisplatin, 5-fluorouracil (ECF), EOF, ECX or EOX. Doses: E 50 mg m⁻², C 60 mg m⁻² and O 130 mg m⁻² i.v. 3 weekly; F 200 mg m⁻² day⁻¹ i.v. and X 500 mg m⁻² b.i.d.⁻¹ (escalated to 625 mg m⁻² b.i.d.⁻¹ after results of first interim analysis) p.o., continuously. First interim analysis was performed when 80 pts had been randomised. Dose-limiting fluoropyrimidine toxicities were stomatitis, palmar plantar erythema (PPE) and diarrhoea; 5.1% of X-treated pts experienced grade 3/4 toxicity. Protocol planned dose escalation of X to 625 mg m⁻² b.i.d.⁻¹ was instituted and a second interim analysis has been performed; results are presented in this paper. A total of 204 pts were randomised at the time of the protocol planned 2nd interim analysis. Grade 3/4 fluoropyrimidine-related toxicity was seen in 13.7% pts receiving F, 8.4% pts receiving X 500 mg m⁻² b.i.d.⁻¹ and 14.7% pts receiving X 625 mg m⁻² b.i.d.⁻¹. Combined complete and partial response rates were ECF 31% (95% CI 18.7–46.3), EOF 39% (95% CI 25.9–53.1), ECX 35% (95% CI 21.4–50.3), EOX 48% (95% CI 33.3–62.8). Grade 3/4 fluoropyrimidine toxicity affected 14.7% of pts treated with X 625 mg m⁻² b.i.d.⁻¹, which is similar to that observed with F, confirming this to be the optimal dose. The replacement of C by O and F by X does not appear to impair efficacy. The trial continues to total accrual of 1000 pts.

Erythromycin as a prokinetic agent in preterm neonates: a systematic review

BACKGROUND

It often takes several days or even weeks to establish full enteral feeds (FEFs) in preterm, especially extremely low birthweight neonates because of feed intolerance related to gastrointestinal hypomotility. Clinical trials of erythromycin as a prokinetic agent in preterm neonates have reported conflicting results.

AIM

To systematically review the efficacy and safety of erythromycin as a prokinetic agent in preterm neonates.

METHODS

Only randomised controlled trials in preterm neonates (gestation < or = 37 weeks) were considered eligible for inclusion. The primary outcome was the time to reach FEFs of 150 ml/kg/day. The secondary outcomes included the incidence of erythromycin related adverse effects such as diarrhoea, cardiac arrhythmias, and hypertrophic pyloric stenosis. No restrictions were applied on the dose (low: 3-12 mg/kg/day; antimicrobial: > or = 12 mg/kg/6-8 hours) and route (oral or intravenous) and mode (prophylactic or rescue) of administration. The standard methodology for systematic reviews was followed. A subgroup analysis was pre-planned based on the dose and mode of drug administration.

RESULTS

Seven trials (three prophylaxis, four rescue) with various doses, routes and modes of administration, and durations of erythromycin treatment and different results were found to be eligible for inclusion in the analysis. Meta-analysis could not be performed, as specific data were either inadequate or not available.

CONCLUSION

The conflicting trial results may be explained by differences in dose and route and mode of administration of erythromycin and in gastrointestinal motor responses in the presence of different feeding conditions-for example, fasting v fed state, intermittent v continuous feeds. Gestational and postnatal ages during erythromycin treatment are also important.

Phase III study of 5FU, etoposide and leucovorin (FELV) compared to epirubicin, cisplatin and 5FU (ECF) in previously untreated patients with advanced biliary cancer

The purpose of this study was to determine whether epirubicin, cisplatin and infused 5FU (ECF) improves overall survival (OS) compared to 5FU, etoposide and leucovorin (FELV) in patients with previously untreated advanced biliary cancer in a prospective randomised study. Patients were randomly assigned to receive epirubicin, cisplatin and infused 5FU ECF or bolus 5FU etoposide and leucovorin (FELV). The primary end point was OS with secondary end points of objective response rate (ORR), failure-free survival (FFS), quality of life (QOL) and toxicity. In all, 54 patients were recruited with 27 randomly assigned to each arm. The median OS for ECF was 9.02 months (95% confidence interval (CI): 6.46–11.51) and FELV 12.03 months (95% CI: 9.3–14.7), P=0.2059. Objective response rates were similar for both arms: ECF 19.2% (95% CI: 6.55–39.3); FELV 15% (95% CI: 3.2–37.9), P=0.72. There was significantly increased grade 3/4 neutropenia with FELV vs ECF (53.8 vs 29.5%, respectively, P=0.020). Symptom resolution was impressive for both regimens. This is the largest reported randomised study to date in this setting. ECF did not improve OS compared to FELV, but was associated with less acute toxicity. These data suggest that chemotherapy can prolong OS and achieve good symptomatic relief in advanced biliary cancer.

Menin molecular interactions: insights into normal functions and tumorigenesis

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disease predisposed by heterozygous germline mutations in the MEN1 tumor suppressor gene. Biallelic loss of MEN1 resulting from small mutation and/or loss of heterozygosity occurs in a large tissue spectrum of MEN1 tumors or non-hereditary tumors. Mouse models of MEN1 underexpression or overexpression have also supported the tumor-suppressor effect of the MEN1 gene. Menin, the 610-amino-acid protein encoded by MEN1, is expressed ubiquitously and found predominantly in the nucleus. Sequence analyses do not reveal motifs of known function other than two nuclear localization sequences. Menin has been found to partner in vitro with a variety of proteins that comprise transcription factors, DNA processing factors, DNA repair proteins, and cytoskeletal proteins. The diverse functions of menin interactors suggest roles for menin in multiple biological pathways. Inactivation of menin switches its JunD partner from a downstream action of growth suppression to growth promotion. This is a plausible mechanism for menin tumorigenesis.

Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital

BACKGROUND AND STUDY AIMS

Colonic tuberculosis is not uncommon in developing countries. As emigration to the West increases, it is worthwhile to recall the clinical, colonoscopic, and histopathological features of this condition.

PATIENTS AND METHODS

The clinical, colonoscopic and histopathological findings were evaluated in 43 patients with colonic tuberculosis.

RESULTS

Abdominal pain, weight loss, diarrhea, fever, and a lump in the abdomen were the commonest symptoms. Extraintestinal tuberculosis was present in 11 patients (26 %). Colonoscopy revealed ulcers in 30 patients (70 %), nodules in 24 (56 %), a deformed cecum and ileocecal valve in 17 (40 %), strictures in 10 (23 %), polypoid lesions in six (14 %), and fibrous bands forming mucosal bridges in three (7 %). The cecum and ascending colon were the commonest sites involved. Segmental tuberculosis was seen in six of the 32 patients (19 %) in whom full-length colonoscopy could be performed. Two or more sites were involved in 19 patients (44 %). Histopathology revealed well-formed granulomas in 23 patients (54 %). Fourteen of the above patients (61 %) had caseation and 11 (48 %) had confluence of the granulomas. Acid-fast bacilli were present in the biopsies from two patients (5 %). Ill-formed granulomas were seen in seven patients (16 %) and chronic inflammatory changes in 13 (30 %). Despite the various histopathological findings, all of the patients responded to antitubercular treatment and continued to remain asymptomatic during the follow-up period.

CONCLUSIONS

Colonoscopy with biopsy is a useful method for diagnosing colonic tuberculosis. Even in the absence of the classic histopathological features, a therapeutic trial may be indicated in a given clinical and colonoscopic setting. Follow-up is essential.

Clinical, colonoscopic, and histological profile of colonic tuberculosis in a tertiary hospital

BACKGROUND AND STUDY AIMS

Colonic tuberculosis is not uncommon in developing countries. As emigration to the West increases, it is worthwhile to recall the clinical, colonoscopic, and histopathological features of this condition.

PATIENTS AND METHODS

The clinical, colonoscopic and histopathological findings were evaluated in 43 patients with colonic tuberculosis.

RESULTS

Abdominal pain, weight loss, diarrhea, fever, and a lump in the abdomen were the commonest symptoms. Extraintestinal tuberculosis was present in 11 patients (26 %). Colonoscopy revealed ulcers in 30 patients (70 %), nodules in 24 (56 %), a deformed cecum and ileocecal valve in 17 (40 %), strictures in 10 (23 %), polypoid lesions in six (14 %), and fibrous bands forming mucosal bridges in three (7 %). The cecum and ascending colon were the commonest sites involved. Segmental tuberculosis was seen in six of the 32 patients (19 %) in whom full-length colonoscopy could be performed. Two or more sites were involved in 19 patients (44 %). Histopathology revealed well-formed granulomas in 23 patients (54 %). Fourteen of the above patients (61 %) had caseation and 11 (48 %) had confluence of the granulomas. Acid-fast bacilli were present in the biopsies from two patients (5 %). Ill-formed granulomas were seen in seven patients (16 %) and chronic inflammatory changes in 13 (30 %). Despite the various histopathological findings, all of the patients responded to antitubercular treatment and continued to remain asymptomatic during the follow-up period.

CONCLUSIONS

Colonoscopy with biopsy is a useful method for diagnosing colonic tuberculosis. Even in the absence of the classic histopathological features, a therapeutic trial may be indicated in a given clinical and colonoscopic setting. Follow-up is essential.

Phase II study of ISIS 3521, an antisense oligodeoxynucleotide to protein kinase C alpha, in patients with previously treated low-grade non-Hodgkin's lymphoma

BACKGROUND

The purpose of this study was to assess the efficacy and safety of ISIS 3521, an antisense phosphorothioate oligonucleotide to protein kinase C alpha in patients with relapsed low-grade non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

Twenty-six patients received ISIS 3521 (2 mg/kg/day) as a continuous infusion over 21 days of each 28-day cycle.

RESULTS

The median age of the patients was 53 years (range 37-77). Histological subtypes were low-grade follicular lymphoma (n = 22) and B-cell small lymphocytic lymphoma (n = 4). Twenty-one (81%) had stage III/IV disease. The median number of previous lines of chemotherapy was two (range one to six). A total of 87 cycles of ISIS 3521 were administered. Twenty-three patients were assessable for response. Three patients achieved a partial response. No complete responses were observed. Ten patients had stable disease. Grade 3-4 toxicity was as follows: neutropenia (3.8%) and thrombocytopenia (26.9%).

CONCLUSIONS

ISIS 3521 has demonstrated anti-tumour activity in patients with relapsed low-grade NHL. There may be a potential role for this agent in combination with conventional chemotherapy for advanced low-grade lymphoma, and further trials are warranted.

Systemic fungal infections in neonates

Advances in neonatal management have led to considerable improvement in newborn survival. However, early (<72 hours) and late (>72 hours) onset systemic infections, both bacterial and fungal, remain a devastating complication and an important cause of morbidity and mortality in these babies. Most neonatal fungal infections are due to Candida species, particularly Candida albicans. The sources of candidiasis in NICU are often endogenous following colonization of the babies with fungi. About 10% of these babies get colonized in first week of life and up to 64% babies get colonized by 4 weeks of hospital stay. Disseminated candidiasis presents like bacterial sepsis and can involve multiple organs such as the kidneys, brain, eye, liver, spleen, bone, joints, meninges and heart. Confirming the diagnosis by laboratory tests is difficult and a high index of suspicion is required. The diagnosis of fungemia can be made definitely only by recovering the organism from blood or other sterile bodily fluid. Amphotericin B continues to be the mainstay of therapy for systemic fungal infections but its use is limited by the risks of nephrotoxicity and hypokalemia. Newer formulations of amphotericin B, namely the liposomal and the lipid complex forms, have recently become available and have been reported to have lesser toxicity. More recently Indian liposomal Amphotericin B derived from neutral lipids (L-Amp-LRC-1) has shown good response with less toxicity. A clinical trial with this preparation has shown to be safe and efficacious in neonatal fungal infections. Compared to other liposomal preparations, L-Amp-LRC-1 is effective at lower dose and is less expensive drug for the treatment of neonatal candidiasis.

Large babies and unplanned Caesarean delivery

OBJECTIVE

The relationship between birth weight > or =4000 g and unplanned Caesarean delivery was examined.

DESIGN

A retrospective cohort study.

SETTING

A district general hospital.

POPULATION

Two thousand three hundred and ninety-three women who delivered babies weighing > or =2500 g.

METHODS

The mode of delivery of babies who weighed > or =4000 g was compared with those who weighed between 2500 and 4000 g. Comparative analysis of data was followed by regression analysis of explanatory variables. The effect of increasing birth weight on unplanned Caesarean delivery was determined.

RESULTS

Women who had an unplanned Caesarean were delivered at an earlier gestation (OR = 0.89, 95% CI 0.81-0.97; P = 0.007), and were more likely to be primiparous (OR 5.4, 95% CI 4.1-7.1; P = 0.0001). Further, women who had an unplanned Caesarean were more likely to have babies weighing > or =4000 g (OR = 2.24, 95% CI 1.61-3.12; P = 0.003). The odds of having an unplanned Caesarean were increased 16.9-fold with a previous Caesarean (95% CI 9.24-30.8; P = 0.001). When a previous Caesarean was combined with a baby weighing > or =4000 g, the odds of having an unplanned Caesarean increased 37.8 times (95% CI 18.8-75.8), compared to a woman who previously had a normal vaginal birth and a baby weighing between 2500 and 4000 g.

CONCLUSION

Birth weight > or =4000 g is associated with more than a two-fold increased risk of an unplanned Caesarean delivery. The risk increased further (37.8 x) when a previous Caesarean delivery was combined with a birth weight > or =4000 g.

Mycobacterium fortuitumBacteraemia in an Immunocompromised Patient

A case of Mycobacterium fortuitum bacteraemia in an immunocompromised patient confirmed by four positive serial blood cultures is reported here. The patient was a known case of acute lymphoblastic leukemia (ALL) on intensive chemotherapy. The source of bacteraemia was most probably a peripherally inserted vascular catheter. After initiation, of treatment with amikacin to which the strain was sensitive and clarithromycin and removal of the central line the patient's fever defervesced and repeat blood cultures were negative. This is the first time we have encountered an immunocompromised patient with M. fortuitum septicaemia in our hospital. The possibility of an infection with rapidly growing mycobacteria is important to consider when conventional organisms are not isolated in culture especially in the context of patients with malignancy.

Phase II study of capecitabine and mitomycin C as first-line treatment in patients with advanced colorectal cancer

This study was designed to assess the safety and efficacy of capecitabine and mitomycin C (MMC) in previously untreated patients with advanced colorectal cancer (CRC). Patients received capecitabine 2500 mg m² day 1, orally divided in two doses of 1250 mg m⁻² in the morning and evening for 14 days every 21 days and MMC 7 mg m⁻² (maximum total dose 14 mg) as an intravenous bolus every 6 weeks for a total of four courses. The median age was 70 years (range 24–85) and the majority of patients (86.9%) were of performance status 1/2. The most common metastatic site was liver. In all, 84 patients were assessable for response. The overall response rate was 38% (95% CI: 27.7–49.3) and a further 33.3% of patients achieved stable disease over 12 weeks. There was good symptom resolution ranging from 64 to 86%. Grade 3/4 toxicity was as follows: hand–foot syndrome 19.7%; diarrhoea 10%; neutropenia 2.4%; infection 2.3%. Capecitabine and MMC have shown encouraging activity with a favourable toxicity profile, a convenient administration schedule, and could be considered for patients deemed unsuitable for oxaliplatin and irinotecan combinations.

Phase III double-blind placebo-controlled study of farnesyl transferase inhibitor R115777 in patients with refractory advanced colorectal cancer

PURPOSE

To determine whether R115777 improves survival in patients with refractory advanced colorectal cancer (CRC) in a multicenter, double-blind, prospective randomized study.

PATIENTS AND METHODS

Three hundred sixty-eight patients were randomly assigned to R115777 (300 mg twice daily) orally for 21 days every 28 days or placebo in a 2:1 ratio. All patients received best supportive care. The primary end point was overall survival; secondary end points were progression free survival, tumor response, toxicity, and quality of life.

RESULTS

The two treatment groups were well balanced for baseline demographics, including previous chemotherapy for advanced CRC. The median overall survival for R115777 was 174 days (95% CI, 157 to 198 days), and 185 days (95% CI, 158 to 238 days) for those patients receiving placebo (P =.376). One patient achieved a partial response in the R115777 arm. Stable disease (> 3 months) was observed in 24.3% patients in the R115777 group compared to 12.8% in the placebo arm. This did not translate into a statistically significant increase in progression-free survival. Overall, treatment was well tolerated. There was an increased incidence of reversible myelosuppression (neutropenia, thrombocytopenia), rash, and grade 1 to 2 diarrhea in the R115777 arm. There was no statistically significant difference in quality of life between arms.

CONCLUSION

Single agent R115777, given at this dose and schedule, has an acceptable toxicity profile, but does not improve overall survival compared to best supportive care alone in refractory advanced CRC.

Completion of the sequence analysis and comparisons of genome segment 2 (encoding outer capsid protein VP2) from representative isolates of the 24 bluetongue virus serotypes

Bluetongue (BT) is a non-contagious, arthropod-transmitted viral disease of domestic and wild ruminants. It is caused by bluetongue virus (BTV), a double-stranded (ds) RNA virus that is classified within the genus Orbivirus, family Reoviridae. There are at least twenty-four serotypes of BTV worldwide, five of which (1, 2, 4, 9 and 16) have been identified recently in Europe. BTV infects ruminants and its distribution throughout temperate and tropical regions of the world is dependent on the activity and abundance of certain vector-competent species of Culicoides midge. The outer capsid protein VP2 of BTV is a major protective antigen and the primary determinant of virus serotype. For the first time, the authors have completed the sequence analysis of full-length VP2 genes from the reference strains of each of the 24 BTV serotypes and their amino acid sequences were deduced. Multiple alignment of the VP2 gene (protein) sequences revealed that the level of nucleotide (amino acid) sequence variation between serotypes ranged from 29% (23%) to 59% (73%), confirming that segment 2/VP2 is the most variable BTV gene/protein. Phylogenetic analysis of VP2 grouped together the BTV types that are known to cross-react serologically. Low identity between types was demonstrated for specific regions within the VP2 amino acid sequences that have been shown to be antigenic and play a role in virus neutralisation. The sequence data represent the completion of an important step in the creation of a comprehensive BTV sequence database, which will support more rapid molecular methods for diagnosis and identification of BTV 'types', as well as continuing molecular epidemiology and surveillance studies of BTV.

Phylogenetic analysis of bluetongue virus genome segment 6 (encoding VP5) from different serotypes

Full-length cDNAs were sequenced for genome segment 6 from representative isolates of all 24 bluetongue virus (BTV) serotypes. Segment 6 is 1635 to 1645 nucleotides in length with a single open reading frame in all isolates. The deduced VP5 protein sequence is 526 amino acids long for most BTVs, except BTV-15 (isolate number RSArrrr/15), which is 527 amino acids long, and BTV-12 (isolate number RSArrrr/12) and BTV-22 (isolate number Nig1982/11), which were 529 amino acids long. Sequence comparisons have revealed the level of genetic diversity in segment 6, between different BTV serotypes and between isolates within a single serotype. The resulting sequences can be used to design RT-PCR primers for amplification and identification of segment 6 from new BTV isolates, providing potentially valuable diagnostic and research tools. These data are available on the international databases and accession numbers are listed on the website of the Institute for Animal Health (iah.bbsrc.ac.uk/dsRNA_virus_proteins/ btv_sequences.htm).

Molecular epidemiology of bluetongue viruses from disease outbreaks in the Mediterranean Basin

Bluetongue virus (BTV) serotype is primarily controlled by the variable outer coat protein VP2, encoded by genome segment 2. Phylogenetic analyses of segment 2 show that recent Mediterranean isolates of BTV-2 have a similar genetic lineage to those from sub-Saharan Africa and North America but are distinct from Asian strains. In contrast, isolates of BTV-9, from the eastern Mediterranean, are related to a genetic lineage from Asia. BTV-1 from Greece 2001 is also more closely related to Indian isolates, suggesting (in both cases) virus movement from east to west. Recent BTV-4 field isolates from Greece and Turkey are similar to each other, but differ from the Turkish type 4 vaccine strain. These sequencing studies are being used to establish a database for molecular epidemiological studies which is available on the website of the Institute for Animal Health. This resource will support and improve BTV serotype identification methods, by using sequence comparisons (via the Web) rather than by conventional serological techniques that require standardised (and therefore expensive) serological reagents. Phylogenetic trees for BTV genome segment 2 are available on the website.

Pediatric tracheostomy: a 13-year experience

Pediatric tracheostomy has been reported to be a surgical procedure with significant morbidity and mortality. The use of tracheostomy in airway management has changed over time as regards indication and outcome. A review of the last 13 years' experience in our institution was carried out to focus on this group of patients and the recent trends in airway management. A retrospective analysis of hospital records was done and information collected with respect to age, gender, indication for tracheostomy, duration, complications, and follow-up. Thirty-nine tracheotomies were done in 36 patients, of whom males outnumbered females 2:1. The mean patient age was 41.6 months while nearly a third were newborns. The indications were congenital and acquired obstructive lesions. Apart from nine cases, all have been treated and decannulated. Follow-up ranged from 1 month to 8 years, and decannulation time from 48 h to 45 months. Home tracheostomy care was very well managed by the parents. One tracheostomy-related death was encountered. Complications were minor and transient and occurred post-decannulation in our series, in contrast to the major complications, both acute and chronic, reported in the literature. More neonates and infants are undergoing tracheostomy and surviving. Pediatric tracheostomy is a safe procedure with home care by parents feasible.

An improved urine collection pad method: a randomised clinical trial

AIM

To evaluate a modified urine collection pad (UCP) method for its ability to reduce heavy mixed growth bacterial contamination of UCP samples in young children with suspected urinary tract infection (UTI).

METHOD

Febrile children under 2 years of age were randomised to two UCP METHODS: the same UCP kept in the nappy until urine was passed (single UCP group), or the UCP replaced with a fresh one every 30 minutes until urine was passed (replaced UCP group). In both groups a moisture sensitive audio alarm was used to signal passage of urine.

RESULTS

Eighty children were enrolled and a satisfactory sample was obtained in 68 (37 in the single UCP group and 31 in the replaced UCP group). In 12 children (15%), collection failed, mainly because of faecal soiling of the pad. UTI occurred in three children (4%). In the remaining 65 samples, heavy mixed growth (> 10(5) organisms/ml) occurred in 1/31 (3%) in the replaced UCP group compared with 10/35 (29%) in the single UCP group (p = 0.008). There were no adverse effects from the use of the moisture sensitive audio alarm.

CONCLUSION

Changing the UCP every 30 minutes almost eliminates heavy mixed growth contamination of UCP samples and substantially increases the proportion of UCP results that confidently exclude UTI. This represents a simple and clinically important improvement to the UCP method which is reliable for diagnosing and excluding UTI in young children still in nappies. It has potential for use in outpatient clinics, in the primary healthcare setting, or at home.

Large scale association analysis for identification of genes underlying premature coronary heart disease: cumulative perspective from analysis of 111 candidate genes

BACKGROUND

to date, only three groups have reported data from large scale genetic association studies of coronary heart disease using a case control design.

METHODS AND RESULTS

to extend our initial report of 62 genes, we present data for 210 polymorphisms in 111 candidate genes genotyped in 352 white subjects with familial, premature coronary heart disease (onset age for men, 45; for women, 50) and a random sample of 418 population based whites. Multivariate logistic regression analysis was used to compare the distributions of genotypes between cases and the comparison group while controlling for age, sex, body mass, diabetes, and hypertension. Significant associations were found with polymorphisms in thrombospondin-4 (THBS4), thrombospondin-2 (THBS2) and plasminogen activator inhibitor-2 (PAI2), the strongest being with the A387P variant in THBS4 (p = 0.002). The THBS2 and THBS4 associations have since been replicated. We evaluated polymorphisms in 40 genes previously associated with coronary heart disease and found significant (p<0.05) associations with 10: ACE, APOE, F7, FGB, GP1BA, IL1RN, LRP1, MTHFR, SELP, and THPO. For five of these genes, the polymorphism associated in our study was different from that previously reported, suggesting linkage disequilibrium as an explanation for failure to replicate associations consistently across studies. We found strong linkage disequilibrium between polymorphisms within and between genes, especially on chromosome 1q22-q25, a region containing several candidate genes.

CONCLUSIONS

despite known caveats of genetic association studies, they can be an effective means of hypothesis generation and complement classic linkage studies for understanding the genetic basis of coronary heart disease.