Prevalence of, and risk factors for, physical ill-health in people with Prader-Willi syndrome: a population-based study

The medical findings from a population-based study of Prader-Willi syndrome (PWS) are discussed (in which birth incidence of PWS was estimated at 1:22,000 and death rate at over 3% per annum). In this study the prevalence of specific medical disorders that might account for a shortened life expectancy were investigated. Of all people with a possible diagnosis of PWS, only those meeting clinical criteria and/or with a confirmed genetic diagnosis were included in the study. Sixty-six individuals, 40 males and 26 females with a mean age of 19 years (range of 0 to 46 years) agreed to participate in the population-based study group. A prevalence rate of 25% for non-insulin dependent diabetes mellitus (NIDDM) was found in adults. Mean age at onset was 20 years. Those with NIDDM had a higher past maximum body weight and a greater likelihood of positive family history. Nearly 50% across the age groups reported a history of recurrent respiratory infections. High rates of fractures (29%), leg ulceration (22% in adults), sleep disorders (20%), and severe scoliosis (15% in childhood) were also reported. It is postulated that hypotonia is a possible contributory factor to the risk of strabismus, scoliosis, and respiratory infections. Other causes of morbidity, in particular the high rates of NIDDM, may be due to a failure to manage over-eating resulting in severe obesity. Early diagnosis and clear guidance to families about these risks and how they might be prevented is recommended. It is hypothesized that the high pain threshold may result in the presence of some illness not being apparent.

Flexible sigmoidoscopy in general practice

OBJECTIVE: Flexible sigmoidoscopy (FS) is increasingly being accepted as the method of choice for initial investigation of rectal bleeding and other lower gastrointestinal symptoms. The aim of this study was to assess the feasibility of FS in general practice and to compare the yield, cost and efficiency of a service provided by a consultant surgeon and a General Practitioner (GP). SUBJECTS AND METHODS: A prospective study of FS was undertaken on 430 unsedated patients with symptoms suggestive of lower bowel disease in two general practices. RESULTS: The yield was comparable to hospital based data. Fifteen (3.5%) cancers were detected, of which 40% were Dukes A, and 46 (10.7%) adenomatous polyps. Cost per patient examination by a GP including capital costs, depreciation of equipment, and training was calculated to be cheaper or at least equivalent to a hospital-based service but inefficient due to the low numbers examined per month. There were no complications and no missed cancers after a minimum follow up of 2 years. CONCLUSIONS: The results suggest that FS can be safely performed by a suitably trained GP in health centres, but better utilization of equipment and value for money would be obtained by providing the service for a group of practices rather than a single practice as in this study.

Pulmonary barotrauma-induced cerebral arterial gas embolism with spontaneous recovery: commentary on the rationale for therapeutic compression

Pulmonary barotrauma-induced cerebral arterial gas embolism (CAGE) continues to complicate compressed gas diving activities. Inadequate lung ventilation secondary to inadvertent breath holding or rapid buoyant ascent can quickly generate a critical state of lung over-pressure. Pulmonary over-pressurization may also occur as a consequence of acute and chronic pulmonary pathologies. Resulting barotrauma frequently causes structural failure within the terminal distal airway. Respiratory gases are then free to embolize the systemic circulation via the pulmonary vasculature and the left heart. The brain is a common target organ. Bubbles that enter the cerebral arteries coalesce to form columns of gas as the vascular network narrows. Small amounts of gas frequently pass directly through the cerebral circulation without occlusion. Larger columns of gas occlude regional brain blood flow, either transiently or permanently, producing a stroke-like clinical picture. In cases of spontaneous redistribution, a period of apparent recovery is frequently followed by relapse. The etiology of relapse appears to be multifactoral, and chiefly the consequence of a failure of reperfusion. Prediction of who will relapse is not possible, and any such relapse is of ominous prognostic significance. It is advisable, therefore, that CAGE patients who undergo spontaneous recovery be promptly recompressed while breathing oxygen. Therapeutic compression will serve to antagonize leukocyte-mediated ischemia-reperfusion injury; limit potential re-embolization of brain blood flow, secondary to further leakage from the original pulmonary lesion or recirculation of gas from the initial occlusive event; protect against embolic injury to other organs; aid in the resolution of component cerebral edema; reduce the likelihood of late brain infarction reported in patients who have undergone spontaneous clinical recovery; and prophylax against decompression sickness in high gas loading dives that precede accelerated ascents and omitted stage decompression.

A survey of attitudes to parent-doctor conflicts over treatment for children

AIMS

To investigate professional and public attitudes to the intervention of the law when parents and doctors disagree about the medical treatment of children.

METHODS

A cross-sectional survey of academic staff at the University of Otago. Random samples of academic medical practitioners and non-Health Sciences academic staff completed written questionnaires, including open and closed questions. Questions focussed on the Liam Williams-Holloway (W-H) and Tovia Laufau (TL) cases.

RESULTS

The response rate was 107/164 (65%) of eligible staff. Support for doctors seeking treatment orders was strong (77% in the W-H case, and in the TL case, 70% believed an order should have been sought). Women were less likely than men to support a treatment order, significantly in the W-H case. There were no significant differences between medical and non-medical respondents. Court processes were viewed as confrontational and a last resort only after mediation failed. Scientific evidence was rated as the most important consideration in treatment decisions, followed by likely outcome, establishment of trust between parents and doctors, and the age of the child.

CONCLUSIONS

Among this highly educated group there was strong support for seeking treatment orders in the child's best interests. But various mediation options were preferred and should be explored further. More evidence is needed on the success of treatment orders and on the attitudes of a more representative sample of the population.

Evidence for the regulation of levels of plasma adhesion molecules by proinflammatory cytokines and their soluble receptors in type 1 diabetes

OBJECTIVES

To investigate the regulation of soluble adhesion molecules by tumour necrosis factor-alpha (TNF-alpha) and interleukin-6 (IL-6), and relationships with circulating cytokine receptors, in vivo, in type 1 diabetes.

DESIGN

Cross-sectional study.

SETTING

University hospital diabetes clinic.

SUBJECTS

A total of 47 non-nephropathic, Caucasian type 1 diabetics and 39 nondiabetic controls.

OUTCOME MEASURES

Plasma levels of TNF-alpha, IL-6, their soluble receptors and adhesion molecules intercellular adhesion molecule-1 (sICAM-1), vascular cell adhesion molecule-1 (sVCAM-1), sE-selectin and von Willebrand factor (vWF), and risk factors for cardiovascular disease.

RESULTS

Plasma concentrations of IL-6 were elevated in diabetic patients compared with controls [median (interquartiles) 1.28 (0.89-2.65) vs. 0.66 (0.45-1.73) pg mL(-1): P=0.016], and in these patients IL-6 and soluble IL-6 receptor (sIL-6R) levels correlated with concentrations of sICAM-1 (r = 0.41, P = 0.012 and r = 0.31, P = 0.04, respectively). Tumour necrosis factor-alpha soluble receptor-2 (sTN-FRII), but not TNF-alpha or tumour necrosis factor soluble receptor-1 (sTNFRI), was elevated in diabetic subjects (P = 0.027). Plasma TNF-alpha levels correlated with sVCAM-1 (r = 0.39, P = 0.008), triglycerides (r = 0.36, P = 0.02 1) and diastolic blood pressure (r = 0.35; P = 0.024). Both sTNFRI and sTNFRII correlated with blood pressure (r = 0.46, P = 0.002; r = 0.32, P = 0.034) and triglycerides (r = 0.33, P = 0.033; r = 0.29, P = 0.05). In contrast, HDL-cholesterol and triglyceride were related to sE-selectin (r = -0.45 and +0.45; both P < 0.001). Neither sE-selectin nor vWF were related to cytokine concentrations. Finally, both TNF-alpha and sIL-6R correlated sTNFRI and RII (r = 0.44-0.49, P < 0.001). None of these interactions were apparent in control subjects.

CONCLUSIONS

(i) IL-6, through effects on sICAM-1, and TNF-alpha via effects on sVCAM-1, may promote vascular adhesion; (ii) plasma levels of TNF-alpha are associated with dyslipidaemia and increased blood pressure, adding to vascular disease risk; (iii) the actions of both cytokines are probably modified by altered production of soluble receptors in diabetic subjects.

Differentiation potential of adult stem cells

In many different adult tissues, stem cells generate new cells either continuously or in response to injury. Such cells were thought to be limited to generating the types of cells normally present in the tissue where the stem cell resides. However, several different stem-cell populations in the adult have been found recently to be capable of generating additional cell types under certain conditions.

Temporal autocorrelation function for a diffusing-wave spectroscopy experiment with a point source and backscattering detection

The autocorrelation function of the backscattered intensity in a diffusing-wave spectroscopy experiment that uses a point source is calculated by use of the diffusive-wave model. We show that in this approximation the calculated autocorrelation function decays faster than if the plane-source approximation were used. The design of a probe that implements this geometry is presented together with preliminary results that show the utility of the probe as a sizing tool in concentrated dispersions.

Automated multiplex assay system for simultaneous detection of hepatitis B virus DNA, hepatitis C virus RNA, and human immunodeficiency virus type 1 RNA

We have developed an automated multiplex system for simultaneously screening hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus type 1 (HIV-1) in blood donations. The assay, designated AMPLINAT MPX HBV/HCV/HIV-1 Test (AMPLINAT MPX), consists of virus extraction and target sequence-specific probe capture on specimen preparation workstation GT-X (Roche Diagnostics K.K., Tokyo, Japan) and amplification and detection by TaqMan PCR on the ABI PRISM 7700 Analyzer (Perkin-Elmer Applied Biosystems, Foster City, Calif.). An internal control (IC) is incorporated in the assay to monitor the extraction, target amplification, and detection processes. The assay yields qualitative results without discrimination of the three targets. Detection limits (95% confidence interval) are 22 to 60 copies/ml for HBV, 61 to 112 IU/ml for HCV, and 33 to 66 copies/ml for HIV-1, using a specimen input volume of 0.2 ml. The AMPLINAT MPX assay detects a broad range of genotypes or subtypes for all three viruses and has a specificity of 99.6% for all three viruses with seronegative specimens. In an evaluation of seroconversion panels, the AMPLINAT MPX assay detects HBV infection an average of 24 days before the detection of HBsAg by enzyme immunoassay. HCV RNA was detected an average of 31 days before HCV antibody. HIV-1 RNA was detected an average of 14 days before HIV-1 antibody and an average of 9 days before p24 antigen. The Japanese Red Cross has been evaluating the AMPLINAT MPX system since October 1999. The clinical performance indicates that the AMPLINAT MPX system is robust, sensitive, and reproducible, with a high percentage of valid assay runs (96.8%), a low false-positive rate (0.34%), and a low IC failure rate (0.24%).

Macrophages transfected with adenovirus to express IL-4 reduce inflammation in experimental glomerulonephritis

Nephrotoxic nephritis (NTN) is characterized by acute macrophage-dependent inflammation and serves as a model of human glomerulonephritis. In this study we have transfected rat macrophages with recombinant adenovirus expressing IL-4 (Ad-IL4) and demonstrated that these transfected macrophages develop fixed properties as a result of transfection, as shown by reduced NO production in response to IFN-gamma and TNF. Ad-IL4-transfected macrophages localized with enhanced efficiency to inflamed glomeruli after renal artery injection in rats with NTN compared with adenovirus expressing beta-galactosidase (Ad-beta gal)-transfected macrophages and produced elevated levels of the cytokine in glomeruli in vivo for up to 4 days. The delivery of IL-4-expressing macrophages produced a marked reduction in the severity of albuminuria (day 2 albuminuria, 61 +/- 15 mg/24 h) compared with unmodified NTN (day 2 albuminuria, 286 +/- 40 mg/24 h; p < 0.01), and this was matched by a reduction in the number of ED1-positive macrophages infiltrating the glomeruli. Interestingly, the injection of IL-4-expressing macrophages into single kidney produced a marked reduction in the numbers of ED1-positive macrophages in the contralateral noninjected kidney, an effect that could not be mimicked by systemic delivery of IL-4-expressing macrophages. This implies that the presence of IL-4-expressing macrophages in a single kidney can alter the systemic development of the inflammatory response. Macrophage transfection and delivery provide a valuable system to study and modulate inflammatory disease and highlight the feasibility of macrophage-based gene therapy.

Replace fine needle aspiration cytology with automated core biopsy in the triple assessment of breast cancer

All patients presenting with a symptomatic breast lump are assessed by means of triple assessment (clinical examination, radiology in the form of mammography and cytology by means of a fine needle aspiration) performed by the clinician in the rapid access breast clinic at the Royal Gwent Hospital, Newport, UK. In our initial experience, it was found that a significant number of patients were returning to clinic for the results of the triple assessment to find that the cytology was not conclusive and hence needed a core biopsy, thus delaying diagnosis and definitive treatment. Therefore, a prospective study was carried out over a 6-month period, where all patients presenting with a symptomatic lump with a clinical or radiological suspicion of breast cancer had, in addition to the standard triple assessment, an automated core biopsy, thus giving rise to the quadruple assessment of the breast lump. A total of 52 patients with a clinical or radiological suspicion of breast cancer were included over this 6-month period. Of these 52 patients, 31 had a definitive diagnosis of breast cancer on fine needle aspiration (sensitivity 60%) compared with 50 of the 52 patients on core biopsy (sensitivity 96%). When radiology was diagnostic of breast cancer (R 5), the sensitivity of cytology was 61% compared with 97% with core biopsy. However, when radiology was not diagnostic of cancer (R 1-4), the sensitivity of cytology fell to 53% while the sensitivity of core biopsy remained high at 95%. The overall cellularity rate for cytology was 96%, which exceeds the BASO requirement for fine needle aspiration cytology. From these results, we conclude that automated core biopsy has a superior diagnostic power when compared with fine needle aspiration cytology and hence should replace fine needle aspiration cytology in the assessment of symptomatic breast lumps.

"Whole body" mobility after one year of intraoral appliance therapy in children with cerebral palsy and moderate eating impairment

The reciprocal influence of body postures on the oral structures, but also of the oral structures on body postures, has been proposed by clinicians and is taken into consideration when treating children with poor postural control and moderate to severe eating impairments. However, this relationship has not been rigorously investigated. The purpose of this study was to document the possible relationships among oral-motor, postural, and ambulatory control. Ambulatory skills [exclusive use of wheelchair (w/c) vs w/c and ambulation], postural control when sitting, "pathologic" reflexes, and lip and tongue posture were recorded before and after one year of therapy with an intraoral appliance (ISMAR) in 20 children with cerebral palsy and moderate eating impairment. Significant improvement occurred in sitting (head-trunk-foot control) following one year of ISMAR therapy. Ambulatory status also significantly improved above the level of maturation. Half of the children showed marked improvement in oral posture, i.e., their resting mouth posture was closed rather than open. These results support an hypothesis of interaction between oral structures and postural control of the "whole body." Further studies are needed to determine the controls of such a relationship.

Relationship of psychosis to aggression, apathy and function in dementia

BACKGROUND

Psychosis has been associated with aggression in dementia, but the nature of this relationship has been unclear. There has been very little research into the relations between apathy and functional status to psychosis in dementia. The purpose of this study is to investigate the relationship between psychosis and aggression, apathy, and functional status in outpatients with dementia.

METHODS

The presence of psychosis was assessed by clinical interview and two scales: the Neuropsychiatric Inventory and the Columbia University Scale for Psychopathology in Alzheimer's Disease. The maximum likelihood estimation technique was used to determine the best estimate of the presence of psychosis. Aggression, apathy, and functional status (activities of daily living: ADLs) were measured using structured instruments.

RESULTS

Sixty-one subjects were included. The CUSPAD and NPI provided low false positive and negative rates. ANCOVA analyses showed that psychosis was significantly associated with aggression, even when controlling for apathy, depression, and ADLs. Psychosis was related to apathy only when depression was controlled for. Hallucinations were related to impaired basic ADLs, even when depression and apathy were controlled for.

CONCLUSIONS

Relationships were found between psychotic symptoms in dementia and aggression as well as apathy and impaired functional status. These relationships suggest pathophysiologic mechanisms and have possible treatment implications.

Large-dose oral dextromethorphan as an adjunct to patient-controlled analgesia with morphine after knee surgery

Dextromethorphan is a weak N-methyl-d-aspartate (NMDA) receptor antagonist that inhibits spinal cord sensitization in animal models of pain and also inhibits the development of cutaneous secondary hyperalgesia after tissue trauma. Perhaps coadministration of an NMDA antagonist with an opioid would lead to better pain relief, particularly with movement and an opioid-sparing effect. This has been shown for ketamine, but previous studies with dextromethorphan that have used small doses have shown only a modest reduction in morphine requirements with no or minimal changes in the postoperative pain experience. We sought to determine whether a large dose of this drug, just below the maximum tolerated dose, could potentiate morphine analgesia while simultaneously causing a significant improvement in the management of the postoperative pain experience. Sixty-six patients undergoing knee surgery were enrolled in the study. The study design was a prospective, randomized double-blinded comparison with placebo of 200 mg of dextromethorphan given eight hourly. Postoperative pain experiences were assessed by postoperative morphine usage. Visual analog and verbal rating scales were used to assess pain with movement as well as side effects. Dextromethorphan treatment led to a significant but modest reduction in morphine requirements (29.3% P < 0.05) but no reduction in postoperative pain levels. We conclude that increasing orally administered dextromethorphan to near maximum tolerated doses does not provide greater morphine sparing than 20-40 mg given 6-8 hourly as in previous studies. Furthermore we conclude that dextromethorphan does not improve pain scores in a manner expected of a drug with NMDA antagonist properties.

Intrathoracic lipoma in a Labrador retriever

Pyrexia, granulocytosis and hyperglobulinaemia were the main clinical findings in an unusual case of intrathoracic lipoma in a 12-year-old male Labrador retriever. The response to antibiotic and anti-inflammatory treatment was poor, prompting further investigation. Survey radiographs and ultrasonography revealed a cavitated, fluid-filled soft tissue mass in the right hemithorax, which was successfully removed resulting in rapid resolution of clinical signs. Lipomas are rare intrathoracic extrapulmonary tumours. Previously reported clinical signs are dyspnoea and coughing, attributed to the mass effect of the lipoma. The unusual presentation in this case was caused by necrosis of the lipoma, probably owing to torsion of the pedicle attaching it to the cranial mediastinum.

What factors contribute to senior psychiatry residents' interest in geriatric psychiatry? a Delphi study

OBJECTIVE

To generate hypotheses regarding factors that influence senior psychiatric residents, to consider treating geriatric patients in their future practices.

METHOD

Using the Delphi technique, designed to generate ideas and consensus, we asked psychiatry residents at the University of Toronto who had completed, or were completing, their geriatric rotation about the factors they thought might influence residents in devoting some of their practice to geriatric patients. Residents then rated the degree of influence of these factors which had been synthesized into a questionnaire.

RESULTS

Twenty-six items were rated according to their degree of influence. The most influential item was positive clinical experiences with seniors. This was followed closely by supervisor characteristics such as enthusiasm, role modeling, competence, and mentoring. Interest in and comfort with the medical psychiatric and neuropsychiatric nature of the field were also felt to be influential.

CONCLUSIONS

The factors that influence senior psychiatry resident interest in the practice of geriatric psychiatry are primarily educational and result from exposure to the field under optimal educational circumstances (positive clinical experiences and excellent supervisors). The medical and neuropsychiatric nature of the field also likely exerts a unique influence and should be considered in stimulating interest in this population.

Maintenance as a corporate strategy

As we move towards the 21st century, those Manufacturing Industries that survive, will have changed their "efficiency" focus away from the conventional wisdom of "efficient individual tasks", to focus on the "effectiveness of a total manufacturing process". This seemingly insignificant change of emphasis, (from task to process) must include "the integration of process plant maintenance into the production process". Manufacturing companies, which do not include an effective plant maintenance strategy into their business strategy, will not survive the business environment of the 21st Century.

Maintenance as a corporate strategy

As we move towards the 21st century, those Manufacturing Industries that survive, will have changed their "efficiency" focus away from the conventional wisdom of "efficient individual tasks", to focus on the "effectiveness of a total manufacturing process". This seemingly insignificant change of emphasis, (from task to process) must include "the integration of process plant maintenance into the production process". Manufacturing companies, which do not include an effective plant maintenance strategy into their business strategy, will not survive the business environment of the 21st Century.

History, present status and future of sentinel node biopsy in breast cancer. The Mary Béves Lecture

The word Sentinel' is defined in The Oxford English Dictionary as 'a guard, one who keeps watch or a sentry'. When translated to the concept of a tumour and its lymph node drainage, the sentinel node could be interpreted to mean the lymph node that guards or keeps watch over a tumour. The sentinel lymph node can thus be defined as the first lymph node that drains a primary tumour within the regional lymphatic basin of that tumour. We know that tumour progression in breast cancer often occurs in an orderly, progressive fashion. So in theory, if the sentinel node is tumour free then the rest of the nodes in the lymphatic basin should also be uninvolved by the tumour.

Positive and negative selection to reduce tumour contamination in peripheral blood stem cell harvests

Peripheral blood progenitor cells used during high dose treatments for malignancy may be contaminated with tumour cells that could later contribute to recurrence. CD34+ selected harvests still contain tumour cells and an additional negative selection may be capable of reducing this contamination. We have assessed a two-stage technique in which a CD34+ selection is followed by a tumour specific depletion stage using a B cell or breast cancer specific antibody panel. Initial small-scale selections on 11 patients with NHL and breast cancer showed that cell loss was greatest following the CD34+ selection with a median yield of 38.8 per cent (range 17. 2-56.4 per cent). The addition of the depletion stage resulted in a minimal loss of CD34+ cells with a yield for this step of 94.2 per cent (range 77.5-99.3 per cent). Clinical scale selections were performed on seven patients with CLL and a median of 2.8x10(6)/kg CD34+ cells (range 1.5-6.1x10(6)/kg) were collected. Cell recovery was 53.3 per cent following CD34+ selection and 76.9 per cent following the tumour specific depletion stage, resulting in a final product containing a median of 1.0x10(6)/kg CD34+ cells (range 0. 55-2.0x10(6)/kg). All unmanipulated harvests were heavily contaminated with tumour cells (median contamination 10.2 per cent, range 2.0-83.1 per cent) as measured by flow cytometry and a median 4.7 log (range 3-5 log) tumour cell purge was produced following two-stage selection. Six of the patients have received cells manipulated in this way with median engraftment times of neutrophils>0.5x10(9)/l=16 days (range 13-20 days) and platelets>20x10(9)/l=16.5 days (range 11-42 days). At a median follow-up of 25 months, these transplanted patients remain well and in molecular complete remission.

The globalization of nursing knowledge

External influences placed upon nurses working in universities and in clinical practice require them to attract research funding, carry out research, generate new knowledge and publish in national and international journals. While there does not appear to be an agreed, unified body of nursing knowledge, critical and scholarly debate is essential to generate knowledge, but this is not an activity in which the majority of nurses can effectively participate. Nevertheless, nurses in the Western world are free to communicate their research, theories or ideas, essentially uncensored, to a vast invisible audience, and there is global dissemination through a vast array of literature and educational materials. This paper challenges nurses to examine the implications of globalization and suggests that the continuing debate on the nature of nursing knowledge should be updated to include consideration of both a change in philosophical stance and the far reaching effects of global dissemination of information.

In vitro differentiation of c-myb(-/-) ES cells reveals that the colony forming capacity of unilineage macrophage precursors and myeloid progenitor commitment are c-Myb independent

Mice homozygous for an inactivated c-myb allele exhibit embryonic (primitive) blood formation but die at about day 15 of gestation because of a failure to generate adult (definitive) haemopoiesis. Recently, it has been shown that commitment to definitive haemopoiesis does occur in vivo, but that some point in the subsequent development towards the differentiated lineages is compromised. Here we have asked whether it is possible to demonstrate this same distinction between the development of primitive and definitive haemopoiesis during the in vitro differentiation of c-myb null ES cells, and whether this can be used to define more precisely at which developmental stage the absence of c-Myb blocks the adult haemopoietic lineages. We investigated the kinetics of progenitor formation and commitment to differentiation using a combination of colony forming assays and analysis of RNA and surface antigen expression. Primitive unilineage macrophage and erythroid precursor commitment could develop in the absence of c-Myb. No precursors characteristic of definitive haemopoiesis were detected; nevertheless, we could show the expression of a programme of transcription and surface antigens which is consistent with the appearance of definitive progenitors blocked at an early multipotential stage.

Comparative genome sequence analysis of the Bpa/Str region in mouse and Man

The progress of human and mouse genome sequencing programs presages the possibility of systematic cross-species comparison of the two genomes as a powerful tool for gene and regulatory element identification. As the opportunities to perform comparative sequence analysis emerge, it is important to develop parameters for such analyses and to examine the outcomes of cross-species comparison. Our analysis used gene prediction and a database search of 430 kb of genomic sequence covering the Bpa/Str region of the mouse X chromosome, and 745 kb of genomic sequence from the homologous human X chromosome region. We identified 11 genes in mouse and 13 genes and two pseudogenes in human. In addition, we compared the mouse and human sequences using pairwise alignment and searches for evolutionary conserved regions (ECRs) exceeding a defined threshold of sequence identity. This approach aided the identification of at least four further putative conserved genes in the region. Comparative sequencing revealed that this region is a mosaic in evolutionary terms, with considerably more rearrangement between the two species than realized previously from comparative mapping studies. Surprisingly, this region showed an extremely high LINE and low SINE content, low G+C content, and yet a relatively high gene density, in contrast to the low gene density usually associated with such regions.

beta-Adrenergic regulation of proinflammatory cytokines in humans

OBJECTIVES

To investigate the effects of beta-adrenergic stimulation on IL-6 secretion in humans, and to determine the potential contribution to this response of adipocytes and peripheral blood cells (PBC).

DESIGN

Experimental study in 8 human volunteers, and in vitro studies on murine adipocyte cell-line, 3T3.L1 and 3T3.F442A, and human PBC.

MEASUREMENTS

Plasma IL-6 and TNFalpha responses to isoprenaline infusion. Cytokine secretion from differentiated adipocyte cell-lines and PBC in response to isoprenaline.

RESULTS

Plasma IL-6 levels increased ninefold (median) by 180 min (baseline median 0.51 [interquartile range 0.47-1.4] vs 180 mins 4.53 [2.58-5.69] pg ml(-1), P=0.01). One hour after infusion, IL-6 levels (2.9 [1.27-3.98]) were lower than at 180 min (P=0.05), but higher than baseline (P=0.01). TNFalpha levels were unchanged. Differentiated adipocytes incubated in isoprenaline (0-0.1 microM) released significantly increased amounts of IL-6 whereas no response was elicited from PBC.

CONCLUSIONS

The induction of IL-6 observed in vivo may be attributed to the beta-adrenergic stimulation of IL-6 release specifically from adipocytes, as opposed to circulating blood cells.

Late-life depression as a possible predictor of dementia: cross-sectional and short-term follow-up results

The authors explored cognitive functioning of a group of elderly subjects with depression. The group as a whole, and, in particular, the late-onset group (LOD), demonstrated cognitive impairment on the Mattis Dementia Rating Scale (MDRS). Subgroup differences were significant at P=0.004. This between-group difference was not seen when age and level of education were controlled. In the LOD group, 47.5% (vs. 31.5% of the early-onset group [P=0.025]), scored below the cutoff for dementia. Age-at-onset status in a logistic regression model predicted MDRS category, and treatment of the depression had little effect on cognition. Results support the hypothesis that late-life depression, particularly LOD, is associated with cognitive impairment that may represent early AD.

The role of depression severity in the cognitive functioning of elderly subjects with central nervous system disease

OBJECTIVE

To examine the hypothesis that there is a causal relation between depression and cognitive dysfunction in patients with central nervous system (CNS) disease.

DESIGN

Retrospective analysis of a clinical database.

SETTING

Tertiary geriatric day hospital.

PATIENTS

Sixty-five patients with depression and CNS disease, and 201 patients with depression but without CNS disease.

OUTCOME MEASURES

Scores on the Hamilton Depression Rating Scale (Ham-D) and the Mattis Dementia Rating Scale (MDRS).

RESULTS

A logistic regression analysis using MDRS status as the dependent variable, and a number of clinical variables as the predictor variables, showed that, in patients with CNS disease, only the Ham-D score predicted MDRS status (R = -0.19, p = 0.02). Ham-D score even more strongly predicted scores on a frontal system subtest of the MDRS (R = -0.262, p = 0.005). Ham-D score did not predict MDRS status in patients without CNS disease. Mean Mini Mental State Examination scores for the group with CNS disease were 25.1 at admission and 26.1 at discharge (p < 0.001).

CONCLUSIONS

These findings suggest that depression contributes to frontal cognitive dysfunction in patients with CNS disease.

Work-based learning as a means of developing and assessing nursing competence

Work-Based Learning is the bringing together of self-knowledge, expertise at work and formal knowledge. It takes a structured and learner-managed approach to maximizing opportunities for learning and professional development in the workplace. The development and assessment of nursing competence can be facilitated through Work-Based Learning, although this may require pedagogic and structural changes within nurse education. There are a number of conditions which must accompany effective participative learning, and these are discussed in the paper in relation to examples of nursing programmes. This method of learning and assessment has potential to bridge the gap between theory and practice, and as such it can only be achieved through commitment and partnership between the individual practitioner, clinical services and universities.

Lessons from the other side: what can we learn from the private sector?

Business has reacted in an impressive manner to increasing globalisation, short-term stock market pressure for performance, emerging industries and new technologies. While the private sector has become increasingly competitive, the public sector has not adopted this commercial rigour. Funding pressures on health services will continue, as will increasing consumer and staff demands and the blurring of public and private health care provision. As a result, there are lessons and techniques the public and private health sectors should learn from each other. I have drawn the issues that follow from my experience in the steel and food industries.

Depression in holocaust survivors: profile and treatment outcome in a geriatric day hospital program

The profile of depressive symptoms and the outcome of treatment in Holocaust Survivors (HS) versus non-Holocaust Survivors (NS), attending a Psychiatric Day Hospital Program for depression, were evaluated retrospectively using a clinical database. Approximately 24% of the study population were Holocaust Survivors (HS). The HS group was more likely to receive a diagnosis of major depressive disorder or episode as one of their diagnoses. The HS group, in particular those survivors who had been in ghettos or in concentration camps, were more likely to be given a diagnosis of post-traumatic stress disorder. Both groups showed improvement from baseline in their ratings of depression on the Hamilton Depression Rating Scale (HDRS) and Geriatric Depression Scale at the time of discharge (p<0.001). However, there were no significant differences between the groups in terms of their ratings of depression either at admission, at discharge or in their degree of improvement. Likewise, there was no significant difference between the groups in the profile of their depression, as per the sub-scales of the HDRS, with the exception that the HS group displayed more 'insight' than the NS group (p=0.002). The NS group scored higher on the Mattis Dementia Rating Scale compared to the HS group (119.1 versus 125.4, p<0.001), even when level of education was covaried; however, language may be an important confound. In conclusion, there was no significant difference in the profile or outcome of depression between groups. However, the HS group was more likely to receive a diagnosis of post-traumatic stress disorder, displayed more 'insight', and appear to differ in their cognitive profile.

Subcutaneous administration of recombinant glycosylated interleukin 6 in patients with cancer: pharmacokinetics, pharmacodynamics and immunomodulatory effects

This is the first report of the serum profile of a glycosylated recombinant form of human IL-6 (rhIL-6) administered subcutaneously (1-10 microg/kg/day) in a phase I/II trial as a thrombopoietic agent in patients with advanced cancer. The pharmacodynamic effects of IL-6 were also examined. Detailed pharmacokinetic measurements were made in four patients. Peak concentrations at 5-8 h and a median t0.5 of ca. 5 h were similar to those previously reported for non-glycosylated IL-6. However, higher peak concentrations and apparent differences in effective dose levels to those previously reported with the non-glycosylated form were seen. Indications of an apparent attenuation in circulating IL-6 concentrations with continuing injections were seen in eight of 10 patients examined but anti-IL-6 antibody generation was seen in only two patients. Soluble interleukin 6 receptor concentrations generally decreased. No major changes in T cell subsets were seen but expression of CD25 and CD54 by T lymphocytes significantly increased, accompanied by marked increases in soluble CD25 (sIL-2R) and CD54 (sICAM-1). No consistent change in B cells, monocytes or NK cells were seen. No evidence for induction of TNF-alpha was found. This study demonstrates similar biological effects of glycosylated rhIL-6 to those reported for the non-glycosylated form but illustrates several apparent differences which are discussed further.

Herpesvirus saimiri-based gene delivery vectors maintain heterologous expression throughout mouse embryonic stem cell differentiation in vitro

In order to achieve a high efficiency of gene delivery into rare cell types like stem cells the use of viral vectors is presently without alternative. An ideal stem cell gene therapy vector would be able to infect primitive progenitor cells and sustain or activate gene expression in differentiated progeny. However, many viral vectors are inactivated when introduced in developing systems where cell differentiation occurs. To this end, we have developed a mouse in vitro model for testing herpesvirus saimiri (HVS)-based gene therapy vectors. We demonstrate here for the first time that HVS is able to infect totipotent mouse embryonic stem (ES) cells with high efficiency. We have transduced ES cells with a recombinant virus carrying the enhanced green fluorescent protein (EGFP) gene and the neomycin resistance gene (NeoR) driven by a CMV promoter and the SV40 promoter, respectively. ES cells maintain the viral episomal genome and can be terminally differentiated into mature haematopoietic cells. Moreover, heterologous gene expression is maintained throughout in vitro differentiation. Besides its obvious use in gene therapy, this unique expression system has wide ranging applications in studies aimed at understanding gene function and expression in cell differentiation and development.

Are there gender differences in patients presenting with unstable angina?

BACKGROUND

There are limited studies on gender differences in patients with unstable angina. We investigated the influence of gender in these patients in a tertiary referral centre.

METHODS AND RESULTS

Three hundred and thirteen consecutive patients (210 men and 103 women) with unstable angina were studied over a 42-month period. Patient characteristics, cardiovascular risk factors and subsequent management including coronary artery bypass graft (CABG) operation and percutaneous transluminal coronary angioplasty (PTCA) were investigated. There was no difference in age [61.6 (11.0) (S.D.) years for men vs. 63.5 (10.5) years for women]. Diabetes mellitus and hypertension were more common in women (diabetes, 11% vs. 23%, P = 0.007; hypertension, 32% vs. 52%; P = 0.001). The number of smokers was greater in men (73% vs. 46%, P = 0.00001). There was no difference in the prevalence of hypercholesterolaemia or in the incidence of previous myocardial infarction, previous history of angina and family history of ischaemic heart disease. The duration of unstable angina before presentation to the referring hospital was similar in both sexes. The use of aspirin, intravenous heparin and antianginal drugs was also comparable in the two genders. The number of coronary arteries involved in men and women appeared similar (one vessel, 22% vs. 27%; two vessels, 26% vs. 21%; three vessels, 52% vs. 52% in men and women, respectively). The proportion of men and women who underwent subsequent revascularisation was also similar (CABG, 31% vs. 33%; PTCA, 42% vs. 40%). The overall in-hospital mortality was higher in women (6.8% vs. 2.8%), but was not statistically significant (P = 0.18).

CONCLUSIONS

Gender differences in unstable angina manifest in the preponderance of selected risk factors including diabetes mellitus and hypertension in women and smoking in men. There is no difference in age, the degree of coronary artery involvement and the subsequent management in a tertiary referral centre.

FreeStyle: a small-volume electrochemical glucose sensor for home blood glucose testing

FreeStyle accurately measures the concentration of glucose in a 300-nL volume of capillary blood obtained with significantly reduced pain from the forearm where the density of capillaries is much lower than in the fingertips. The readings are independent of temperature, of altitude (O2 pressure) and of hematocrit in the 0%-60% range. At their physiological levels, none of the often interfering constituents of blood affect the readings.

Effects of hyperbaric oxygen on ventricular performance, pulmonary blood volume, and systemic and pulmonary vascular resistance

The cardiovascular effects of hyperbaric (3 atm abs) air, 100% oxygen, and hyperbaric oxygen (HBO2) at 3 atm abs were investigated in 13 pentobarbital-anesthetized dogs. We measured heart rate, arterial pressure, pulmonary artery pressure, right atrial pressure, left and right ventricular pressure, and cardiac output. From these we determined end diastolic pressure, +/-maximal dp/dt, maximal (dp/p), end systolic elastance, cardiac work, and systemic (SVR) and pulmonary vascular resistance (PVR). Pulmonary blood volume was obtained from the mean transit time of ascorbic acid. The significant results with HBO2 were a decrease in heart rate, cardiac output, and cardiac work. All left ventricular performance indices decreased, without a change in preload or afterload. In contrast, only right ventricular -dp/dt decreased. SVR increased but PVR did not change; 100% O2 produced similar but less pronounced responses. Hyperbaric air had only mild effects. Pulmonary blood volume and lung wet/dry ratio did not change. Our data suggest that HBO2 may act by a differential effect on the autonomic innervation of the right and left ventricles. The resultant ventricular imbalance may be of clinical importance in the mechanism of pulmonary edema in patients in congestive heart failure undergoing hyperbaric therapy.

Evidence for triacylglycerol synthesis in the lumen of microsomes via a lipolysis-esterification pathway involving carnitine acyltransferases

In this study a pathway for the synthesis of triacylglycerol (TAG) within the lumen of the endoplasmic reticulum has been identified, using microsomes that had been preconditioned by depleting their endogenous substrates and then fusing them with biotinylated phosphatidylserine liposomes containing CoASH and Mg(2+). Incubating these fused microsomes with tri[(3)H] oleoylglycerol and [(14)C]oleoyl-CoA yielded microsome-associated triacylglycerol, which resisted extensive washing and had a [(3)H]:[(14)C] ratio close to 2:1. The data suggest that the precursor tri[(3)H]oleoylglycerol was hydrolyzed by microsomal lipase to membrane-bound di[(3)H]oleoylglycerol and subsequently re-esterified with luminal [(14)C]oleoyl-CoA. The accumulation of TAG within the microsomes, even when overt diacylglycerol acyltransferase (DGAT I) was inactive, is consistent with the existence of a latent diacylglycerol acyltransferase (DGAT II) within the microsomal lumen. Moreover, because luminal synthesis of TAG was carnitine-dependent and markedly reduced by glybenclamide, a potent carnitine acyltransferase inhibitor, microsomal carnitine acyltransferase appears to be essential for trafficking the [(14)C]oleoyl-CoA into the microsomal lumen for subsequent incorporation into newly synthesized TAG. This study thus provides the first direct demonstration of an enzymatic process leading to the synthesis of luminal triacylglycerol, which is a major component of very low density lipoproteins.

Stent implantation reduces restenosis in patients with suboptimal results following coronary angioplasty

BACKGROUND

Primary intracoronary stenting reduces the rate of restenosis when compared with balloon angioplasty (PTCA) in selected patients. The strategy of PTCA followed by provisional stent placement for suboptimal PTCA results may be preferable to universal stenting but has not yet been tested in a randomized trial.

METHODS

An attempt was made to obtain an optimal result with PTCA alone in 143 patients. Stenting was required in 50 patients (35%) for significant coronary dissection or PTCA failure. In the remaining 93 patients, the angiographic result was assessed immediately using on-line quantitative coronary angiography and classified as either optimal (<15% residual stenosis) or suboptimal (>/=15% residual stenosis). Sixteen patients (11%) had an optimal result from PTCA. The remaining 77 (54%) patients had a suboptimal result and were immediately randomized either to no further treatment or to the placement of a stent. The primary end-point was the rate of restenosis (>50% stenosis), assessed by quantitative coronary angiography, at 6 months.

RESULTS

Angiographic follow-up was completed in 132 patients. Restenosis occurred in 53 (36,69)% of patients with a suboptimal result randomized to PTCA alone compared with 24 (12,41)% of patients randomized to stent (P=0.023). There was no significant difference in minimal luminal diameter at follow-up between the randomized groups. The rate of restenosis was 14 (2,43)% in patients with an optimal PTCA result and 14 (5,28)% in those that required stenting.

CONCLUSIONS

Optimal angiographic results following conventional PTCA are rare and the restenosis rate following suboptimal results is high. The strategy of stenting suboptimal results is associated with a significant reduction in the rate of stenosis.

Reading numbers aloud: a measure of the limiting effect of breathlessness in patients with cancer

BACKGROUND

Progress in the treatment of breathlessness at rest or on minimum exertion in patients with cancer requires a practical and valid method of measuring symptoms. A study was undertaken to explore the practicality, repeatability, and sensitivity of reading numbers as a form of exercise test in this group of patients.

METHODS

Thirty patients with cancer and 30 age matched healthy subjects read numbers aloud as quickly and clearly as they could for 60 seconds. After five readings the maximum number of numbers read and the number read per breath was noted. This procedure was carried out twice in one day and one week later to assess within and between day repeatability. The sensitivity of the test was assessed by making measurements in 13 patients with cancer before and after drainage of their pleural effusion.

RESULTS

The concept was easily understood by all subjects. Twelve patients were unable to complete five readings in all tests due to tiredness. Compared with control subjects patients read fewer numbers in the three tests (87-89% of control) and fewer numbers per breath (59-60% of control). Repeatability was good both within and between days. After drainage of their effusion all patients were less breathless and there was an increase in both the maximum number of numbers read (23%) and the number read per breath (60%).

CONCLUSIONS

The number of numbers read and the number read per breath over 60 seconds was practical, easy to carry out, showed good repeatability within and between days and was sensitive to the improvement seen following drainage of a pleural effusion. It may be a useful measure of the limiting effect of breathlessness in this group of patients.

How well do we monitor patient satisfaction? Problems with the nation-wide patient survey

AIM

To outline and assess the accuracy and usefulness of the quarterly nation-wide patient survey of all New Zealand hospitals.

METHOD

Data generated by an improved patient survey at South Auckland Health (SAH) was used to examine some of the problems and issues pertaining to this survey: i.e. the format of the questionnaire; unintended consequences of the specific methodology employed and the usefulness of the obtained information.

RESULTS

Evidence is provided to show that the inpatient sample is not representative of the SAH patient population and that patients across different socio-demographic groups have different satisfaction rates. Additional research projects undertaken by the authors at SAH suggest that different methods of completing the questionnaire can significantly influence the results.

CONCLUSION

The nation-wide patient survey is in need of revision, if it is to be used as an effective management tool within hospitals and for the sector as a whole.