Superior beta cell proliferation, function and gene expression in a subpopulation of rat islets identified by high blood perfusion

AIMS/HYPOTHESIS

The blood perfusion of individual pancreatic islets is highly variable, with a subgroup of islets having high perfusion and blood vessels responsive to further blood flow increase induced by glucose. This study tested the hypothesis that there is heterogeneity between islets with regard to beta cell proliferation, function and gene expression based on differences in their blood perfusion.

METHODS

Fluorescent microspheres were injected into the ascending aorta, and then microsphere-containing and non-microsphere-containing pancreatic islets were isolated for investigation. By this procedure, the 5% of islets with the greatest blood perfusion were identified for study. Islet endothelial cells were isolated separately to investigate the role of improved vascular support in the observed differences.

RESULTS

The vascular network was found to be more dense and tortuous in microsphere-containing than other islets. The most highly blood-perfused islets also had a higher rate of beta cell proliferation, superior beta cell function and a markedly different gene expression from other islets. Cultured islets exposed to islet endothelial cell products had a similarly increased beta cell proliferation rate, yet significantly fewer changes in gene expression than observed in the most highly blood-perfused islets.

CONCLUSIONS/INTERPRETATION

A novel heterogeneity between islets was observed, with superior beta cell proliferation, function and gene expression in a subpopulation of islets identified by high blood perfusion. In contrast with a previously described population of low-oxygenated, sleeping islets, which are recruited into functionality when needed, the presently described heterogeneity is shown to remain in vitro after islet isolation.

Abstract 3862: The potential role of CD44 in liver regeneration

Background and Aim: Liver regeneration occurs after liver damage by ischaemia, hepatitis, or in hepatocellular carcinoma (HCC) patients receiving hepatic resection or liver transplantation. Understanding the molecular bases of this process will provide novel therapeutic approaches for patients with various liver diseases. Previous studies suggested the linkage between CD44, a multifunctional cell surface receptor, and liver regeneration. The detailed role of this receptor in liver regeneration, however, remained unclear. The present study aimed at elucidating the role of CD44 in liver regeneration. Materials and Methods: A mouse model of liver regeneration induced by partial hepatectomy (PH) was employed. Serum and liver tissues were collected at different time points after PH. ELISA was performed to measure hyaluronic acid (ligand for CD44) level in serum. Flow cytometry was done to characterize liver cell populations after PH. Liver regeneration was quantified by measurement of liver mass and by immunohistochemical staining for PCNA (a proliferation marker). Quantitative PCR was performed to compare gene expression pattern of 46 genes between CD45− CD44+ cells and their CD44− counterparts. Results: Firstly, serum hyaluronic acid level was elevated at the early stage of liver regeneration. Secondly, by flow cytometry, an increase in CD45− CD44+ cell population was found. Thirdly, immunohistochemical analysis revealed active hepatocyte proliferation during this period. Interestingly, the hepatectomy-induced cell proliferation was suppressed after treating mice with anti-CD44 antibody, suggesting a functional role of CD44 in liver regeneration. Lastly, dysregulation of genes involving in cell proliferation, angiogenesis, and metabolism of hyaluronic acid was disclosed in CD45− CD44+ cells. Conclusion: The present study indicated that CD44-mediated pathways are required for liver regeneration, which may have therapeutic implications in treating liver diseases, including HCC.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3862. doi:1538-7445.AM2012-3862

Impact of internal mammary node inclusion in the radiation treatment volume on the outcomes of patients with breast cancer treated with locoregional radiation after six years of follow-up

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Background: There is ongoing controversy about radiotherapy (RT) to internal mammary nodes (IMNs). Proponents of IMN RT cite the survival benefit seen in postmastectomy RT trials that included IMNs. However, others point out that benefit cannot be definitively attributed to IMN inclusion, as other lymph node regions were included in the RT arms. The issue is important, as IMN RT potentially increases cardiac and respiratory morbidity.

Methods: 2,413 women referred to a provincial RT program with newly diagnosed node positive, or T3/4N0 non-M1 invasive breast cancer, treated with a complete course of locoregional RT from 2001 to 2006, were retrospectively identified in a provincial database. IMN RT inclusion versus exclusion was determined through review of patient charts and RT treatment plans. Breast cancer-specific survival (BCSS), relapse-free survival (RFS), and overall survival (OS) were compared between the two groups using univariate and multivariable analyses.

Results: Analyses were performed at a median follow-up of 6.2 years. 41.4% of the subjects received IMN RT. The 5-year BCSS for the IMN inclusion and exclusion group was 84.8% versus 82.9%, respectively (HR 0.93 [95% CI 0.76, 1.14]; p=.51); the 5-year RFS was 87.4% versus 86.9% (HR 0.993 [0.83, 1.19]; p=0.94); and the 5-year OS was 84.8% versus 82.9% (HR 0.84 [0.70, 1.01]; p=0.06). After controlling for potentially confounding variables, there was no significant difference in BCSS (HR 0.96 [0.78, 1.18], p=0.88), RFS (HR 1.02 [0.84, 1.22], p=0.87), or OS (HR 0.91 [0.76, 1.10]; p=0.35).

Conclusions: After a median follow-up of 6.2 years, this population-based study shows no benefit from including IMNs in the locoregional RT volume after adjusting for other prognostic and treatment variables.

Accuracy of symptoms and signs in predicting hypoxaemia among young children with acute respiratory infection: a meta-analysis

OBJECTIVE

To assess the accuracy of clinical symptoms and signs in predicting hypoxaemia among young children with acute respiratory infection (ARI).

METHODS

We conducted a systematic review and meta-analysis of prospective diagnostic studies that evaluated the accuracy of individual or combined clinical symptoms and signs in predicting hypoxaemia among children aged <5 years with ARI. MEDLINE® was searched for articles published between 1950 and March 2010. Measurement of arterial haemoglobin oxygen saturation by pulse oximetry was used as reference standard. The hierarchical summary receiver operating characteristic model for meta-analyses was applied.

RESULTS

Eleven diagnostic studies with 5787 patients were included in the review. There was substantial variation in sensitivity and specificity between different symptoms and signs as well as across studies. Cyanosis, inability to feed, head nodding, respiratory rate > 70/min and unresponsiveness/impaired rousability had high specificity but low sensitivity. In contrast, reported rapid breathing and crepitations in lung auscultation had relatively high sensitivity but low specificity. Five models of a combination of symptoms and signs presented moderate sensitivity (range 0.60-0.84) and specificity (range 0.63-0.82).

CONCLUSIONS

Neither single nor combined symptoms and signs have satisfactory performance in predicting hypoxaemia among young children with ARI. Improved access to pulse oximetry is needed in developing countries.

Prevalence and effectiveness of treatment of hypertension on cardiovascular morbidity and mortality in an elderly population aged 70 years and over

The prevalence of hypertension, effectiveness of blood pressure control and compliance, and the effectiveness of treatment on 18-month overall mortality and development of cardiovascular disease in an elderly Chinese population were studied. The study group examined were aged 70 years and over, and consisted of a random sample of subjects on the Old Age and Disability Allowance register. They were stratified by sex and 5-year age groups from 70-74 to 90+ years. Information obtained at baseline included medical history, use of drugs, and measurement of blood pressure. Subjects with a blood pressure > 160/90 were classified as hypertensive. The overall prevalence of hypertension was 48%, 19% being undiagnosed. Among subjects with a known history of hypertension and taking drugs, only approximately half had adequate control (BP < or = 160/90). One fifth of those with a known diagnosis of hypertension were not taking drugs. Subjects who developed stroke had a higher mean systolic and pulse pressure at baseline; no difference in mean pressures was observed for overall mortality or development of heart disease. No difference in mortality or development of cardiovascular disease was observed between the following groups: known history of hypertension and taking medication with controlled blood pressure, known history and taking medication and blood pressure poorly controlled or not taking drugs, and normal blood pressure with no history of hypertension.

Endothelial cell signalling supports pancreatic beta cell function in the rat

AIMS/HYPOTHESIS

The proximity of endothelial cells and beta cells in islets by necessity means that they are exposed to each other's products. Whereas islet endothelial cells require signals from beta cells to function properly, endothelin-1, thrombospondin-1 and laminins, among others, have been identified as endothelial-derived molecules, although their full effects on beta cells have not been explored. We tested the hypothesis that islet endothelial-derived products affect beta cell function.

METHODS

Endothelial cells from rat islets were proliferated and purified. Endothelium-conditioned culture medium (ECCM) was obtained by maintaining the endothelial cells in culture medium. Islet function was evaluated following exposure of cultured islets to standard culture medium or ECCM. Changes in mRNA levels for key beta cell metabolic enzymes were also measured in islets after ECCM exposure.

RESULTS

Glucose-stimulated insulin release and islet insulin content were markedly enhanced by exposure to ECCM. This was at least partly explained by improved mitochondrial function, as assessed by glucose oxidation and an upregulation of the mitochondrial gene for glycerol-3-phosphate dehydrogenase (mGpdh [also known as Gpd2]), combined with upregulation of the rate-limiting enzyme in the glycolysis, glucokinase, in the islets. The intracellular degradation of insulin was also decreased in the islets. Islet endothelial cells produced laminins, and the positive effects of islet endothelial cells were prevented by addition of a neutralising antibody to the beta1-chain of laminin. Addition of exogenous laminin stimulated islet function.

CONCLUSIONS/INTERPRETATION

This study provides proof of principle that endothelial cells can affect the function of beta cells in their vicinity and that this is at least partially mediated by laminins.

APOE gene polymorphisms and response to statin therapy

Published studies investigating the role of APOE gene on lipid response (total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglycerides) to statin treatment have reported inconsistent results. A meta-analysis was conducted to estimate the lipid response to statin treatment among APOE genetic variants (e2 carriers, e3e3 homozygotes and e4 carriers). Twenty-four studies were included in the meta-analyses. The pooled mean reduction (Delta mu) in TC from baseline was significant for all variants (e2 carriers: Delta mu=-27.7% (-32.5 to -22.8%), e3e3: Delta mu=-25.3% (-28.0 to -22.6%) and e4 carriers: Delta mu=-25.1% (-29.3 to -21.0%)). Significant changes in LDL-C, HDL-C and triglyceride levels were also noted for all genotypes, although these changes did not differ significantly among genotypic groups. There was significant heterogeneity among the studies. Given these non-significant effects of APOE genotypes on lipid responses, there is little reason to consider the use of APOE genetic testing for guiding treatment with statins.

Organ-specific hemosiderosis and functional correlation in Chinese patients with thalassemia intermedia and hemoglobin H disease

We performed MRI assessment in 37 adult Chinese patients with thalassemia intermedia and hemoglobin H disease. Despite abnormal ferritin and liver T2*, only 5% of patients had cardiac hemosiderosis. The two patients with reduced ejection fraction had normal cardiac T2*. Half of the cases showed pituitary and pancreatic iron loading. Subclinical endocrine abnormalities (HOMA, insulin growth factor) showed correlation with pancreatic, pituitary, and cardiac MRI values. Prospective data with serial functional and imaging monitoring is needed to verify the utility for chelation to improve cardiac and endocrine function in this group of patients.

Intravenous esomeprazole for prevention of peptic ulcer re-bleeding: rationale/design of Peptic Ulcer Bleed study

BACKGROUND

A limited number of trials have investigated the efficacy of proton pump inhibitors for peptic ulcer bleeding, and some study design issues have been identified.

AIM

To present the design of a large trial evaluating the effects of intravenous esomeprazole on clinical outcomes in high-risk patients who have undergone endoscopic haemostasis for peptic ulcer bleeding.

METHODS

The Peptic Ulcer Bleed study is an international, randomized, double-blind, placebo-controlled trial comparing either esomeprazole 80 mg intravenous bolus infusion for 30 min followed by esomeprazole 8 mg/h intravenously for 71.5 h, or placebo infusion for 72 h, after successful endoscopic haemostasis in patients with peptic ulcer bleeding and associated high-risk stigmata. All patients will receive once daily oral esomeprazole 40 mg for 27 days after intravenous therapy. The primary end point is the rate of clinically significant re-bleeding during the first 72 h after endoscopy. Secondary end points include: rate of re-bleeding during the first 7 and 30 days after treatment; length of hospitalization; mortality; blood transfusion; endoscopic re-treatment and surgery.

RESULTS

Expected 2008.

CONCLUSIONS

The carefully designed protocol and quality control measures represent a pragmatic approach to contemporary challenges in peptic ulcer bleeding management and, it is hoped, qualify the Peptic Ulcer Bleed study as a new standard for future interventional studies.

Maternal obesity and risk of cesarean delivery: a meta-analysis

Despite numerous studies reporting an increased risk of cesarean delivery among overweight or obese compared with normal weight women, the magnitude of the association remains uncertain. Therefore, we conducted a meta-analysis of the current literature to provide a quantitative estimate of this association. We identified studies from three sources: (i) a PubMed search of relevant articles published between January 1980 and September 2005; (ii) reference lists of publications selected from the search; and (iii) reference lists of review articles published between 2000 and 2005. We included cohort designed studies that reported obesity measures reflecting pregnancy body mass, had a normal weight comparison group, and presented data allowing a quantitative measurement of risk. We used a Bayesian random effects model to perform the meta-analysis and meta-regression. Thirty-three studies were included. The unadjusted odd ratios of a cesarean delivery were 1.46 [95% confidence interval (CI): 1.34-1.60], 2.05 (95% CI: 1.86-2.27) and 2.89 (95% CI: 2.28-3.79) among overweight, obese and severely obese women, respectively, compared with normal weight pregnant women. The meta-regression found no evidence that these estimates were affected by selected study characteristics. Our findings provide a quantitative estimate of the risk of cesarean delivery associated with high maternal body mass.

Preoperative endoscopic retrograde cholangiopancreatographic treatment of complicated choledochal cysts in children: a retrospective case series

We report our experience with endoscopic retrograde cholangiopancreatography-(ERCP-)based interventions in children with complicated choledochal cysts that are refractory to conservative management. Between 1999 and 2006, 42 children (12 boys, 30 girls; median age 3 years, range 2-14.5 years) were admitted for surgical treatment of choledochal cysts. Seven of these patients (16.7%; one boy, six girls; median age 3 years, range 2-12 years) showed signs of complicated choledochal cysts, and presented with pancreatitis/cholangitis (n = 4) and obstructive jaundice (n = 3). The anatomical classification of the cysts was type Ic (n = 3), type If (n = 3), and type IV (n = 1). ERCP was successfully performed in 6/7 patients, and therapeutic interventions included removal of debris (n = 3), sphincterotomy (n = 3), and stent placement (n = 4). One patient required blood transfusion for post-sphincterotomy bleeding. The patient in whom the ERCP failed underwent ultrasound-guided percutaneous transhepatic biliary drainage. Definitive surgery was performed after a median interval of 10 days (range 7-68 days) after the ERCP intervention.

The Kidney Disease: Improving Global Outcomes website: Comparison of guidelines as a tool for harmonization

Chronic kidney disease (CKD) is a worldwide public health problem with significant comorbidity and mortality. Improving quality of life and survival of CKD patients necessitates a large number of preventive and therapeutic interventions. To resolve these issues several organizations have developed guidelines, which are difficult to compare comprehensively. The Kidney Disease: Improving Global Outcomes website at http://kdigo.org compares five major guidelines. The section 'compare guidelines' covers 41 topics distributed over five major subjects: (1) general clinics; (2) hemodialysis (HD); (3) vascular access for HD; (4) peritoneal dialysis; and (5) chemistries. The tables compare guideline recommendations and the evidence levels on which they are based, with direct links to each of the guidelines. These data show that the different guideline groups tend to propose similar targets, but that nuances in the guideline statements, their rationale, and grading of evidence levels present some discrepancies, although most guidelines are based on the same literature. We conclude that there is an urgent need to harmonize existing guidelines, and for a global initiative to avoid the parallel development of conflicting guidelines on the same topics. The tables displayed on the website offer a basis for structuring this process, a procedure which has recently been initiated by a body composed of the five guideline development groups.

VZV infection in pregnancy: a retrospective review over 5 years in Sheffield and discussion on the potential utilisation of varicella vaccine in prevention

OBJECTIVES

To study retrospectively the epidemiology, demography and clinical issues related to varicella in pregnancy in a UK city over a 5-year period and help inform the debate on the potential of varicella immunisation in prevention.

METHODS

The hospital records of pregnant women with varicella receiving care at the Regional Department of Infection and Tropical Medicine in Sheffield between 1997 and 2002 were reviewed. Data on pregnant women with varicella not presenting acutely to medical care were obtained. The use of Varicella Zoster Immune Globulin (VZIG) in prevention of varicella during the same 5-year period was determined. The records from the maternity department of Sheffield Hospitals for women undergoing VZV antibody testing between January and December 2004 were reviewed. Data on annual number of deliveries were recorded and the neonatology database used as a source of information regarding effects of chickenpox on the baby.

RESULTS

The incidence of varicella infection in pregnancy was at least 6 per 10,000 deliveries. Nineteen pregnant women with varicella were admitted to hospital. Three had pneumonia. Infection occurred in the first pregnancy in a quarter of cases. The minimum cost for all cases admitted to hospital during this period (basic costs per day) was 20,520 pounds sterling. The cost of VZIG use for chickenpox during the same period adjusted for the population size was 10,881 pounds sterling. This was not a comprehensive health economic study and did not attempt to assess additional GP, midwifery, obstetric or social costs nor costs associated with those who did not attend hospital. Two hundred and thirty-three women underwent VZV antibody test during 2004 usually after contact with chickenpox. Sixty percent of women in contact with chickenpox did not present to their GP or hospital immediately.

CONCLUSION

Varicella in pregnancy may be associated with significant morbidity and health care cost and prevention by immunisation is desirable. Though targeted vaccination is attractive, screening in pregnancy followed by a post-partum varicella immunisation programme would fail to protect 25% and would be associated with logistical challenges not occurring with rubella immunisation. Varicella is now a preventable disease by immunisation. Exposure in pregnancy with or without infection has financial costs related to antibody testing and prophylaxis. Infection in pregnancy may be associated with additional costs and potential morbidity to mother and baby. Potential immunisation strategies are considered.

Grading evidence and recommendations for clinical practice guidelines in nephrology. A position statement from Kidney Disease: Improving Global Outcomes (KDIGO)

Considerable variation in grading systems used to rate the strength of guideline recommendations and the quality of the supporting evidence in Nephrology highlights the need for a uniform, internationally accepted, rigorous system. In 2004, Kidney Disease: Improving Global Outcomes (KDIGO) commissioned a methods expert group to recommend an approach for grading in future nephrology guidelines. This position statement by KDIGO recommends adopting the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach for the grading of evidence and guidelines on interventions. The GRADE approach appraises systematic reviews of the benefits and harms of an intervention to determine its net health benefit. The system considers the design, quality, and quantity of studies as well as the consistency and directness of findings when grading the quality of evidence. The strength of the recommendation builds on the quality of the evidence and additional considerations including costs. Adaptations of the GRADE approach are presented to address some issues pertinent to the field of nephrology, including (1) the need to extrapolate from studies performed predominantly in patients without kidney disease, and (2) the need to use qualitative summaries of effects when it is not feasible to quantitatively summarize them. Further refinement of the system will be required for grading of evidence on questions other than those related to intervention effects, such as diagnostic accuracy and prognosis.

Patient controlled opioid analgesia versus conventional opioid analgesia for postoperative pain

BACKGROUND

Patients may control postoperative pain by self-administration of intravenous opioids using devices designed for this purpose (patient controlled analgesia or PCA). A 1992 meta-analysis by Ballantyne found a strong patient preference for PCA over conventional analgesia but disclosed no differences in analgesic consumption or length of postoperative hospital stay. Although Ballantyne's meta-analysis found that PCA did have a small but statistically significant benefit upon pain intensity, Walder's review in 2001 did not find a significant differences in pain intensity and pain relief between PCA and conventionally treated groups.

OBJECTIVES

To evaluate the efficacy of PCA versus conventional analgesia (such as a nurse administering an analgesic upon a patient's request) for postoperative pain control.

SEARCH STRATEGY

Randomized controlled trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2004, Issue 3), MEDLINE (1966 to 2004), and EMBASE (1994 to 2004). Additional reports were identified from the reference lists of retrieved papers.

SELECTION CRITERIA

RCTs of PCA versus conventional analgesia that employed pain intensity as a primary or secondary outcome were selected. These trials included RCTs that compared PCA without a continuous background infusion versus conventional parenteral analgesic regimens. Studies that explicitly stated they involved patients with chronic pain were excluded.

DATA COLLECTION AND ANALYSIS

Trials were scored using the Oxford Quality Scale. Meta-analyses were performed of outcomes that included analgesic efficacy assessed by a Visual Analog Scale (VAS), analgesic consumption, patient satisfaction, length of stay and adverse effects. A sufficient number of the retrieved trials reported these parameters to permit meta-analyses.

MAIN RESULTS

Fifty-five studies with 2023 patients receiving PCA and 1838 patients assigned to a control group met inclusion criteria. PCA provided better pain control and greater patient satisfaction than conventional parenteral 'as-needed' analgesia. Patients using PCA consumed higher amounts of opioids than the controls and had a higher incidence of pruritus (itching) but had a similar incidence of other adverse effects. There was no difference in the length of hospital stay.

AUTHORS' CONCLUSIONS

This review provides evidence that PCA is an efficacious alternative to conventional systemic analgesia for postoperative pain control.

Transient risk factors for acute traumatic hand injuries: a case-crossover study in Hong Kong

OBJECTIVES

To identify the remediable transient risk factors of occupational hand injuries in Hong Kong in order to guide the development of prevention strategies.

METHODS

The case-crossover study design was adopted. Study subjects were workers with acute hand injuries presenting to the government Occupational Medicine Unit for compensation claims within 90 days from the date of injury. Detailed information on exposures to specific transient factors during the 60 minutes prior to the occurrence of the injury, during the same time interval on the day prior to the injury, as well as the usual exposure during the past work-month was obtained through telephone interviews. Both matched-pair interval approach and usual frequency approach were adopted to assess the associations between transient exposures in the workplace and the short-term risk of sustaining a hand injury.

RESULTS

A total of 196 injured workers were interviewed. The results of the matched-pair interval analysis matched well with the results obtained using the usual frequency analysis. Seven significant transient risk factors were identified: using malfunctioning equipment/materials, using a different work method, performing an unusual work task, working overtime, feeling ill, being distracted and rushing, with odds ratios ranging from 10.5 to 26.0 in the matched-pair interval analysis and relative risks ranging between 8.0 and 28.3 with the usual frequency analysis. Wearing gloves was found to have an insignificant protective effect on the occurrence of hand injury in both analyses.

CONCLUSIONS

Using the case-crossover study design for acute occupational hand injuries, seven transient risk factors that were mostly modifiable were identified. It is suggested that workers and their employers should increase their awareness of these risk factors, and efforts should be made to avoid exposures to these factors by means of engineering and administrative controls supplemented by safety education and training.

Efficacy of Haemophilus influenzae type b vaccination of children: a meta-analysis

Haemophilus influenzae type b (Hib) infection is a leading cause of meningitis and pneumonia in infants and children in developing countries, and yet the implementation of routine Hib vaccination is very slow. The aim of the present study was to quantify the protective efficacy of H. influenzae type b vaccination of young children. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials Register were searched. References of selected articles were also reviewed and experts contacted. Eight randomized trials were found that compared the efficacy of H. influenzae type b conjugate vaccine to placebo or no vaccine. Information on study design, patients enrolled, age, vaccine type, cases of invasive H. influenzae type b disease, adverse events, and items to assess potential for bias was recorded. The incidence of invasive H. influenzae type b infection formed the primary outcome. The odds ratio (OR) of developing Hib infection was combined using a random effects model to provide a measure of vaccine efficacy. The protective effect, defined as the relative risk reduction, was estimated as (1-OR). From eight trials, the protective efficacy of the Hib conjugate vaccine was 84% (OR 0.16; 95%CI 0.08-0.30) against invasive Hib disease, 75% (OR 0.25; 95%CI 0.08-0.84) against meningitis, and 69% (OR 0.31; 95%CI 0.10-0.97) against pneumonia. Serious adverse events were rare. The results provide firm evidence that Hib conjugate vaccines are safe and effective in reducing the risk of all forms of invasive Hib disease, further establishing that vaccination of children in developing countries can protect them from a potentially fatal yet preventable disease.

Short-term treatment with proton pump inhibitors, H2-receptor antagonists and prokinetics for gastro-oesophageal reflux disease-like symptoms and endoscopy negative reflux disease

BACKGROUND

Approximately 25% of adults experience heartburn, the cardinal feature of gastro-oesophageal reflux disease (GORD), at least monthly. The evaluation and treatment of patients with suspected GORD is associated with a substantial economic burden. Most patients are treated empirically (without specific diagnostic evaluation). They include a wide range of underlying oesophageal injury. The severity of oesophageal injury can only be established in those who have undergone upper endoscopy. Patients without visible damage to the oesophagus have been referred to as having endoscopy negative reflux disease (ENRD). The pathogenesis of ENRD as well as its response to treatment may differ from GORD with oesophagitis.

OBJECTIVES

Summarise, quantify and compare the efficacy of the short-term use of proton pump inhibitors (PPI), H2-receptor antagonists (H2RA) and prokinetics in adults with GORD, treated empirically and in those with endoscopy negative reflux disease (ENRD).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE (January 1966 to December 2005), EMBASE (January 1988 to December 2005).

SELECTION CRITERIA

Randomised controlled trials focussing on symptomatic outcome after short-term treatment for GORD using proton pump inhibitors, H2-receptor antagonists or prokinetic agents. Studies were included provided that participants could be classified in the empirical treatment group (no endoscopy used in treatment allocation) or in the endoscopy negative reflux disease group (no endoscopic signs of erosive oesophagitis).

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Thirty-one trials (9457 participants) were included: fifteen in the empirical treatment group, twelve in the ENRD group and four in both. In empirical treatment of GORD the relative risk (RR) for heartburn remission (the primary efficacy variable) in placebo-controlled trials for PPI was 0.37 (two trials, 95% confidence interval (CI) 0.32 to 0.44), for H2RAs 0.77 (two trials, 95% CI 0.60 to 0.99) and for prokinetics 0.86 (one trial, 95% CI 0.73 to 1.01). In a direct comparison PPIs were more effective than H2RAs (seven trials, RR 0.66, 95% CI 0.60 to 0.73) and prokinetics (two trials, RR 0.53, 95% CI 0.32 to 0.87). In treatment of ENRD, the RR for heartburn remission for PPI versus placebo was 0.69 (seven trials, 95% CI 0.62 to 0.78) and for H2RA versus placebo was 0.84 (two trials, 95% CI 0.74 to 0.95). The RR for PPI versus H2RA was 0.78 (three trials, 95% CI 0.62 to 0.97) and for PPI versus prokinetic 0.72 (one trial, 95% CI 0.56 to 0.92).

AUTHORS' CONCLUSIONS

PPIs are more effective than H2RAs in relieving heartburn in patients with GORD who are treated empirically and in those with ENRD, although the magnitude of benefit is greater for those treated empirically.

Acupuncture for stroke rehabilitation

BACKGROUND

Stroke is the third leading cause of death in Western society; in China it is the second most common cause of death in cities and the third in rural areas. It is also a main cause of adult disability and dependency. Acupuncture for stroke has been used in China for hundreds of years and is increasingly practiced in some Western countries.

OBJECTIVES

To assess the efficacy and safety of acupuncture for patients with stroke in the subacute or chronic stage.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (November 2005), the Cochrane Complementary Medicine Field Trials Register (November 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to November 2005), EMBASE (1980 to November 2005), CINAHL (1982 to November 2005), AMED (1985 to November 2005), the Chinese Stroke Trials Register (November 2005), the Chinese Acupuncture Trials Register (November 2005), the Chinese Biological Medicine Database (1977 to November 2005), the National Center for Complementary and Alternative Medicine Register (November 2005), and the National Institute of Health Clinical Trials Database (November 2005). We handsearched four Chinese journals and checked reference lists of all papers identified for further trials.

SELECTION CRITERIA

Truly randomised unconfounded clinical trials among patients with ischemic or hemorrhagic stroke, in the subacute or chronic stage, which compared acupuncture involving needling with either placebo acupuncture, sham acupuncture or no acupuncture.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed quality, extracted and cross-checked the data.

MAIN RESULTS

Five trials (368 patients) met the inclusion criteria. Methodological quality was considered inadequate in all trials. Although the overall estimate from four trials suggested the odds of improvement in global neurological deficit was higher in the acupuncture group compared with the control group (odds ratio (OR) 6.55, 95% confidence interval (CI) 1.89 to 22.76), this estimate may not be reliable since there was substantial heterogeneity (I(2 )= 68%). One trial showed no significant improvement of motor function between the real acupuncture group and the sham acupuncture group (OR 9.00, 95% CI 0.40 to 203.30), but the confidence interval was wide and included clinically significant effects in both directions. No data on death, dependency, institutional care, change of neurological deficit score, quality of life or adverse events were available.

AUTHORS' CONCLUSIONS

Currently there is no clear evidence on the effects of acupuncture on subacute or chronic stroke. Large, methodologically-sound trials are required.

Hedgehog signaling in pancreas development and disease

Since its discovery, numerous studies have shown that the Hedgehog (Hh) signaling pathway plays an instrumental role during diverse processes of cell differentiation and organ development. More recently, it has become evident that Hh signaling is not restricted to developmental events, but retains some of its activity during adult life. In mature tissues, Hh signaling has been implicated in the maintenance of stem cell niches in the brain, renewal of the gut epithelium and differentiation of hematopoietic cells. In addition to the basal function in adult tissue, deregulated signaling has been implicated in a variety of cancers, including basal cell carcinoma, glioma and small cell lung cancer. Here, we will focus on the role of Hh signaling in pancreas development and pancreatic diseases, including diabetes mellitus, chronic pancreatitis and pancreatic cancer.

Islets transplanted intraportally into the liver are stimulated to insulin and glucagon release exclusively through the hepatic artery

Not much is known about the physiology of intraportally transplanted islets. One reason for this is that it is difficult to study such islets, since they are scattered throughout the liver. We employed a perfusion technique to characterize the functional properties of syngeneic intrahepatic 1-month-old islet grafts, and compared them to islets transplanted beneath the kidney capsule, as well as native islets. The cellular composition of the islet grafts was also examined. Glucose and arginine administered through the hepatic artery, but not through the portal vein, induced insulin release from the intraportally implanted islets. Moreover, arginine, only when administered through the hepatic artery, induced glucagon release from the same islets. The first phase of glucose-stimulated insulin release from both islets transplanted to the liver and kidney was delayed, and less prominent when compared to the pancreas. Intraportally transplanted islets contained fewer glucagon-positive cells than islets transplanted to the kidney and native islets. Our findings demonstrate that intraportally transplanted islets respond with insulin and glucagon to secretagogues, but only when stimulated through the hepatic artery. Whether intrahepatic islets may sense other substances than glucose or arginine occurring in high concentrations in the portal vein following intestinal uptake remains to be studied.

Music for pain relief

BACKGROUND

The efficacy of music for the treatment of pain has not been established.

OBJECTIVES

To evaluate the effect of music on acute, chronic or cancer pain intensity, pain relief, and analgesic requirements.

SEARCH STRATEGY

We searched The Cochrane Library, MEDLINE, EMBASE, PsycINFO, LILACS and the references in retrieved manuscripts. There was no language restriction.

SELECTION CRITERIA

We included randomized controlled trials that evaluated the effect of music on any type of pain in children or adults. We excluded trials that reported results of concurrent non-pharmacological therapies.

DATA COLLECTION AND ANALYSIS

Data was extracted by two independent review authors. We calculated the mean difference in pain intensity levels, percentage of patients with at least 50% pain relief, and opioid requirements. We converted opioid consumption to morphine equivalents. To explore heterogeneity, studies that evaluated adults, children, acute, chronic, malignant, labor, procedural, or experimental pain were evaluated separately, as well as those studies in which patients chose the type of music.

MAIN RESULTS

Fifty-one studies involving 1867 subjects exposed to music and 1796 controls met inclusion criteria. In the 31 studies evaluating mean pain intensity there was a considerable variation in the effect of music, indicating statistical heterogeneity ( I(2) = 85.3%). After grouping the studies according to the pain model, this heterogeneity remained, with the exception of the studies that evaluated acute postoperative pain. In this last group, patients exposed to music had pain intensity that was 0.5 units lower on a zero to ten scale than unexposed subjects (95% CI: -0.9 to -0.2). Studies that permitted patients to select the music did not reveal a benefit from music; the decline in pain intensity was 0.2 units, 95% CI (-0.7 to 0.2). Four studies reported the proportion of subjects with at least 50% pain relief; subjects exposed to music had a 70% higher likelihood of having pain relief than unexposed subjects (95% CI: 1.21 to 2.37). NNT = 5 (95% CI: 4 to 13). Three studies evaluated opioid requirements two hours after surgery: subjects exposed to music required 1.0 mg (18.4%) less morphine (95% CI: -2.0 to -0.2) than unexposed subjects. Five studies assessed requirements 24 hours after surgery: the music group required 5.7 mg (15.4%) less morphine than the unexposed group (95% CI: -8.8 to -2.6). Five studies evaluated requirements during painful procedures: the difference in requirements showed a trend towards favoring the music group (-0.7 mg, 95% CI: -1.8 to 0.4).

AUTHORS' CONCLUSIONS

Listening to music reduces pain intensity levels and opioid requirements, but the magnitude of these benefits is small and, therefore, its clinical importance unclear.

Limbs Anthropometry of Singleton Chinese Newborns of 28–42 Weeks’ Gestation

Abnormalities of limbs are important features of some syndromes recognizable at birth. The purpose of this study was to establish normal standards of limbs including arm length, arm circumference, upper arm length, lower arm length, leg length, thigh circumference, upper leg length, and lower leg length. 10,226 infants (5,422 males, 4,804 females) with gestation 28-42 weeks from 12 hospitals were included. The LMS method using maximum penalized likelihood was used to perform model fitting of the anthropometric centiles for these parameters. This study provided the first set of references for the limbs of the infants by gestation and gender. Racial differences were found when comparing with other populations. The parameters are useful for evaluation of morphologic disorders involving the limbs.

Introduction to cumulative meta-analysis in dentistry: lessons learned from undertaking a cumulative meta-analysis in periodontology

Improving health and well-being from the consideration of isolated studies is problematic. Systematic reviews have been developed to address this problem and may include a quantitative data synthesis in the form of a meta-analysis, or a cumulative meta-analysis. The value of systematic reviews depends greatly on the availability and quality of the results of primary research. The objective of the current project was to demonstrate the technique of cumulative meta-analysis in dentistry using data from a previously published systematic review. The process highlights an issue that some trials could not be synthesized due to the lack of reporting of measures of variation. This represents a potential source of bias. Investigators are encouraged to consider their trials as part of an information continuum and to report sufficient detail to permit the trials' incorporation into subsequent syntheses.

Local anesthetic sympathetic blockade for complex regional pain syndrome

BACKGROUND

Local anesthetic blockade of the sympathetic chain is widely used to treat reflex sympathetic dystrophy (RSD) and causalgia. These two pain syndromes are now conceptualized as variants of a single entity: complex regional pain syndrome (CRPS). A recent meta-analysis of the topic has been published. However, this study only evaluated studies in English language and therefore it could have overlooked some randomized controlled trials.

OBJECTIVES

This systematic review had three objectives: to determine the likelihood of pain alleviation after sympathetic blockade with local anesthetics in the patient with CRPS; to assess how long any benefit persists; and to evaluate the incidence of adverse effects of the procedure.

SEARCH STRATEGY

We searched the Cochrane Pain, Palliative and Supportive Care Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, LILACS, and conference abstracts of the World Congresses of the International Association for the Study of Pain. Bibliographies from retrieved articles were also searched for additional studies.

SELECTION CRITERIA

We considered for inclusion randomized controlled trials that evaluated the effect of sympathetic blockade with local anesthetics in children or in adult patients to treat RSD, causalgia, or CRPS.

DATA COLLECTION AND ANALYSIS

The outcomes of interest were the number of patients who obtained at least 50% of pain relief shortly after sympathetic blockade (30 minutes to 2 hours) and 48 hours or later. We also assessed the presence of adverse effects in each treatment arm. A random effects model was used to combine the studies.

MAIN RESULTS

Two small randomized double blind cross over studies that evaluated 23 subjects were found. The combined effect of the two trials produced a relative risk (RR) to achieve at least 50% of pain relief 30 minutes to 2 hours after the sympathetic blockade of 1.17 (95% CI 0.80-1.72). It was not possible to determine the effect of sympathetic blockade on long-term pain relief because the authors of the two studies evaluated different outcomes.

AUTHORS' CONCLUSIONS

This systematic review revealed the scarcity of published evidence to support the use of local anesthetic sympathetic blockade as the 'gold standard' treatment for CRPS. The two randomized studies that met inclusion criteria had very small sample sizes, therefore, no conclusion concerning the effectiveness of this procedure could be drawn. There is a need to conduct randomized controlled trials to address the value of sympathetic blockade with local anesthetic for the treatment of CRPS.

Trunk anthropometry of Hong Kong Chinese infants

BACKGROUND

Disturbed growth of the trunk may result in abnormal sternocostal relationship and a variety of pectus deformities.

AIMS

The purposes of this study were to establish norms of trunk anthropometry for dysmorphology identification in the newborns and to evaluate chest circumference as a predictor for low birth weight for outborn infants where weighing scales were unavailable.

STUDY DESIGN AND SUBJECTS

A total of 10,339 Chinese infants (5478 males, 4861 females) with gestation 24-42 weeks from 12 hospitals were included. The anthropometric measurements analyzed included chest circumference, inter-nipple distance, sternal length and abdominal circumference.

OUTCOME MEASURES

The LMS method using maximum penalized likelihood was used to perform model fitting of the anthropometric centiles for these physical parameters.

RESULTS

References tables of the four physical parameters for newborns were constructed. Chest circumference showed the highest correlation with birth weight (male: r = 0.866, female: r = 0.883). The cut-off points for chest circumference of 295 (male) and 299 mm (female) were the best predictor for low birth weight. There were also racial differences in these parameters. When compared with French infants, Chinese newborns had smaller chest circumference.

CONCLUSION

These physical parameters provide useful references and aid dysmorphology diagnosis in newborns of ethnic Chinese origin.

Normative Data of Penile Length for Term Chinese Newborns

Careful examination and assessment of penile length in the newborn is important because micropenis is associated with hypothalamic disorders. This prospective cross-sectional study was designed to establish the norm of penile length for term Hong Kong Chinese newborns. 4,628 full-term healthy male newborns were enrolled in the study. Penile length was measured from pubic ramus to the tip of the glans penis by placing the end of a straight edge ruler against the pubic ramus. A gestation-associated graph of 3rd, 10th, 25th, 50th, 75th, 90th and 97th centiles for the penile length was created. The penile length was significantly correlated with gestational age, birth weight and body length. When compared with published data for other populations, Hong Kong newborns have significantly shorter penile length. The norm of the penile length is useful in diagnostic and therapeutics for the ethnic Chinese male newborns.

Long-term non-pharmacologic weight loss interventions for adults with type 2 diabetes

BACKGROUND

Most persons with type 2 diabetes are overweight and obesity worsens the metabolic and physiologic abnormalities associated with diabetes.

OBJECTIVES

The objective of this review is to assess the effectiveness of lifestyle and behavioral weight loss and weight control interventions for adults with type 2 diabetes.

SEARCH STRATEGY

Studies were obtained from computerized searches of multiple electronic bibliographic databases, supplemented with hand searches of selected journals and consultation with experts in obesity research. The last search was conducted May, 2004.

SELECTION CRITERIA

Studies were included if they were published or unpublished randomized controlled trials in any language, and examined weight loss or weight control strategies using one or more dietary, physical activity, or behavioral interventions, with a follow-up interval of at least 12 months.

DATA COLLECTION AND ANALYSIS

Effects were combined using a random effects model.

MAIN RESULTS

The 22 studies of weight loss interventions identified had a 4,659 participants and follow-up of 1 to 5 years. The pooled weight loss for any intervention in comparison to usual care among 585 subjects was 1.7 kg (95 % confidence interval [CI] 0.3 to 3.2), or 3.1% of baseline body weight among 517 subjects. Other main comparisons demonstrated nonsignificant results: among 126 persons receiving a physical activity and behavioral intervention, those who also received a very low calorie diet lost 3.0 kg (95% CI -0.5 to 6.4), or 1.6% of baseline body weight, more than persons receiving a low-calorie diet. Among 53 persons receiving identical dietary and behavioral interventions, those receiving more intense physical activity interventions lost 3.9 kg (95% CI -1.9 to 9.7), or 3.6% of baseline body weight, more than those receiving a less intense or no physical activity intervention. Comparison groups often achieved significant weight loss (up to 10.0 kg), minimizing between-group differences. Changes in glycated hemoglobin generally corresponded to changes in weight and were not significant when between-group differences were examined. No data were identified on quality of life and mortality.

AUTHORS' CONCLUSIONS

Weight loss strategies using dietary, physical activity, or behavioral interventions produced small between-group improvements in weight. These results were minimized by weight loss in the comparison group, however, and examination of individual study arms revealed that multicomponent interventions including very low calorie diets or low calorie diets may hold promise for achieving weight loss in adults with type 2 diabetes.

Long-term non-pharmacological weight loss interventions for adults with prediabetes

BACKGROUND

Most persons with prediabetes (impaired glucose tolerance or impaired fasting glucose) are overweight, and obesity worsens the metabolic and physiologic abnormalities associated with this condition. Prediabetes is an important risk factor for the development of type 2 diabetes.

OBJECTIVES

The objective of this review was to assess the effectiveness of dietary, physical activity, and behavioral weight loss, and weight control interventions for adults with prediabetes.

SEARCH STRATEGY

Studies were obtained from computerized searches of multiple electronic bibliographic databases, supplemented by hand searches of selected journals, and consultation with experts in obesity research. The last search was conducted May, 2004.

SELECTION CRITERIA

Studies were included if they were published or unpublished randomized controlled trials in any language and examined weight loss or weight control strategies using one or more dietary, physical activity, or behavioral interventions, with a follow-up interval of at least 12 months.

DATA COLLECTION AND ANALYSIS

Effects were combined using a random-effects model.

MAIN RESULTS

Nine studies were identified, with a total of 5,168 participants. Follow-up ranged from 1 to 10 years. Quantitative synthesis was limited by the heterogeneity of populations, settings, and interventions and by the small number of studies that examined outcomes other than weight. Overall, in comparisons with usual care, four studies with a follow-up of one year reduced weight by 2.8 kg (95 % confidence interval (CI) 1.0 to 4.7) (3.3% of baseline body weight) and decreased body mass index by 1.3 kg/m(2) (95% CI 0.8 to 1.9). Weight loss at two years was 2.6 kg (95% CI 1.9 to 3.3) (three studies). Modest improvements were noted in the few studies that examined glycemic control, blood pressure, or lipid concentrations (P > 0.05). No data on quality of life or mortality were found. The incidence of diabetes was significantly lower in the intervention groups versus the controls in three of five studies examining this outcome at 3 to 6 years follow-up.

AUTHORS' CONCLUSIONS

Overall, weight loss strategies using dietary, physical activity, or behavioral interventions produced significant improvements in weight among persons with prediabetes and a significant decrease in diabetes incidence. Further work is needed on the long-term effects of these interventions on morbidity and mortality and on how to implement these interventions in diverse community settings.

Biocompatible hemodialysis membranes for acute renal failure

BACKGROUND

Acute renal failure (ARF) is associated with substantial morbidity and mortality. Some trials have reported a survival advantage among patients dialyzed with biocompatible membranes (BCM) compared to bioincompatible membranes (BICM). These findings were not consistently observed in subsequent studies.

OBJECTIVES

To ascertain whether the use of BCM confers an advantage in either survival or recovery of renal function over the use of BICM in adult patients with ARF requiring intermittent hemodialysis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL, in The Cochrane Library - Issue 1, 2004), MEDLINE (1966 to January 2004), EMBASE (1980 to January 2004), the Mexican Index of Latin American Biomedical Journals IMBIOMED (1990 to January 2004), the Latin American and Caribbean Health Sciences Literature Database LILACS (1982 to January 2004), and reference lists of articles.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials comparing the use of a BCM with a BICM in patients > 18 years of age with ARF requiring intermittent hemodialysis.

DATA COLLECTION AND ANALYSIS

Two authors extracted the data independently. Cellulose-derived dialysis membranes were classified as BICM, and synthetic dialyzers were considered as BCM. The main outcomes were all-cause mortality and recovery of renal function by type of dialyzer. We further explored these outcomes according to the flux properties (high-flux or low-flux) of each of these dialyzers. A meta-analysis was conducted by combining data using a random-effects model.

MAIN RESULTS

Nine studies were included in the primary analysis of mortality, with a total of 1062 patients. None of the pooled RR's reached statistical significance. The pooled relative risk (RR) for mortality was 0.93 (95% confidence interval (CI) = 0.81 to 1.07). The overall RR for recovery of renal function, inclusive of 1038 patients from nine studies was 1.09 (95% CI 0.90 to 1.31). The pooled RR for mortality by dialyzer flux property was 1.03 (95% CI 0.82 to 1.30). The RR for recovery of renal function by flux property was 0.85 (95% CI 0.55 to 1.31). A meta-analysis of mortality of kidney transplant recipients was not possible, but the analysis of recovery of renal function in this patient population was 1.09 (95% CI 0.91to 1.31). Results of sensitivity analyses did not differ significantly from the primary analyses.

AUTHORS' CONCLUSIONS

There is no demonstrable clinical advantage to the use of BCM versus BICM in patients with ARF who require intermittent hemodialysis.