Testing of veterinary clostridial vaccines: from mouse to microtitre plate

Vaccines to protect against clostridial diseases are among the most common veterinary biologicals. Each batch of these materials is subjected to a variety of toxicity and antigenicity tests. The potency of the final vaccine is then assessed by Toxin Neutralisation Test (TNT). All of these tests use mice and have lethal endpoints. Development of alternatives for potency testing was based on ELISAs able to measure antibody levels to the specific toxins relative to a standard serum with a defined unitage. These alternative assays were shown to correlate with the relevant TNTs and have been accepted by European Regulatory Authorities as batch release potency tests. Recently we have developed in vitro cell line alternatives for the toxicity and antigenicity tests for Cl. septicum using the VERO cell line. With this cell line it has been possible to develop in vitro assays which, when compared with the in vivo tests, gave correlations of 87% to 100%. Having shown proof of principle, similar cell line assays have been developed for Cl. novyi and Cl. perfringens types C and D.

Volumetric modulated arc therapy: a review of current literature and clinical use in practice

Volumetric modulated arc therapy (VMAT) is a novel radiation technique, which can achieve highly conformal dose distributions with improved target volume coverage and sparing of normal tissues compared with conventional radiotherapy techniques. VMAT also has the potential to offer additional advantages, such as reduced treatment delivery time compared with conventional static field intensity modulated radiotherapy (IMRT). The clinical worldwide use of VMAT is increasing significantly. Currently the majority of published data on VMAT are limited to planning and feasibility studies, although there is emerging clinical outcome data in several tumour sites. This article aims to discuss the current use of VMAT techniques in practice and review the available data from planning and clinical outcome studies in various tumour sites including prostate, pelvis (lower gastrointestinal, gynaecological), head and neck, thoracic, central nervous system, breast and other tumour sites.

The paediatric transfusion challenge on deployed operations

This paper briefly touches on the problem of dealing with the severely injured child requiring massive transfusion and produces a guide on the management of this based on the current Surgeon General's Operational Policy Letter. There are no known UK guidelines on massive transfusion in trauma in the paediatric population although many specialist centres have guidance for dealing with cases in theatre during elective surgery. It is hoped that these guidelines will be used by deployed military anaesthetists to aid in their management of these difficult cases, not normally seen in the U.K.

Enhanced diagnosis of HIV-1-associated tuberculosis by relating T-SPOT.TB and CD4 counts

The sensitivity of the tuberculin skin test is impaired in HIV-1-infected persons. Enzyme-linked immunospot-based detection of immune sensitisation may be less affected. Furthermore, the quantitative response can be related to the CD4 count, potentially improving specificity for active disease. The T-SPOT.TB assay was performed on HIV-1-infected participants, 85 with active tuberculosis (TB) and 81 healthy patients (non-TB). The ratio of the sum of the 6-kDa early secretory antigenic target and culture filtrate protein 10 response to the CD4 count (spot-forming cell (SFC)/CD4) was calculated. Using the manufacturer's guidelines, active TB was diagnosed with 76% sensitivity and 53% specificity. Using an SFC/CD4 ratio of 0.12, sensitivity (80%) and specificity (62%) improved. The quantitative T-cell response increased with increasing smear-positivity in the active TB group (p = 0.0008). In the non-TB group, the proportion of persons scored positive by T-SPOT.TB assay was lower in the group with a CD4 count of <200 cells·mm(-3) (p = 0.029). The ratio of the summed T-cell response to CD4 count improved the diagnostic accuracy of the T-SPOT.TB assay in HIV-1-infected persons, and a ratio of SFC/CD4 of >0.12 should prompt investigation for active disease. A strong association between the degree of sputum positivity and T-SPOT.TB score was found. The sensitivity of the T-SPOT.TB assay in active disease may be less impaired by advanced immunosuppression.

The neural basis of effective memory therapy in a patient with limbic encephalitis

BACKGROUND

An fMRI study is described in which a postencephalitic woman with amnesia used a wearable camera which takes photographs passively, without user intervention, to record and review recent autobiographical events. "SenseCam" generates hundreds of images which can subsequently be reviewed quickly or one by one.

RESULTS

Memory for a significant event was improved substantially when tested after 4.5 weeks, if the patient viewed SenseCam images of the event every 2 days for 3 weeks. In contrast, after only 3.5 weeks, her memory was at chance levels for a similarly significant event which was reviewed equally often, but using a written diary. During the fMRI scan, the patient viewed images of these two events, plus images of an unrehearsed event and images from a novel "control" event that she had never experienced. There was no difference in behavioural responses or in activation when the unrehearsed and novel conditions were compared. Relative to the written-rehearsed condition, successful recognition of the images in the SenseCam-rehearsed condition was associated with activation of frontal and posterior cortical regions associated with normal episodic memory.

CONCLUSION

SenseCam images may provide powerful cues that trigger the recall and consolidation of stored but inaccessible memories.

Translating transplantation tolerance in the clinic: where are we, where do we go?

Research networks dedicated to translation of immune tolerance in the clinic currently support pilot trials aiming at immunosuppression withdrawal in kidney or liver allograft recipients. Although results obtained so far indicate that significant hurdles still need to be overcome before organ transplant recipients can be weaned off drugs safely and routinely, recent advances suggest that immunosuppression minimization on the basis of validated biomarkers might become standard practice in a near future.

From shell to cell: neutron scattering studies of biological water dynamics and coupling to activity

An integrated picture of hydration shell dynamics and of its coupling to functional macromolecular motions is proposed from studies on a soluble protein, on a membrane protein in its natural lipid environment, and on the intracellular environment in bacteria and red blood cells. Water dynamics in multimolar salt solutions was also examined, in the context of the very slow water component previously discovered in the cytoplasm of extreme halophilic archaea. The data were obtained from neutron scattering by using deuterium labelling to focus on the dynamics of different parts of the complex systems examined.

Adrenergic and serotonergic mechanisms in depression and their response to amitriptyline

Our investigations into the chemical pathology of the affective disorders have indicated that depressed patients not only have significantly reduced rates of accumulation of 5-hydroxytryptamine (5-HT) into their blood platelets but their peripheral alpha-adrenoreceptors are supersensitive. Investigations into the mode of action of amitriptyline have centred on these abnormal adrenergic and serotonergic mechanisms in depressed patients. We have not detected any significant relationship between blood platelet 5-HT re-uptake inhibition and therapeutic response to amitriptyline in depressed patients, although there is a significant correlation with plasma levels of the drug. It is interesting to note that nortriptyline, the major metabolite of amitriptyline, blocks the alpha-adrenoreceptor but the degree of blocking of this supersensitive receptor is significantly correlated to poor outcome. Amitriptyline does not appear to correct these abnormal mechanisms in depressed patients. These results are discussed with reference to other pharmacological actions of amitriptyline and other antidepressant drugs.

Dynamical heterogeneity of specific amino acids in bacteriorhodopsin

Components of biological macromolecules, complexes and membranes are animated by motions occurring over a wide range of time and length scales, the synergy of which is at the basis of biological activity. Understanding biological function thus requires a detailed analysis of the underlying dynamical heterogeneity. Neutron scattering, using specific isotope labeling, and molecular dynamics simulations were combined in order to study the dynamics of specific amino acid types in bacteriorhodopsin within the purple membrane (PM) of Halobacterium salinarum. Motions of leucine, isoleucine and tyrosine residues on the pico- to nanosecond time scale were examined separately as a function of temperature from 20 to 300 K. The dynamics of the three residue types displayed different temperature dependence: isoleucine residues have larger displacements compared to the global PM above 120 K; leucine residues have displacements similar to that of PM in the entire temperature range studied; and tyrosine residues have displacements smaller than that of the average membrane in an intermediate temperature range. Experimental features were mostly well reproduced by molecular dynamics simulations performed at five temperatures, which allowed the dynamical characterisation of the amino acids under study as a function of local environment. The resulting dynamical map of bacteriorhodopsin revealed that movements of a specific residue are determined by both its environment and its residue type.

Dynamics of hydration water in deuterated purple membranes explored by neutron scattering

The function and dynamics of proteins depend on their direct environment, and much evidence has pointed to a strong coupling between water and protein motions. Recently however, neutron scattering measurements on deuterated and natural-abundance purple membrane (PM), hydrated in H2O and D2O, respectively, revealed that membrane and water motions on the ns-ps time scale are not directly coupled below 260 K (Wood et al. in Proc Natl Acad Sci USA 104:18049-18054, 2007). In the initial study, samples with a high level of hydration were measured. Here, we have measured the dynamics of PM and water separately, at a low-hydration level corresponding to the first layer of hydration water only. As in the case of the higher hydration samples previously studied, the dynamics of PM and water display different temperature dependencies, with a transition in the hydration water at 200 K not triggering a transition in the membrane at the same temperature. Furthermore, neutron diffraction experiments were carried out to monitor the lamellar spacing of a flash-cooled deuterated PM stack hydrated in H2O as a function of temperature. At 200 K, a sudden decrease in lamellar spacing indicated the onset of long-range translational water diffusion in the second hydration layer as has already been observed on flash-cooled natural-abundance PM stacks hydrated in D2O (Weik et al. in J Mol Biol 275:632-634, 2005), excluding thus a notable isotope effect. Our results reinforce the notion that membrane-protein dynamics may be less strongly coupled to hydration water motions than the dynamics of soluble proteins.

Rapid onset intratubular calcification following renal transplantation requiring urgent parathyroidectomy

BACKGROUND

Secondary hyperparathyroidism is a common complication of end-stage renal disease often requiring parathyroidectomy. Renal transplant with the restoration of normal renal function often allows resolution of hyperparathyroidism, avoiding the need for parathyroid surgery. However, a proportion of patients with hyperparathyroidism become overtly hypercalcemic after renal transplantation which poses management dilemmas between medical and surgical treatment.

CASE

We present the case of a 48-yearold man with end-stage renal failure known to have secondary hyperparathyroidism who received a living related renal transplant. Postoperatively he developed prompt hypercalcemia, polyuria, polydipsia and rapid onset intratubular calcification, leading to acute tubular necrosis diagnosed on renal biopsy on Day 7 post transplantation. He underwent surgical parathyroidectomy with resolution of his hypercalcemia and improved renal transplant function.

DISCUSSION

This case emphasizes the need for good management of secondary hyperparathyroidism together with close surveillance of PTH in patients awaiting renal transplantation. With good renal transplant function hyperparathyroidism usually resolves. Posttransplant surgical parathyroidectomy should be reserved for severe progressive end organ damage.

The ankle brachial index in chronic spinal cord injury: a pilot study

BACKGROUND

Recent case reports implicate peripheral vascular disease (PVD) as an etiology for pressure ulcers (PU), failed myocutaneous flap surgeries, and amputation in spinal cord injury (SCI). Early detection of PVD is complicated by motor and sensory deficits in this population. The ankle-brachial index (ABI) is used to quantify PVD in the able-bodied population. We hypothesized that the ABI would be a useful screening tool for detecting PVD in patients with SCI. Differences in baseline blood pressure, as well as motor and sympathetic function, could potentially alter ABI, so values were studied in a sample of patients with SCI without risk factors or signs of PVD, and compared to those in able-bodied controls without PVD.

METHODS

ABI values were measured in 15 healthy individuals with chronic complete SCI above the T6 level, who had no evidence for risk factors or physical findings of PVD, and compared with the values for a group of 10 able-bodied controls.

RESULTS

No statistically significant difference in ABI was found between patients with SCI and the able-bodied comparison group. There was no statistically significant correlation between ABI and post-injury duration or incidence of PU.

CONCLUSION

ABI may prove to be a useful screening device in individuals with SCI. Follow-up studies are needed to confirm these findings and to ascertain that the ABI correlates with presence and severity of PVD in patients with SCI who have risk factors and signs of PVD.

Phase II trial investigating the effects of zoledronate and dexamethasone in hormone resistant prostate cancer

15629

Background: Response rates to second line therapy in hormone resistant prostate cancer have been shown to be relatively low. Current options of management include dexamethasone, zoledronate or more recently, cytotoxic chemotherapy. Many trials have studied their effects as monotherapy. The aim of this study is to assess the efficacy and safety of the combination of zoledronate and dexamethasone in these patients. Methods: 20 patients were identified in 2004–2005. All had histologically confirmed prostatic adenocarcinoma and biochemically confirmed hormone resistance. All patients had bone metastases as confirmed on radionuclide imaging. Treatment consisted of 6 cycles of zoledronate at a dose of 4 mg, given at 4 weekly intervals, in combination with dexamethasone 2–4 mg once a day. Calcium/vitamin D supplementation was given throughout the zoledronate treatment. Data was collected prospectively on serum PSA, quality of life and pain score. Results: Of the 20 patients in the study, 11 completed the full 24 weeks of treatment. Reasons for not completing the study included disease progression, treatment toxicity, fracture and death. The overall response rate, as defined by an initial fall of serum PSA of more than 50%, was 35% (7 out of 20 patients). In those who responded, the sustained fall in PSA, during the trial period, lasted on average 3.0 months. Conclusion: This study has demonstrated clinically significant effects on tumour response for the combination of zoledronate and dexamethasone in hormone resistant prostate carcinoma. With the emergence of newer chemotherapeutic agents, this combination could be used as an effective, but less toxic alternative.

No significant financial relationships to disclose.

Outcome of a risk-related therapeutic strategy used prospectively in a population-based study of Hodgkin's lymphoma in adolescents

The aim was to assess outcome in a population-based cohort of adolescents with Hodgkin's lymphoma (HL) diagnosed in the UK's northern region over a 10-year period. Among a population of 3.09 million, 55 of 676 patients (8%) diagnosed with HL were aged 13–19. Seven had nodular lymphocyte-predominant HL, 48 classical HL (cHL). Of the latter, 36 were ⩾16 years. Application of the Scottish and Newcastle Lymphoma Group (SNLG) prognostic index meant 21 patients were considered high risk (index ⩾0.5). They received PVACEBOP multi-agent chemotherapy as primary therapy. Standard risk patients (SNLG index <0.5) were treated with standard ChlVPP or ABVD chemotherapy±radiotherapy. Scottish and Newcastle Lymphoma Group indexing is not valid for patients under 16. Twelve patients therefore received UKCCSG protocols (n=8), ABVD plus radiotherapy (n=2), or PVACEBOP (n=2). Forty-six patients with cHL (96%) achieved complete remission. Seven patients relapsed but all entered complete remission after salvage therapy. Five patients died: three of HL, one in an accident and one of disseminated varicella complicating cystic fibrosis. Five- and 10-year overall survival was 93 and 86%, respectively; disease-specific survival was 95 and 92%. The data suggest that older adolescents with high-risk HL require intensive protocols as primary therapy to secure optimal outcome.

Identification of gene markers for the prediction of allograft rejection or permanent acceptance

The clinical success of new treatment strategies aiming on inducing permanent graft acceptance will rely on the ability to determine whether specific unresponsiveness to donor alloantigens has developed and for how long it is maintained. To identify markers for such posttransplant monitoring, genes differentially expressed by graft infiltrating leukocytes during tolerance induction or rejection after kidney transplantation in rats were compared. A subsequently performed full kinetic analysis in two different transplant models, kidney and heart, in two species, rat and mouse identified two markers (TOAG-1, alpha-1,2-mannosidase) with high specificity and reproducibility, which are highly expressed during induction and maintenance of acceptance, and downregulated during rejection. Expression level of these markers showed a strong positive correlation with graft function. In addition, expression of both genes was downregulated in the peripheral blood and the graft prior to rejection, suggesting that these markers may be useful for monitoring in clinical transplantation where peripheral blood is the most easily accessible patient sample. Interestingly, downregulation of TOAG-1 and alpha-1,2-mannosidase expression occurred in graft infiltrating cells and expression of both genes was also downregulated after T-cell activation in vitro.

GITR ligation blocks allograft protection by induced CD25+CD4+ regulatory T cells without enhancing effector T-cell function

The induction of operational tolerance prior to transplant could provide a solution to the complications of current immunosuppression in transplantation. In rodents, operational tolerance frequently correlates with the presence of CD25(+)CD4(+) regulatory T cells (Tregs) but their function is usually demonstrated by adoptive transfer into lymphopenic hosts leading some to question their relevance to normal immunocompetent recipients. The role of these cells in primary transplant recipients has been explored using anti-CD25 antibody but specific targeting of Treg is not possible since CD25 is also up-regulated on activated effector T cells. To overcome this limitation we targeted the Treg associated molecule GITR in tolerized primary transplant recipients. This reverses regulation resulting in acute allograft rejection. This is not due to co-stimulation of effector cells since rejection mediated by isolated populations of CD4(+)CD25(-) or CD8(+)CD25(-) T cells transferred into Rag(-/-) mice was not enhanced by anti-GITR antibody. Furthermore, GITR cross-linking does not provide co-stimulation for in vitro proliferation of the same CD4(+)CD25(-) or CD8(+)CD25(-) T-cell populations in response donor-strain APC. Thus, CD4(+)CD25(+)GITR(+) Treg play an essential role in early graft protection in primary transplant recipients following tolerance induction providing further support for protocols that might generate similar populations in clinical transplantation.

Phosphorus removal from soy protein wastewater using novel crystallisation technology

The objective of this work was to identify and implement a treatment method that would reduce the phosphorus (P) content of soy protein isolate manufacturing wastewater to an average of 2 mg L(-1) total P without increasing soluble salts in order to comply with discharge and receiving-water requirements. A novel crystallisation technology was evaluated through pilot studies that demonstrated these objectives could be met. Rapid settling (3.6 cm min(-1)) and filterable particles (65% filter cake dry solids content) were produced with lime precipitation at 10.0-10.2 pH in the high-aspect ratio, draft tube crystalliser (HARDTAC). Crystal growth in the full-scale system has yielded mean particle sizes of >60 microm. Also, minimal carbonate removal resulted in residual sludge generation of 0.6-0.8 g and lime consumption of 0.40-0.75 g per litre treated, which is substantially less than with a complete softening reaction. This paper describes the technical evaluation and full-scale treatment system that has been in operation since late 2005.

A cluster randomized-controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: trial design, methods and baseline findings

OBJECTIVE

To describe the study design, methods and baseline findings of a behavioural intervention trial aimed at reducing HIV incidence.

METHOD

A cluster randomized-controlled trial (RCT) conducted in 70 villages in rural South Africa. A behavioural intervention, Stepping Stones, was implemented in 35 communities in two workshops of 20 men and 20 women in each community who met for 17 sessions (50 h) over a period of 3-12 weeks. Individuals in the control arm communities attended a single session of about 3 h on HIV and safer sex. Impact assessment was conducted through two questionnaire and serological surveys at 12-month intervals. The primary outcome was HIV incidence and secondary measures included changes in knowledge, attitude and sexual behaviours. Qualitative research was also undertaken with 10 men and 10 women from two sites receiving the intervention (one rural and one urban) and five men and five women from one village in the control arm. They were interviewed individually three times prior to the workshops and then 9-12 months later.

RESULTS

A total of 2776 participants (1409 intervention and 1367 control) were enrolled at baseline and had an interview, and HIV sero-status was established. HIV baseline prevalence rates in women were 9.8% in the intervention arm and 12.8% in the control arm. In men the prevalence was 1.7% in the intervention arm and 2.1% in the control arm. Demographic and behavioural characteristics were similar in the two arms. In the intervention groups 59.9% of participants attended more than 75% of the sessions. In the control group 66.3% attended the control session.

CONCLUSION

This is the third RCT to be conducted in sub-Saharan Africa evaluating a behavioural intervention using HIV incidence as a primary outcome. It is of particular interest as the intervention in question is used in many developing countries. There is good baseline comparability between the study arms and the process data on the workshops suggested that the interventions were feasible and adequately implemented.

Phosphorus removal using novel crystallisation technology

A soy protein manufacturing facility was faced with the challenge of reducing its effluent phosphorus (P) content from 20-50 mg L(-1) down to <2 mg L(-1) total P without increasing soluble salt levels to comply with discharge and receiving water requirements. A number of biological and chemical P removal technologies previously evaluated either failed to achieve the new standards or would have produced prohibitive amounts of residual sludge and unacceptably high effluent salt concentrations. Lime precipitation, utilising a novel crystallisation technology, was demonstrated through on-site pilot testing to meet the process objectives. It is capable of achieving the required P removal at pH 10 while not increasing soluble salts and producing rapid settling and filterable particles. Also, minimal carbonate removal was observed with residual solids generation being only 40% of a complete lime softening reaction. This paper describes the technical evaluation that led to the full-scale treatment system that was put into operation in late 2005.

Audit of nutritional guidelines for head and neck cancer patients undergoing radiotherapy

BACKGROUND

Head and neck cancer patients being treated with radiotherapy are at an increased risk of malnutrition due to the severe side-effects, e.g. mucositis, odynophagia and xerostomia, impacting on the ability to eat and drink. Effective dietetic management involves identifying those patients malnourished or at risk of becoming so and incorporating nutritional intervention into their treatment plan. The use of gastrostomy tubes in this patient group has been shown to be acceptable. By placing them prophylactically, the aim is to prevent a disruption to treatment and avoid an unnecessary admission for feeding. This audit was carried out to determine whether the implementation of locally produced nutritional guidelines improved the dietetic management of this patient group.

METHOD

A prospective audit tool was used to collect data on 32 head and neck cancer patients undergoing radiotherapy. Data was collected weekly during the course of treatment and compared with data from previous audits. Weight change was the nutritional outcome measured.

RESULTS

More patients underwent combined treatment (radiotherapy postoperatively or with concurrent weekly chemotherapy) when compared with previous audits. However, implementation of the guidelines appeared to contribute to an improvement in dietetic management, as fewer patients lost weight over the course of radiotherapy and there were no admissions for feeding. The presence of a dietitian at the multidisciplinary head and neck clinic improved access and communication and this is also likely to have contributed to the improved management.

CONCLUSIONS

Implementation of the guidelines led to an improvement in the nutritional management of this patient group. Implementation may be more likely if a dietitian is present at the combined head and neck clinic.

The impact of speed of processing training on cognitive and everyday performance

The purpose of the present investigation was to examine the impact of speed of processing training on the cognitive and everyday abilities of older adults with initial processing speed or processing difficulty. Participants were randomized to either a speed of processing intervention or a social- and computer-contact control group. Results indicate that speed of processing training not only improves processing speed, as indicated by performance on the Useful Field of View test (UFOV), but also transfers to certain everyday functions, as indicated by improved performance on Timed Instrumental Activities of Daily Living (Timed IADL). Transfer of speed of processing training to other cognitive domains was not evident. This study provides additional evidence that speed of processing training has the potential to enhance everyday functions that maintain independence and quality of life, particularly when the training is targeted toward individuals who most need it. Further study is needed to learn about the long-term effects of such training in relation to everyday abilities.

Enzyme-linked immunospot assay responses to early secretory antigenic target 6, culture filtrate protein 10, and purified protein derivative among children with tuberculosis: implications for diagnosis and monitoring of therapy

BACKGROUND

The ability to detect tuberculosis-specific lymphocytes by enzyme-linked immunospot (ELISPOT) assay may have important implications for the diagnosis and monitoring of tuberculosis in children, for which routine methods lack sensitivity. We conducted a study to determine the presence and time course of ELISPOT responses in children with tuberculosis.

METHODS

Blood samples were obtained from children with a clinical diagnosis of tuberculosis, and interferon-gamma ELISPOT assays were performed using purified protein derivative (PPD), early secretory antigenic target 6 (ESAT-6), and culture filtrate protein 10 (CFP10) as stimulants. A subset of children were retested after 1, 3, and 6 months of therapy.

RESULTS

Detectable responses to ESAT-6 or CFP10 were found in 49 of 70 children with clinical tuberculosis but were more frequently found in those with culture-proven disease (P = .05). The number of subjects with responses to PPD increased after 1 month of therapy (P = .0004) and decreased at 3 and 6 months.

CONCLUSION

Tuberculosis-specific ELISPOT testing is a promising tool that should be evaluated as a potential diagnostic test for childhood tuberculosis. We caution against the use of an early decrease in response as a marker of successful antituberculous chemotherapy.

Metastases to the thyroid gland: the Royal Marsden experience

AIM

A review of patients seen at the Royal Marsden Hospital with metastases to the thyroid gland.

METHOD

Experience reported on 15 patients that were seen at our institution between 1985 and 2002.

RESULTS

The most common site of origin was the kidney (4/15). Ages ranged between 26 and 76 years. Twelve presented with a neck mass. Most had metastatic disease elsewhere at the time of presentation (9/15). Diagnosis was made by fine needle aspiration cytology (5), tru-cut biopsy (1), or surgery (9); surgery comprised total thyroidectomy (3), subtotal thyroidectomy (3) or lobectomy (3). Radiotherapy resulted in disease stabilisation in three patients. Chemotherapy was used to treat local recurrence in two patients post-operatively. The interval from diagnosis of the primary tumour to thyroid metastasis varied from 0 months to 15 years. Thyroid gland metastasis was the initial manifestation of metastatic disease in five patients. Five patients are alive, with one disease free 7 years following resection of the thyroid metastasis.

CONCLUSIONS

Thyroid metastases are clinically rare, with the kidney the most common primary site of origin. They usually occur when there are metastases elsewhere, sometimes many years after diagnosis of the original primary tumour. Surgical resection of an isolated metastasis may result in prolonged disease-free survival. Radiotherapy and chemotherapy may be of value in specific situations.

Aboriginal perspective on middle ear disease in the arid zone of Western Australia

OBJECTIVES

To explore perceptions, knowledge and experience of otitis media (OM) and barriers to compliance with treatment among Aboriginal people of the Kalgoorlie-Boulder area, Western Australia.

METHODS

This qualitative applied research study is based on a holistic design. We conducted structured interviews with three community focus groups, 56 key informants, and 22 mothers of babies known to have suffered from OM. Written records of interviews were checked with participants. The three sources of data enabled comparison and verification of results.

RESULTS

People were concerned about serious consequences of OM, especially deafness and learning difficulties. Since early disease may have no localizing symptoms, not surprisingly, people had limited understanding of the aetiology of OM and were often only aware of disease once ear discharge was visible. Nevertheless, they usually sought treatment for non-specific symptoms. Competing demands in people's daily lives and the unpleasant, intensive nature of treatment result in families becoming resigned to a child's chronic ear discharge. Someone other than the biological mother within the extended family may be responsible for administering treatments. Half the carers thought passive smoking may predispose children to OM and 70% suggested clearing the nasal passages to prevent OM. Results of surgery were viewed positively but specialist services were not always readily accessible.

CONCLUSIONS

Since responsibility for treatment may not lie with the biological mother, awareness campaigns must target the entire community. As early OM may be asymptomatic, health personnel should be encouraged to do otoscopy on all children with non-specific symptoms.

Strategic approach to the management of Hodgkin's disease incorporating salvage therapy with high-dose ifosfamide, etoposide and epirubicin: a Northern Region Lymphoma Group study (UK)

The Northern Region Lymphoma Group is a population-based group covering 3.1 million people in Northern England. From 1991 total data collection for all Hodgkin's disease patients for this population has been in place and it has been possible to demonstrate that the overall survival for Hodgkin's disease for younger patients within this population has moved from 80% pre- 1988 to 87% post- 1988. This improvement has been brought about by the introduction of clinical trials for advanced stage disease and effective salvage regimens. This report describes the outcome of 51 patients treated with the ifosfamide, etoposide and epirubicin (IVE)schedule and includes 28 males and 23 females with a median age of 34 years. Overall 43 of 51 patients responded to treatment (84%) with 31 achieving a complete response, four a good partial response and eight a partial response. Thirty-one proceeded to autologous stem-cell transplantation. In total, with a median follow-up of 24 months (range 6-51), 26 patients remain alive and in continuous remission. Haematological toxicity,in particular neutropenia WHO grade 4, was observed in all cases but improved over the three courses of treatment. Non-haematological toxicity was not a major problem, with no significant cardiac, hepatic, renal or neurotoxicity. We conclude that the high-dose ifosfamide-containing regimens should be prospectively evaluated in the various types of non-responsive and relapsing Hodgkin's disease.

Operative compared with nonoperative treatment of a thoracolumbar burst fracture without neurological deficit. A prospective, randomized study

BACKGROUND

To our knowledge, a prospective, randomized study comparing operative and nonoperative treatment of a thoracolumbar burst fracture in patients without a neurological deficit has never been performed. Our hypothesis was that operative treatment would lead to superior long-term clinical outcomes.

METHODS

From 1994 to 1998, forty-seven consecutive patients (thirty-two men and fifteen women) with a stable thoracolumbar burst fracture and no neurological deficit were randomized to one of two treatment groups: operative (posterior or anterior arthrodesis and instrumentation) or nonoperative treatment (application of a body cast or orthosis). Radiographs and computed tomography scans were analyzed for sagittal alignment and canal compromise. All patients completed a questionnaire to assess any disability they may have had before the injury, and they indicated the degree of pain at the time of presentation with use of a visual analog scale. The average duration of follow-up was forty-four months (minimum, twenty-four months). After treatment, patients indicated the degree of pain with use of the visual analog scale and they completed the Roland and Morris disability questionnaire, the Oswestry back-pain questionnaire, and the Short Form-36 (SF-36) health survey.

RESULTS

In the operative group (twenty-four patients), the average fracture kyphosis was 10.1 degrees at the time of admission and 13 degrees at the final follow-up evaluation. The average canal compromise was 39% on admission, and it improved to 22% at the final follow-up examination. In the nonoperative group (twenty-three patients), the average kyphosis was 11.3 degrees at the time of admission and 13.8 degrees at the final follow-up examination after treatment. The average canal compromise was 34% at the time of admission and improved to 19% at the final follow-up examination. On the basis of the numbers available, no significant difference was found between the two groups with respect to return to work. The average pain scores at the time of the latest follow-up were similar for both groups. The preinjury scores were similar for both groups; however, at the time of the final follow-up, those who were treated nonoperatively reported less disability. Final scores on the SF-36 and Oswestry questionnaires were similar for the two groups, although certain trends favored those treated without surgery. Complications were more frequent in the operative group.

CONCLUSION

We found that operative treatment of patients with a stable thoracolumbar burst fracture and normal findings on the neurological examination provided no major long-term advantage compared with nonoperative treatment.

The FOXP1 winged helix transcription factor is a novel candidate tumor suppressor gene on chromosome 3p

The JC12 monoclonal antibody recognizes a previously unknown nuclear protein that showed a restricted distribution in normal tonsil and was also overexpressed in a subset of diffuse large B-cell lymphomas. Using this reagent, we expression cloned cDNAs encoding its antigenic target and identified this protein as a novel putative transcription factor, FOXP1. The FOXP1 protein sequence contains predicted domains characteristic of transcription factors, including a winged helix DNA-binding motif, a second potential DNA-binding motif, a C(2)H(2) zinc finger, nuclear localization signals, coiled-coil regions, PEST sequences, and potential transactivation domains. The FOXP1 gene has been mapped to chromosome 3p14.1, a region that commonly shows loss of heterozygosity in a wide range of tumors and which is reported to contain a tumor suppressor gene(s). Using tissue arrays and immunohistochemistry, we demonstrate that both the FOXP1 mRNA and protein are widely expressed in normal tissues. The levels of FOXP1 mRNA were compared in paired normal and tumor tissues (from the same patient) using a tissue array containing cDNAs extracted from 68 samples taken from kidney, breast, prostate, uterus, ovary, cervix, colon, lung, stomach, rectum, small intestine, and from nine cancer cell lines. Differences in FOXP1 mRNA expression between normal and tumor samples were observed in 51% of cases. Most striking was the comparative loss of expression in 73% of colon tumors and comparative overexpression of FOXP1 mRNA in 75% of stomach tumors. Analysis of the FOXP1 mRNA expression in normal tissues (not taken from cancer patients) indicated that loss of FOXP1 expression may occur in some histologically normal tissues adjacent to tumors. Immunohistochemical analysis of FOXP1 protein expression was performed on 128 solid tumors, including 16 renal, 9 breast, 12 lung, 20 colon, 21 stomach, 10 head and neck, 35 prostate, and 5 pancreatic cases. Complete loss of expression, increased expression, and cytoplasmic mislocalization of the predominantly nuclear FOXP1 protein were frequently observed in neoplastic cells. Our study identifies FOXP1 as a new candidate tumor suppressor gene localized to the chromosome 3p14.1 region.

Childhood outcome after early high-frequency oscillatory ventilation for neonatal respiratory distress syndrome

OBJECTIVE

In a previous multicenter controlled clinical trial, we randomly assigned surfactant-treated premature newborns with moderate to severe respiratory distress syndrome to early treatment with high-frequency oscillatory ventilation (HFOV) or to conventional ventilation (CV). Compared with control infants who were treated with CV, neonates who were treated with HFOV using a strategy designed to recruit and maintain lung volume and minimize oxygen exposure had clinical evidence of improved pulmonary outcome and less lung injury. We report a follow-up study designed to determine whether clinical differences persisted between these study groups.

METHODS

Patients were recruited from 81 survivors at 1 center (Provo, Utah) and evaluated for sociodemographic and health history, growth, mental development, motor proficiency, and pulmonary function.

RESULTS

Eighty-seven percent of the cohort who originally were assigned to treatment with HFOV (n = 36) or CV (n = 33) were seen in follow-up at a mean age of 77 months (6.4 years). There were no differences in the frequency of hospitalization, pulmonary illness, asthma, or disabilities. Growth, verbal IQ, and motor development were appropriate for age and not different between groups. Patients who initially were randomized to treatment with CV showed pulmonary function evidence of decreased peak expiratory flow, increased residual lung volume, and maldistribution of ventilation.

CONCLUSION

Neurodevelopmental childhood outcome after early intervention HFOV was normal and not different compared with patients who were treated with CV. Surfactant replacement combined with early HFOV using a lung recruitment strategy ameliorates the acute lung injury in respiratory distress syndrome that predisposes some preterm infants to develop chronic lung disease.