Resource utilisation and costs of palliative cancer care in an interdisciplinary health care model

This paper presents a detailed description of health care resource utilisation and costs of a pilot interdisciplinary health care model of palliative home care in Ontario, Canada. The descriptive evaluation entailed examining the use of services and costs of the pilot program: patient demographics, length of stay broken down by disposition (discharged, alive, death), access to services/resources, use of family physician and specialist services, and drug use. There were 434 patients included in the pilot program. Total costs were approximately CAN$2.4 million, and the cost per person amounted to approximately CAN$5586.33 with average length of stay equal to over 2 months (64.22 days). One may assume that length of stay would be influenced by the amount of service and support available. Future research might investigate whether in-home palliative home care is the most cost effective and suitable care setting for those patients requiring home care services for expected periods of time.

Professional assistance during birth and maternal mortality in two Indonesian districts

OBJECTIVE

To examine determinants of maternal mortality and assess the effect of programmes aimed at increasing the number of births attended by health professionals in two districts in West Java, Indonesia.

METHODS

We used informant networks to characterize all maternal deaths, and a capture-recapture method to estimate the total number of maternal deaths. Through a survey of recent births we counted all midwives practising in the two study districts. We used case-control analysis to examine determinants of maternal mortality, and cohort analysis to estimate overall maternal mortality ratios.

FINDINGS

The overall maternal mortality ratio was 435 per 100,000 live births (95% confidence interval, CI: 376-498). Only 33% of women gave birth with assistance from a health professional, and among them, mortality was extremely high for those in the lowest wealth quartile range (2303 per 100,000) and remained very high for those in the lower middle and upper middle quartile ranges (1218 and 778 per 100,000, respectively). This is perhaps because the women, especially poor ones, may have sought help only once a serious complication had arisen.

CONCLUSION

Achieving equitable coverage of all births by health professionals is still a distant goal in Indonesia, but even among women who receive professional care, maternal mortality ratios remain surprisingly high. This may reflect the limitations of home-based care. Phased introduction of fee exemption and transport incentives to enable all women to access skilled delivery care in health centres and emergency care in hospitals may be a feasible, sustainable way to reduce Indonesia's maternal mortality ratio.

Functional and computational assessment of missense variants in the ataxia-telangiectasia mutated (ATM) gene: mutations with increased cancer risk

The functional consequences of missense variants are often difficult to predict. This becomes especially relevant when DNA sequence changes are used to determine a diagnosis or prognosis. To analyze the consequences of 12 missense variants in patients with mild forms of ataxia-telangiectasia (A-T), we employed site-directed mutagenesis of ataxia-telangiectasia mutated (ATM) cDNA followed by stable transfections into a single A-T cell line to isolate the effects of each allele on the cellular phenotype. After induction of the transfected cells with CdCl2, we monitored for successful ATM transcription and subsequently assessed: 1) intracellular ATM protein levels; 2) ionizing radiation (IR)-induced ATM kinase activity; and 3) cellular radiosensitivity. We then calculated SIFT and PolyPhen scores for the missense changes. Nine variants produced little or no correction of the A-T cellular phenotype and were interpreted to be ATM mutations; SIFT/PolyPhen scores supported this. Three variants corrected the cellular phenotype, suggesting that they represented benign variants or polymorphisms. SIFT and PolyPhen scores supported the functional analyses for one of these variants (c.1709T>C); the other two were predicted to be "not tolerated" (c.6188G>A and c.6325T>G) and were classified as "operationally neutral." Genotype/phenotype relationships were compared: three deleterious missense variants were associated with an increased risk of cancer (c.6679C>T, c.7271T>G, and c.8494C>T). In situ mutagenesis represents an effective experimental approach for distinguishing deleterious missense mutations from benign or operationally neutral missense variants.

Non-astigmatic imaging with matched pairs of spherically bent crystals or reflectors

This paper defines the exact conditions for the application of a previously proposed, general, non-astigmatic, imaging scheme, consisting of a matched pair of spherically bent crystals or reflectors, to x rays. These conditions lead to two specific experimental arrangements, of which one can provide large magnifications. Potential applications include the x-ray diagnosis of laser-produced plasmas and x-ray imaging of, e.g., biological samples, using the highly monochromatic radiation at synchrotron light sources. The results obtained for x rays are, however, valid for a wide spectrum of the electromagnetic radiation so that, for instance, an application of one of the imaging schemes to lithography in the EUV wavelength range should also be possible, if the spherically bent crystals are replaced by appropriate spherical reflectors. Also described is the design of an x-ray crystal spectrometer, which meets the here defined, necessary requirements for the observation of the x-ray spectra of helium-like argon.

Spatially resolved high resolution x-ray spectroscopy for magnetically confined fusion plasmas (invited)

The use of high resolution x-ray crystal spectrometers to diagnose fusion plasmas has been limited by the poor spatial localization associated with chord integrated measurements. Taking advantage of a new x-ray imaging spectrometer concept [M. Bitter et al., Rev. Sci. Instrum. 75, 3660 (2004)], and improvements in x-ray detector technology [Ch. Broennimann et al., J. Synchrotron Radiat. 13, 120 (2006)], a spatially resolving high resolution x-ray spectrometer has been built and installed on the Alcator C-Mod tokamak. This instrument utilizes a spherically bent quartz crystal and a set of two dimensional x-ray detectors arranged in the Johann configuration [H. H. Johann, Z. Phys. 69, 185 (1931)] to image the entire plasma cross section with a spatial resolution of about 1 cm. The spectrometer was designed to measure line emission from H-like and He-like argon in the wavelength range 3.7 and 4.0 A with a resolving power of approximately 10,000 at frame rates up to 200 Hz. Using spectral tomographic techniques [I. Condrea, Phys. Plasmas 11, 2427 (2004)] the line integrated spectra can be inverted to infer profiles of impurity emissivity, velocity, and temperature. From these quantities it is then possible to calculate impurity density and electron temperature profiles. An overview of the instrument, analysis techniques, and example profiles are presented.

Wide-angle point-to-point x-ray imaging with almost arbitrarily large angles of incidence

The paper describes a new scheme for wide-angle point-to-point x-ray imaging with almost arbitrarily large angles of incidence by a matched pair of spherically bent crystals to eliminate the astigmatism, which is a well-known imaging error of spherical mirrors. In addition to x rays, the scheme should be applicable to a very broad spectrum of the electromagnetic radiation, including microwaves, infrared and visible light, as well as UV and extreme UV radiation, if the crystals are replaced with appropriate spherical reflectors. The scheme may also be applicable to the imaging with ultrasound.

Glucose-stimulated increment in oxygen consumption rate as a standardized test of human islet quality

Standardized assessment of islet quality is imperative for clinical islet transplantation. We have previously shown that the increment in oxygen consumption rate stimulated by glucose (DeltaOCR(glc)) can predict in vivo efficacy of islet transplantation in mice. To further evaluate the approach, we studied three factors: islet specificity, islet composition and agreement between results obtained by different groups. Equivalent perifusion systems were set up at the City of Hope and the University of Washington and the values of DeltaOCR(glc) obtained at both institutions were compared. Islet specificity was determined by comparing DeltaOCR(glc) in islet and nonislet tissue. The DeltaOCR(glc) ranged from 0.01 to 0.19 nmol/min/100 islets (n = 14), a wide range in islet quality, but the values obtained by the two centers were similar. The contribution from nonislet impurities was negligible (DeltaOCR(glc) was 0.12 nmol/min/100 islets vs. 0.007 nmol/min/100 nonislet clusters). The DeltaOCR(glc) was statistically independent of percent beta cells, demonstrating that DeltaOCR(glc) is governed more by islet quality than by islet composition. The DeltaOCR(glc), but not the absolute level of OCR, was predictive of reversal of hyperglycemia in diabetic mice. These demonstrations lay the foundation for testing DeltaOCR(glc) as a measurement of islet quality for human islet transplantation.

Educational quality improvement report: outcomes from a revised morbidity and mortality format that emphasised patient safety

PROBLEM

Although morbidity and mortality conferences (MMCs) are meant to promote quality care through careful analysis of adverse events, focus on individual actions or the fear of incrimination may interfere with identification of system issues contributing to the adverse outcomes.

DESIGN

Participant attitudes before and after the intervention towards patient safety and conference redesign were assessed using an attitudinal survey. A list of contributing factors, recommended solutions and targeted system improvements was maintained with ongoing progress recorded.

SETTING

Department of Internal Medicine training programme at University of Missouri-Columbia.

PARTICIPANTS

Residents and fellows from the above residency programme.

EDUCATIONAL OBJECTIVES

(1) Distinguish between culture of blame/shame and patient safety culture, (2) identify gaps in quality contributing to adverse outcomes (3) identify strategies to close gaps and (4) participate in root cause analysis, demonstrating an ability to review an adverse event and recommend an action plan.

STRATEGIES FOR CHANGE

An interdisciplinary team modified the internal medicine MMC to emphasise a better understanding of patient safety principles and system-based practice interventions. For each adverse event analysed, root causes were identified, followed by discussion of system interventions that might prevent future such events.

KEY MEASURES FOR IMPROVEMENT

(1) Attitudes of residents and fellows regarding patient safety, as measured on a 20-item, five-point ordinal scale survey, (2) system improvements generated from the patient safety MMC (PSMMC) and (3) attendance at PSMMC.

EFFECTS OF CHANGE

Clinical outcomes: 121 system improvement recommendations were made and 39 were pursued on the basis of likelihood of achieving high impact changes. 23 improvements were implemented, 11 were partially implemented or in progress, and 5 were abandoned due to impracticality or redundancy. Educational outcomes: 58 residents and fellows completed surveys before and after modification of conference format. 6/20 survey items showed substantial change with four of these changes occurring in the desired direction. Eleven of the remaining 14 responses changed in the desired direction. Average MMC attendance increased from 41+/-8 to 50+/-10 participants (p<0.03).

LESSONS LEARNT

The new PSMMC initiated multiple improvements in the quality of patient care without sacrificing attendance or attitudes of the residents or fellows. The new PSMMC promotes opportunities for participants to improve quality of patient care in a safe and nurturing environment.

The key role of nutrition in controlling human population dynamics

The early hominids and their successors, the nomadic hunter–gatherers, were evolutionarily adapted to an omnivorous diet. Their food was well balanced nutritionally and they acquired adequate supplies with relatively little expenditure of energy. The complete change to a fixed agricultural lifestyle (the Neolithic revolution) took place only some 12 000 years ago and was the most momentous event in human history. Being tied to the land that they worked led eventually to the city states and the great civilisations of history, which brought with them wars and epidemics of infectious diseases. Much more serious were the insidious effects of the new cereal-based diet which persisted until the twentieth century. Not only was it labour intensive, but also for the bulk of the population it was often deficient in vitamins, minerals and energy, particularly at certain times of the year. Time-series analysis reveals a regular short wavelength oscillation in the grain supply that persisted for at least 350 years and dominated the population dynamics of pre-industrial England. In addition to reducing fertility, it acted primarily via its effects on the nutrition of the pregnant woman. Malnutrition during one of the critical trimesters of pregnancy could have far-reaching effects not only on the health of the fetus and neonate but also on the illnesses of later, adult life. These consequences were insidiously and inevitably carried forward to the subsequent generations. Girls who were born with a low birth weight produced daughters and granddaughters of low birth weight, irrespective of their nutrition during childhood. These intergenerational, knock-on effects established a vicious circle from which there was little chance of escape.

Safety, feasibility and weight loss after transoral gastroplasty: First human multicenter study

OBJECTIVE

To evaluate the safety and feasibility in human subjects of a new transoral restrictive procedure for the treatment of obesity.

METHODS

The protocol was approved by the institutional review boards (IRBs) of both centers involved, and all patients gave informed consent. Patients met established inclusion criteria for bariatric surgery. The TOGa system (Satiety Inc., Palo Alto, CA), a set of transoral endoscopically guided staplers, was used to create a stapled restrictive pouch along the lesser curve of the stomach. Patients were hospitalized overnight for observation and underwent barium upper gastrointestinal (UGI) the next morning. Post procedure, all patients were placed on a liquid diet for 1 month and asked to begin an exercise program. Follow-up was carried out at 1 week and 1, 3, 4, 5, and 6 months.

RESULTS

Twenty one patients were enrolled [17 female, age 43.7 (22-57) years, BMI 43.3 (35-53) kg/m(2)]. Device introduction was completed safely in all patients. There were no serious adverse events (AEs). The most commonly reported procedure or device related adverse events were vomiting, pain, nausea, and transient dysphagia. At 6 month endoscopy, all patients had persistent full or partial stapled sleeves. Gaps in the staple line were evident in 13 patients. Patients lost an average 17.6 pounds at 1 month, 24.5 pounds at three months, and 26.5 pounds at 6 months post-treatment [excess weight loss (EWL) of 16.2%, 22.6%, and 24.4%, respectively].

CONCLUSIONS

There is great interest in new procedures for morbid obesity that could offer lower morbidity than current options. Early experience with the TOGa procedure indicates that this transoral approach may be safe and feasible. Further experience with the device and technique should improve anatomic and functional outcomes in the future. Additional studies are underway.

Use of the clock-drawing test in a hospice population

BACKGROUND

Cognitive impairment is common in patients with advanced disease and has significant implications for the patient, their carers and hospice staff. The effectiveness of screening tools is limited by a number of factors. The clock-drawing test (CDT) has performed well in other settings but has rarely been studied in the hospice setting.

AIM

To assess the performance of the CDT in a hospice population.

METHODS

Consecutive admissions to a large hospice over three months were assessed using the CDT, the abbreviated mental test score and brief tests of attention and memory function.

RESULTS

One-hundred and nine eligible patients were admitted and 77% took part. Thirty per cent were cognitively impaired. The CDT had a sensitivity of 0.92, a specificity of 0.73 and a negative predictive value of 0.95. No patient refused to complete it.

CONCLUSIONS

The CDT performs well as a screening tool for cognitive impairment in a hospice population.

Impact of a theoretically based sex education programme (SHARE) delivered by teachers on NHS registered conceptions and terminations: final results of cluster randomised trial

OBJECTIVE

To assess the impact of a theoretically based sex education programme (SHARE) delivered by teachers compared with conventional education in terms of conceptions and terminations registered by the NHS.

DESIGN

Follow-up of cluster randomised trial 4.5 years after intervention.

SETTING

NHS records of women who had attended 25 secondary schools in east Scotland.

PARTICIPANTS

4196 women (99.5% of those eligible).

INTERVENTION

SHARE programme (intervention group) v existing sex education (control group).

MAIN OUTCOME MEASURE

NHS recorded conceptions and terminations for the achieved sample linked at age 20.

RESULTS

In an "intention to treat" analysis there were no significant differences between the groups in registered conceptions per 1000 pupils (300 SHARE v 274 control; difference 26, 95% confidence interval -33 to 86) and terminations per 1000 pupils (127 v 112; difference 15, -13 to 42) between ages 16 and 20.

CONCLUSIONS

This specially designed sex education programme did not reduce conceptions or terminations by age 20 compared with conventional provision. The lack of effect was not due to quality of delivery. Enhancing teacher led school sex education beyond conventional provision in eastern Scotland is unlikely to reduce terminations in teenagers.

TRIAL REGISTRATION

ISRCTN48719575 [controlled-trials.com].

Mutations in WNT7A cause a range of limb malformations, including Fuhrmann syndrome and Al-Awadi/Raas-Rothschild/Schinzel phocomelia syndrome

Fuhrmann syndrome and the Al-Awadi/Raas-Rothschild/Schinzel phocomelia syndrome are considered to be distinct limb-malformation disorders characterized by various degrees of limb aplasia/hypoplasia and joint dysplasia in humans. In families with these syndromes, we found homozygous missense mutations in the dorsoventral-patterning gene WNT7A and confirmed their functional significance in retroviral-mediated transfection of chicken mesenchyme cell cultures and developing limbs. The results suggest that a partial loss of WNT7A function causes Fuhrmann syndrome (and a phenotype similar to mouse Wnt7a knockout), whereas the more-severe limb truncation phenotypes observed in Al-Awadi/Raas-Rothschild/Schinzel phocomelia syndrome result from null mutations (and cause a phenotype similar to mouse Shh knockout). These findings illustrate the specific and conserved importance of WNT7A in multiple aspects of vertebrate limb development.

Increasing the physical fitness of low-fit recruits before basic combat training: an evaluation of fitness, injuries, and training outcomes

Recruits arriving for basic combat training (BCT) between October 1999 and May 2004 were administered an entry-level physical fitness test at the reception station. If they failed the test, then they entered the Fitness Assessment Program (FAP), where they physically trained until they passed the test and subsequently entered BCT. The effectiveness of the FAP was evaluated by examining fitness, injury, and training outcomes. Recruits who failed the test, trained in the FAP, and entered BCT after passing the test were designated the preconditioning (PC) group (64 men and 94 women). Recruits who failed the test but were allowed to enter BCT without going into the FAP were called the no preconditioning (NPC) group (32 men and 73 women). Recruits who passed the test and directly entered BCT were designated the no need of preconditioning (NNPC) group (1,078 men and 731 women). Army Physical Fitness Test (APFT) scores and training outcomes were obtained from a company-level database, and injured recruits were identified from cases documented in medical records. The proportions of NPC, PC, and NNPC recruits who completed the 9-week BCT cycle were 59%, 83%, and 87% for men (p < 0.01) and 52%, 69%, and 78% for women (p < 0.01), respectively. Because of attrition, only 63% of the NPC group took the week 7 APFT, compared with 84% and 86% of the PC and NNPC groups, respectively. The proportions of NPC, PC, and NNPC recruits who passed the final APFT after all retakes were 88%, 92%, and 98% for men (p < 0.01) and 89%, 92%, and 97% for women (p < 0.01), respectively. Compared with NNPC men, injury risk was 1.5 (95% confidence interval, 1.0-2.2) and 1.7 (95% confidence interval, 1.0-3.1) times higher for PC and NPC men, respectively. Compared with NNPC women, injury risk was 1.2 (95% confidence interval, 0.9-1.6) and 1.5 (95% confidence interval, 1.1-2.1) times higher for PC and NPC women, respectively. This program evaluation showed that low-fit recruits who preconditioned before BCT had reduced attrition and tended to have lower injury risk, compared with recruits of similar low fitness who did not precondition.

Reappraisal of the historical selective pressures for the CCR5-Delta32 mutation

HIV strains are unable to enter macrophages that carry the CCR5-Delta32 deletion; the average frequency of this allele is 10% in European populations. A mathematical model based on the changing demography of Europe from 1000 to 1800 AD demonstrates how plague epidemics, 1347 to 1670, could have provided the selection pressure that raised the frequency of the mutation to the level seen today. It is suggested that the original single mutation appeared over 2500 years ago and that persistent epidemics of a haemorrhagic fever that struck at the early classical civilisations served to force up the frequency to about 5x10(-5) at the time of the Black Death in 1347.

What caused the Black Death?

For the whole of the 20th century it was believed that the Black Death and all the plagues of Europe (1347-1670) were epidemics of bubonic plague. This review presents evidence that this view is incorrect and that the disease was a viral haemorrhagic fever, characterised by a long incubation period of 32 days, which allowed it to be spread widely even with the limited transport of the Middle Ages. It is suggested that haemorrhagic plague emerged from its animal host in Ethiopia and struck repeatedly at European/Asian civilisations, before appearing as the Black Death. The CCR5-Delta32 mutation confers protection against HIV-1 in an average of 10% of the people of European origin today. It is suggested that all the Deltaccr5 alleles originated from a single mutation event that occurred before 1000 BC and the subsequent epidemics of haemorrhagic plague gently forced up its frequency to 5 x 10(-5) at the time of the Black Death. Epidemics of haemorrhagic plague over the next three centuries then steadily raised the frequency in Europe (but not elsewhere) to present day values.

Creating a DIN to tackle drug-related deaths in the community

Brighton and Hove has one of the highest rates of drug-related deaths in the UK. The deceased commonly have had contact with a number of organizations isolated from each other. The aim of this study was to explore aspects of drug addiction in Brighton as the first stage in the creation of a local Drug addiction Intervention Network (DIN) and to make recommendations about improving the effectiveness of medical contacts so that modifiable risk factors could be addressed appropriately and consistently. The coroner's records of the drug-related deaths in 1998 for Brighton and Hove were cross-referenced with computerized records of the Accident & Emergency department of the local hospital and the police station. Of the 36 drug misusers who died during the year, most were male, mean age 34 years. Alcohol was a common comorbid finding. Seventy-eight per cent were known to the A&E department and 62% had been arrested locally during 1997 or 1998. Such retrospective data can only give limited information. We, therefore, performed a prospective survey. It was carried out by the forensic medical examiner (FME) in 1997-1998, interviewing 41 arrestees to give a profile of the criminally involved drug misusers. With the information obtained, the A&E doctors and FMEs were able to review the medical advice given and establish a protocol for the transfer of severely intoxicated arrestees.

Evaluation of a synthetic CArG promoter for nitric oxide synthase gene therapy of cancer

Nitric oxide synthase gene therapy has been shown to be effective at inducing apoptosis in experimental tumours and sensitizing them to radiotherapy. We have also shown that expression of inducible nitric oxide synthase (iNOS) can be effectively restricted to the tumour volume by the use of the radiation inducible promoter (WAF1) to drive the transgene in clinically relevant protocols. A synthetic construct (pE9), incorporating nine radiosensitive CArG elements from the Egr1 promoter, has recently been developed for cancer gene therapy. We have now investigated basal gene expression of transgenes driven by this promoter to assess its suitability for use in iNOS gene therapy protocols in vivo. Transfection of human microvascular endothelial cells (HMEC-1) with pE9iNOS, using a cationic lipid vector, resulted in progressively increasing (<5-fold) levels of iNOS protein expression up to 8 h after transfection. Transfection of an ex vivo rat artery preparation with pE9iNOS caused 83% inhibition of response to the vasoconstrictor phenylephrine (PE). CMViNOS transfection also reduced response to PE, but by only 52%. A single injection of 25 microg of pE9iNOS DNA in a lipid vector into the centre of a murine sarcoma (RIF1) induced iNOS protein expression by four-fold and increased nitrite concentration eight-fold. This caused a 7-day delay in tumour growth and was more effective than the constitutive CMV-driven construct. Our data suggest that generation of NO*, as a result of iNOS overexpression, is capable of further activating the E9 promoter, through a positive feedback loop, yielding stronger and sustained levels of NO*. This pE9iNOS combination may, therefore, be particularly useful in an anticancer gene therapy strategy as its antitumour effect in vivo was clearly superior to that of the strong constitutive promoter, CMV.

Repositioning the patient: the implications of being ‘at risk’

In the modern era of biomedical practice, genetic knowledge has redefined the idea of 'the patient' to include those who are 'at risk' of disease alongside those who are already sick. For such individuals, it is risk itself that constitutes the raison d'être of medical intervention. Using data from interviews with 58 users of a UK cancer genetics service together with data derived from clinical consultations, we consider the way such patients or clients make sense of a cancer genetic risk estimate and how they integrate genetic risk information into their lifeworld. In particular, we note that patient-clients who are 'at risk' tend to see themselves in a liminal position betwixt the healthy and the sick, and that such individuals consequently seek recourse to systems of medical surveillance that can continuously monitor their state of health. Our analysis also revealed the fact that many of those deemed by professionals to be at low risk of inheriting cancer-related mutations subsequently strove to be re-categorised as being at moderate or high risk of an adverse outcome. A number of explanations concerning lay health beliefs, lay 'representations' of health and the nature of the patient-client's lifeworld are examined and assessed in order to account for this apparent paradox.

Deafness to fear in boys with psychopathic tendencies

The processing of the emotional signals of others is fundamental for normal socialization and interaction. Reduced responsiveness to the expressions of sadness and fear has been implicated in the development of psychopathy (Blair, 1995). The current study investigates the ability of boys with psychopathic tendencies to process auditory affect information. Boys with psychopathic tendencies and a comparison group, as defined by the Antisocial Process Screening Device (APSD: Frick & Hare, 2001), were presented with neutral words spoken with intonations conveying happiness, disgust, anger, sadness and fear and were asked to identify the emotion of the speaker based on prosody. The boys with psychopathic tendencies presented with a selective impairment for the recognition of fearful vocal affect. These results are interpreted with reference to amygdala dysfunction and components of the Integrated Emotion Systems model.

Lower phenytoin serum levels in persons switched from brand to generic phenytoin

After generic phenytoin (PHT) was marketed, the authors identified eight adult patients (ages 34 to 49) whose seizures increased enough to require intervention after switching to generic PHT. The mean total PHT concentration on brand (before generic) was 17.7 +/- 5.3 mg/L, decreased to 12.5 +/- 2.7 mg/L with generic, and increased to 17.8 +/- 3.9 mg/L after brand was re-introduced. Brand and generic PHT do not yield equivalent concentrations in some patients and substitution should not be permitted without physician notification.

Meiotic defects in a man with non-obstructive azoospermia: Case report

Infertile men have an increased frequency of aneuploid sperm. We have determined that decreased recombination is associated with the production of aneuploid sperm in humans. The aim of this study was to determine whether some cases of infertility are associated with decreased meiotic recombination. Analysis of the early stages of meiosis was performed in a 33-year-old man with non-obstructive azoospermia. Newly developed immunocytogenetic techniques were used to identify the synaptonemal complex (SC) in various stages of prophase. Antibodies to meiotic proteins identified the SC (SYN1/SCP3), the centromere (CREST) and recombination sites (MLH1). Only 36 meiotic spreads were recovered from the infertile man, compared with hundreds available from controls. One-third of the cells were in zygotene compared with 4% in controls, demonstrating an inability of bivalents to synapse and progress to pachytene. The infertile man had a greatly reduced frequency of recombination, with a mean of only 32.7 MLH1 foci/cell (range 1-60) compared with 46.0 (range 21-62) in control donors. A high proportion of cells (73%) contained at least one autosomal bivalent with zero MLH1 foci, compared with only 4.5% in control donors. Discontinuities in the SC were also more prevalent (68% of cells versus 26% in controls). This is the first demonstration of dramatic pachytene-stage abnormalities in an infertile man using these powerful new immunocytogenetic techniques.

Paying attention to meaning

Several paradigms show that responses to one event compromise responses to a second event for around 500 ms. Such effects are generally attributed to attentional capacity limitations associated with processing information in the first event. In a task in which targets could be distinguished only by their meaning, we varied the semantic relationship between distractors and targets following at different lags. Semantic relatedness alone produced a classic attentional blink. We conclude by discussing how attention theory might best accommodate these new effects.

Abnormal depolarizing patterns in three patients with filarial infection

Several authors have described a particular potential of automated depolarization analysis in detecting malaria infection as part of the routine full blood count (FBC) performed by the Cell-Dyn 4000 analyzer. In these cases, abnormal depolarizing patterns are due to the presence of leukocyte-associated malaria hemozoin, a pigment which depolarizes the laser light. In this report we describe samples from three individual patients who did not have malaria infection but showed abnormal depolarizing events. Further investigation determined that these samples were from patients infected by the nematode Mansonella perstans. The observed depolarizing pattern consisted of a normal depolarizing eosinophil population and in addition an abnormal depolarizing population that showed a close "linear" relationship between "granularity" (90 degrees depolarization) and "lobularity" (90 degrees polarization). This atypical population was smaller than normal leukocytes and thus clearly different from the patterns associated with malaria infection. Abnormal depolarization patterns of M. perstans clearly do not reflect leukocyte-associated malaria hemozoin. It is possible however that the erythrocyte-lysing agent used to facilitate leukocyte analysis by the instrument may have caused microfilaria fragmentation and thus the distinctive "straight-line" features of the abnormal scatter plots

Localized radiation increases morbidity and mortality after TBI-containing autologous stem cell transplantation in patients with lymphoma

The purpose of this study is to assess the relationship between involved field radiation therapy (IFRT) and treatment-related morbidity and mortality in patients receiving high-dose chemotherapy (HDC), total body irradiation (TBI) and autologous peripheral stem cell transplant (PSCT) for Hodgkin's and non-Hodgkin's lymphoma. Between January 1994 and May 2002, 156 patients underwent HDC, TBI and autologous PSCT. Localized external beam radiation therapy was given to 21 patients for consolidation, or to achieve control of symptomatic or active disease prior to or after transplant. Among patients who had IFRT prior to autologous PSCT, five treatment-related deaths were observed, compared to seven deaths in 135 patients who had autologous PSCT without IFRT (P<0.01). Most deaths were attributable to sepsis and multiorgan failure. A higher incidence of pneumonitis was also noted in patients exposed to mediastinal irradiation. No adverse impact on long-term survival could be demonstrated. Involved field radiation prior to TBI is associated with higher treatment-related mortality in lymphoma patients undergoing autologous peripheral stem cell transplant, necessitating careful monitoring.

LR-90 a new advanced glycation endproduct inhibitor prevents progression of diabetic nephropathy in streptozotocin-diabetic rats

AIMS/HYPOTHESIS

Advanced glycation and lipoxidation endproducts have been implicated in the pathogenesis of diabetic complications, including diabetic nephropathy. LR-90, a new advanced glycation endproduct inhibitor, was investigated for its effects on the development of renal disease in diabetic rats.

METHODS

Diabetic animals were randomly allocated into groups receiving LR-90 or vehicle (untreated). Age- and weight-matched non-diabetic rats were studied concurrently. Body weight, plasma glucose, glycated haemoglobin, urinary albumin and creatine excretions were measured serially. Kidney histopathology, AGE accumulation in cells and tissues, protein oxidation, were also examined. In vitro assays were used to assess the possible mechanism of action of LR-90.

RESULTS

LR-90 inhibited the increase in albumin and creatinine concentrations, and concentrations of circulating AGE in diabetic rats without any effect on glycaemic control. LR-90 treated-rats also showed higher body weights than untreated diabetic rats. LR-90 prevented glomerulosclerosis, tubular degeneration and collagen deposition in the kidney. AGE-induced cross-linking and fluorescence of tail collagen were reduced by LR-90 treatment. LR-90 also decreased AGE accumulation in kidney glomeruli and nitrotyrosine deposition in the renal cortex. In vitro, LR-90 was capable of reacting with reactive carbonyl compounds and was a more potent metal chelator than pyridoxamine and aminoguanidine.

CONCLUSION/INTERPRETATION

LR-90 reduces in vivo AGE accumulation, AGE-protein cross-linking and protein oxidation, and could be beneficial in preventing the progression of diabetic nephropathy. The AGE inhibitory and therapeutic effects of LR-90 could be attributed, at least in part, to its ability to react with reactive carbonyl species and/or potent metal chelating activity that inhibits glycoxidative-AGE formation.

A comparison of physician and patient perception of the problems of habitual snoring

Assumptions are often made by doctors about the nature of the impact of uncomplicated snoring. The aim of this study was to provide a comprehensive view of the problems experienced by snoring patients, and to compare these with the perceptions of otolaryngologists. Part 1: 121 snorers and 419 otolaryngologists completed open-ended problems lists; Part 2: 56 snorers and 63 matched controls completed a mood questionnaire and the Golombok Rust Inventory of Marital State (GRIMS.) There was a clear agreement between snorers and otolaryngologists that sleep-related difficulties comprise the most frequent category of problems that may result from snoring. Snorers report a significantly greater number of physical problems and significantly fewer relationship problems than perceived by otolaryngologists. GRIMS scores were similar in patients and controls. Snorers, however, were significantly more depressed. Doctors appear to address snoring from the twin perspectives of damaged relationships and possible sleep apnoea. Their patients are more concerned about disturbing the sleep of others, and are subject to low mood. The snorers' 25 different responses are now being used as the basis for a Snoring Symptom Index.