Health-related quality-of-life outcomes from adult cochlear implantation: a cross-sectional survey

PURPOSE

The purpose of this study was to examine the extent to which cochlear implants and related rehabilitation improve health-related quality-of-life (HRQoL) and social participation for deafened adults and their partners.

METHOD

A cross-sectional survey was used to examine HRQoL and social participation experiences of 202 deafened adults (148 with implants and 54 without) and 136 partners associated with cochlear implant clinics in Australia and New Zealand. Respondents completed a mailed survey consisting of the Assessment of Quality of Life instrument (a utility instrument), the Participation Scale and questions concerning their socioeconomic status. Both univariate and multivariate analyses were performed.

RESULTS

Controlling for socioeconomic factors, people with cochlear implants reported improved HRQoL and social participation when compared with non-implantees. Implantees reported a relative gain in health utility of 50%, and a relative improvement in social participation of 31%. Such differences were not reported by partners, although patient and partner HRQoL were weakly correlated.

CONCLUSION

The results of this cross-sectional study suggest that cochlear implantation contributes significantly to improvements for deafened adults in everyday communication settings and makes a major contribution to their HRQoL. Nonetheless, when compared with population-based studies, this population continues to report considerably reduced quality of life. Partners also report significantly reduced quality of life when compared to population norms.

Endoscopic transanal resection of rectal adenomas using the urological resectoscope

OBJECTIVE

Large sessile rectal adenomas are often difficult to excise and several different techniques have been described. This study evaluates the results of adenoma excision by endoscopic transanal resection using the urological resectoscope by a single surgeon in a UK district general hospital.

METHOD

Between January 1989 and November 2004, data on all patients treated by endoscopic transanal resection of benign rectal tumours using a urological resectoscope (ETAR) were prospectively collected and analysed.

RESULTS

Forty patients (50% male, median age 72 years) underwent a total of 81 endoscopic transanal resections. The tumour characteristics were: size > 2 cm (83%), location in lower 2/3 of rectum (83%) and extensive circumferential carpet-like appearances (13%). Fifty percent of the patients required only one procedure to achieve clearance. Mean operative time was 26 min (range 10-65 min). Seventy-eight percent of the patients were discharged home within 24 h. Postoperative morbidity was 8% and in-hospital mortality was zero. Histology revealed severe dysplasia in 48% of the tumours and five patients were incidentally found to have foci of rectal adenocarcinoma. With a median follow-up of 47 months (range 2-162 months), local recurrences occurred in 13% (n = 5) of patients. All, except one, were treated successfully with further endoscopic transanal resections.

CONCLUSION

ETAR is simple and safe for managing rectal adenomas.

Elucidation of the metabolic and elimination pathways of panobinostat (LBH589) using [14C]-panobinostat

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Background: Panobinostat (PAN), a hydroxamic acid derivative, is a potent pan-deacetylase inhibitor, demonstrating anti-tumor activities in a wide variety of preclinical models and showing promising clinical activity. This study elucidates the metabolic and elimination pathways of PAN using [14C]-PAN. Methods: Four patients with advanced cancer received a single oral 20 mg dose of [14C]-PAN (50 μCi). Whole blood, plasma, urine, and feces were collected over 7 days. Total radioactivity was measured in blood, plasma, and excreta by liquid scintillation counting. PAN and its metabolite concentrations in plasma and excreta were measured by LC-MS/MS and HPLC with radiometric detection. Patients were monitored for safety. Results: The single PAN dose was well tolerated with no clinically significant laboratory or ECG abnormalities observed. PAN had a rapid oral absorption [median Tmax 0.8 h (range, 0.5–1 h)] and moderate elimination (median t1/2 31 h). The median t1/2 for blood and plasma radioactivity was 54 and 75 hours, respectively. Mass balance was achieved with ≥87% of the administered radioactivity being recovered in the excreta of all patients after 7 days. 44–77% and 29–51% of the dose was recovered in the feces and urine, respectively. Unchanged PAN accounted for ≤3% of the administered dose in the feces, suggesting good oral absorption. The most prominent metabolic pathways involved modifications of the hydroxamic acid (HA) side chain, to form an amide via reduction, carboxylic acid via either hydrolysis or one- and two-carbon (M1) shortening of the HA side chain. Oxygenation and glucuronidation were also observed. PAN accounted for ≤9% of the total radioactivity AUC. The most abundant circulating metabolites in plasma were the glucuronide of M1 (19%) and carbamoyl glucuronide of PAN (13%). At least 40 metabolites, many at trace levels, were observed circulating in plasma. Conclusions: PAN and its metabolites are equally excreted in the urine and feces. Elimination of PAN is primarily by metabolism via reduction, hydrolysis, oxidation and glucuronidation. The balanced elimination and absence of a single major route of PAN metabolism suggest that clinical drug-drug interactions are unlikely with PAN.

[Table: see text]

Effects of local anesthetic and a nonsteroidal antiinflammatory drug on pain responses of dairy calves to hot-iron dehorning

This study examined the effects of a nonsteroidal antiinflammatory agent (NSAID) on physiological responses of calves immediately after hot-iron dehorning (DH) and during the time that local anesthetic (LA) wears off (2 to 3 h) after this procedure. Forty-six calves (33 +/- 0.3 d of age) were randomly assigned to 6 treatments: hot-iron DH versus sham DH with either no pain mitigation, LA alone, or LA with NSAID (i.v. Meloxicam). Eye temperature (measured using infrared thermography) was recorded every 5 min for 3 h after treatments. Heart rate (HR) and heart rate variability (HRV) were recorded continuously; for analysis of HRV, short segments of 512 interbeat intervals were examined. After DH without LA or NSAID, HR increased by 35 +/- 3.0 beats/min in the first 5 min and remained elevated above baseline for 3 h. The HRV around the time of DH did not differ between treatments; however, the root mean square of successive differences decreased from 68 to 41 +/- 12.6 ms immediately following DH without pain relief, suggesting a decrease in vagal tone at this time. Between 2 and 3 h following DH with LA, there was a decrease in eye temperature (-0.6 +/- 0.1 degrees C), an increase in HR (8 +/- 3.0 beats per min) and changes in HRV. Changes in HRV at this time included a decreased high-frequency power and an increase in the low-frequency power and low-frequency/high-frequency ratio, indicating a change in sympatho-vagal balance. The changes in eye temperature, HR, and HRV between 2 and 3 h following DH with LA indicated the onset of pain coinciding with the time that the LA effects wear off. In addition, this study demonstrated that the combination of LA and NSAID mitigated the onset of pain responses when the LA wanes.

How to obtain excellent response rates when surveying physicians

This paper outlines ways to maximize response rates to surveys by summarizing the most relevant literature to date and demonstrating how these techniques have resulted in consistently high rates of return in family practice research. We describe the methodology used in recent surveys of physicians conducted by the Centre for Studies in Family Medicine through its Thames Valley Family Practice Research Unit, located in London, Ontario, Canada and funded by the Ontario Ministry of Health and Long-Term Care. The identification and implementation of these techniques to maximize response rates is critical, as primary health care researchers often rely on information gathered through questionnaires to study physicians' practice profiles, experiences and attitudes. Four separate and distinct mailed surveys of physicians using a modified Dillman approach were conducted from 2001 to 2004. The sampling strategies, topics, types of questions and response formats of these surveys varied. The first survey did not use any incentives or recorded delivery/registered mail and received a response rate of 48%. In sharp contrast, the other three surveys obtained responses rates of 76%, 74%, 74%, respectively, achieved through the use of gift certificates and recorded delivery/registered mail. Sending a survey by recorded delivery/registered mail tends to result in the survey package being given priority in the physicians' incoming mail at the practice. Gift certificates partially compensate physicians for time spent completing the survey and recognition of the time required is appreciated. The response rates achieved provide strong evidence to support the use of monetary incentives and recorded delivery/registered mail (along with the Dillman approach) in survey research. It is anticipated that this evidence will be used by other researchers to justify requests for funding to cover the costs associated with incentives and recorded delivery/registered mail. We recommend the use of these strategies to maximize response rates and improve the quality of this type of primary health care research.

Cardiac sympathetic nerve activity during kainic acid-induced limbic cortical seizures in rats

We sought to define changes in cardiac sympathetic nerve activity that occur during seizures. We studied kainic acid-induced limbic cortical seizures in urethane-anesthetized rats using cardiac sympathetic nerve, blood pressure, and electrocardiography (ECG) recordings. We studied changes in ventilation rate before and during seizures. Cardiac sympathetic nerve activity was increased during limbic cortical seizures. The modest increases were similar to changes induced by nitroprusside infusion. The normal relation of cardiac sympathetic nerve activity to ventilation rate was lost during seizure activity. Changes in cardiac sympathetic nerve activity caused by changes in ventilation rate became unpredictable, and could be extreme. We conclude that the modest changes in cardiac sympathetic nerve activity contribute to the predominantly parasympathetic effects on the heart during limbic cortical seizures and periods of asphyxia. Further, ventilation rate changes might be associated with large sudden increases or decreases in cardiac sympathetic outflow during seizures.

Analysis of breeding and pathology helps refine management practices of a large-scale N'-ethyl-N'-nitrosourea mouse mutagenesis programme

N'-ethyl-N'-nitrosourea (ENU) is a powerful germline mutagen used in conjunction with phenotype-driven screens to generate novel mouse mutants. ENU also induces genetic lesions in somatic cells and dosage requires optimization between maximum germline mutation rate versus induced sterility and tumourigenesis that compromise the welfare and fecundity of the ENU-treated males. Here, we present our experience with BALB/cAnNCrl and C57BL/6J mice in terms of the pathology induced by ENU and its impact on breeding. In both mouse strains, morbidity and mortality rises with ENU dose. In more than 75% of C57BL/6J males, morbidity and mortality were attributable to the development of malignant T-lymphoblastic lymphoma. Approximately 50% of ENU-treated BALB/cAnNCrl males develop early malignant T-lymphoblastic lymphoma, but the cohort that survives develops late-onset lung carcinoma. Within strains, the latency of these clinically important tumour(s) was not dosage-dependent, but the proportion of mice developing tumours and consequently removed from the breeding programme increased with ENU dosage. The median number of offspring per ENU-treated C57BL/6J male in standard matings with C3H/HeH females decreased with increasing dosage. The two most important underlying causes for lower male fecundity were increased infertility in the highest dosage group and reduced numbers of litters born to the remaining fertile C57BL/6J males due to a higher incidence of morbidity. These findings have allowed us to refine breeding strategy. To maximize the number of offspring from each ENU-treated male, we now rotate productive males between two cages to expose them to more females. This optimizes the number of mutation carrying offspring while reducing the number of ENU-treated males that must be generated.

Superficial zone chondrocytes in normal and osteoarthritic human articular cartilages synthesize novel truncated forms of inter-alpha-trypsin inhibitor heavy chains which are attached to a chondroitin sulfate proteoglycan other than bikunin

OBJECTIVE

We have examined the occurrence of the inflammation-associated inter-alpha-trypsin inhibitor (IalphaI) components, bikunin, heavy chain (HC)1 and HC2 in normal cartilage and osteoarthritis (OA) cartilage and synovial fluids.

DESIGN/METHODS

Cartilage extracts from normal donors and late-stage OA patients, and synovial fluids from OA patients were studied by Western blot with multiple antibodies to bikunin, HC1 and HC2. Cell and matrix localization was determined by immunohistochemistry and mRNA by RT-PCR.

RESULTS

Bikunin.chondroitin sulfate (CS) and IalphaI were abundant in OA cartilages, but virtually undetectable in normal. In both OA and normal cartilages, HCs were largely present in a novel C-terminally truncated 50-kDa form, with most, if not all of these being attached to CS on a proteoglycan other than bikunin. Synovial fluids from OA patients contained bikunin.CS and full-length (approximately 90 kDa) HCs linked to hyaluronan (HA) as HC.HA (SHAP.HA). Immunohistochemistry showed intracellular and cell-associated staining for bikunin and HCs, consistent with their synthesis by superficial zone chondrocytes. PCR on multiple human normal and OA cartilage samples detected transcripts for HC1 and HC2 but not for bikunin. In OA cartilages, immunostaining was predominantly matrix-associated, being most intense in regions with a pannus-like fibrotic overgrowth.

CONCLUSION

The truncated structure of HCs, their attachment to a proteoglycan other than bikunin, PCR data and intracellular staining are all consistent with synthesis of HC1 and HC2 by human articular chondrocytes. The presence of bikunin.CS and IalphaI in OA cartilage, but not in normal, appears to be due to diffusional uptake and retention through fibrillated (but not deeply fissured) cartilage surfaces.

Combined endoscopic trans-anal rectal mucosal ablation and laparoscopic partial proctectomy for ulcerative colitis--a new procedure

A case is reported in which endoscopic trans-anal rectal mucosal ablation (ETARMA) was employed in combination with laparoscopic partial proctectomy in order to decrease complications associated with open surgery.

Biomechanical evaluation of 10 configurations of a small external fixator set

The small AO (Synthes, Paoli, Pa) external fixator is a valuable tool for the treatment of distal radius fractures. The construct has many possible bar and pin configurations. However, there are no data regarding which construct is optimal with respect to strength and versatility. We tested 10 configurations to determine bending stiffness, rotation, and axial loading. Although slight variations were found between constructs for bending and rotation forces, there were marked differences between constructs during axial loading. A frame design without bar-to-bar clamps was determined stiffest. However, this configuration may be more difficult to apply and adjust in the clinical setting. Although an "ideal" construct applicable to all fracture types does not exist, knowledge of the strengths of various configurations may allow for optimization of fixator assembly to meet specific clinical needs.

Broadening of activity with flow across neural structures

Synfire chains have long been suggested as a substrate for perception and information processing in the nervous system. However, embedding activation chains in a densely connected nervous matrix risks spread of signal that will obscure or obliterate the message. We used computer modeling and physiological measurements in rat hippocampus to assess this problem of activity broadening. We simulated a series of neural modules with feedforward propagation and random connectivity within each module and from one module to the next. We found that activity broadened as it propagated from one module to the next. This occurred over a wide array of parameters with greater broadening seen with increasing excitatory-excitatory synaptic strength. Activity broadening correlated positively with propagation velocity. Multi-electrode measurements of activity propagation in disinhibited CA1 slice demonstrated broadening of about 50% over 1 mm. Such broadening is a problem for information transfer that must be dealt with in a fully functioning nervous system.

Adapting the learning-cycle to enrich undergraduate neuroscience education for all students

A learning-cycle approach to science instruction is not new to science educators (Karplus, 1977; Kolb, 1984; Bergquist, 1991; Zollman, 1990; Allard and Barman, 1994). Somewhat less known, however, is the usefulness of this approach for creating lab activities for a broad audience of undergraduates. The following paper presents a brief overview of a laboratory activity that can be adapted for use by instructors of introductory neuroscience courses. The three-hour activity is geared towards tapping key elements of the learning-cycle approach, with a particular emphasis on the exploration phase of the model. Students work as members of small teams to explore a contemporary issue involving memory and gain hands-on experience from the outset, to which conceptual information is then added during lecture the following week. The approach is in marked contrast to the more traditional practice in the sciences where laboratory activities generally serve to punctuate already presented lecture material.

Data mining through simulation

Data integration is particularly difficult in neuroscience; we must organize vast amounts of data around only a few fragmentary functional hypotheses. It has often been noted that computer simulation, by providing explicit hypotheses for a particular system and bridging across different levels of organization, can provide an organizational focus, which can be leveraged to form substantive hypotheses. Simulations lend meaning to data and can be updated and adapted as further data come in. The use of simulation in this context suggests the need for simulator adjuncts to manage and evaluate data. We have developed a neural query system (NQS) within the NEURON simulator, providing a relational database system, a query function, and basic data-mining tools. NQS is used within the simulation context to manage, verify, and evaluate model parameterizations. More importantly, it is used for data mining of simulation data and comparison with neurophysiology.

Oral vasodilators for primary Raynaud's phenomenon

BACKGROUND

Many different drugs have been suggested for the symptomatic treatment of primary Raynaud's phenomenon. Apart from calcium channel blockers, which are considered the drugs of choice, the evidence of the effects of alternative pharmacological treatments is limited.

OBJECTIVES

To assess the effects of various drugs with vasodilator actions on primary Raynaud's phenomenon.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched 24 July 2007), and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 3, 2007). In addition, we searched MEDLINE (January 1966 to July 2007), EMBASE (1980 to July 2007) and reference lists of relevant articles. We contacted pharmaceutical companies. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials evaluating the effects of oral formulations of any drug with vasodilator effects on subjective symptoms in primary Raynaud's phenomenon. Treatment with, or comparison with, calcium channel blockers was not assessed in this review.

DATA COLLECTION AND ANALYSIS

Both authors assessed the trials for inclusion and their quality. One author (BV) extracted the data MS checked the results. Data extraction included adverse events. we contacted trial authors for missing data.

MAIN RESULTS

Eight studies involving 290 participants were included. Two trials examined the effects of captopril, the rest were single trials on single drugs. All comparisons were with placebo. The methodological quality of most trials was poor. Enalapril was associated with a small increase in the frequency of attacks per week (difference in means 0.8; 95% CI 0.43 to 1.17). The difference between the intervention groups on a subjective improvement score was non-significant. There was a significant effect of buflomedil on the frequency of attacks per week (weighted mean difference (WMD) -8.8; 95% CI -17.55 to -0.09), but there was no evidence of effect on the severity score. The proportion with fewer attacks was significantly higher on moxisylyte than on placebo (relative risk (RR) 4.33; 95% CI 1.36 to 13.81). For captopril, beraprost, dazoxiben and ketanserin there was no evidence of an effect on the frequency, severity or duration of attacks. Beraprost and moxisylyte gave significantly more adverse effects than placebo.

AUTHORS' CONCLUSIONS

Poor methodological quality, small sample sizes and the limited data available resulted in low precision of the statistical results and limited value of the overall results . The overall results show that there is no evidence for an effect of vasodilator drugs on primary Raynaud's phenomenon.

Beyond the printed page: physiology education without a textbook?

Pedagogical innovations, ideas, and outcomes designed to enhance student learning in physiology courses are encouraged by our professional organizations and are actively discussed at conferences and in Advance in Physiological Education. Here, we report our experiment with freely available internet-based material as a substitute for the textbook for a single chapter on muscle physiology in a sophomore-level Human Physiology course. Student reactions to the textbookless curriculum were registered with the use of a questionnaire. Their responses indicated that they enjoyed the online material (animations, images, reviews, etc.), the emphasis on important concepts, and the variety of resources. Furthermore, students were almost unanimous in their praise for such pedagogical approaches to science education. Yet, students were reluctant to part with their textbooks. We believe that with subsequent iterations of this course we will be more successful at further separating the learning experience from the textbook. Reliance on freely available material may eventually relieve students from the burden of purchasing a costly textbook.

Early weaning is related to weight and rate of weight gain in infancy

BACKGROUND

Evidence relating to the effect of early weaning on infant weight and weight gain is conflicting. The aim of this paper is to compare weight and weight gain in two groups of infants; one group weaned before 4 months (early weaned), the other weaned at 4 months or after.

METHODS

Feeding practices were assessed through semistructured interviews with mothers of 1-year-old infants. Weight at birth, 8 weeks and 7 months were taken from an administrative database (Child Health System), and an additional measure of weight was taken at 14 months.

RESULTS

Infants weaned early were heavier at 7 and 14 months, and gained more weight between 8 weeks and 14 months, even after breastfeeding was controlled for.

CONCLUSION

Early weaning is related to rapid weight gain in infancy. This may have implications for childhood obesity.

Comparison of fixed-dose rosiglitazone/metformin combination therapy with sulphonylurea plus metformin in overweight individuals with Type 2 diabetes inadequately controlled on metformin alone

AIM

This 52-week, randomized, double-blind, parallel-group study was designed to compare rosiglitazone/metformin fixed-dose combination therapy with combination sulphonylurea plus metformin therapy in overweight individuals with inadequately controlled type 2 diabetes mellitus.

METHOD

Individuals with inadequate glycaemic control (HbA (1c)> or =7%) while on metformin monotherapy (> or =0.85 g/day) entered a 4-week run-in period during which they received metformin 2 g/day. At the end of the run-in, individuals with fasting plasma glucose > or =7.0 mmol/l were randomized to treatment with metformin (2 g/day) and either rosiglitazone (4 mg/day; RSG+MET [N=294]) or a sulphonylurea (glibenclamide 5 mg/day or gliclazide 80 mg/day; SU+MET [N=302]). Medications were up-titrated to maximum tolerated doses (rosiglitazone 8 mg, glibenclamide 15 mg or gliclazide 320 mg plus metformin 2 g/day) during the first 12 weeks of double-blind treatment. The primary efficacy end point was the change in HbA (1c) from baseline after 52 weeks of treatment.

RESULTS

RSG+MET was non-inferior to SU+MET with respect to changes in HbA (1c) after one year of treatment (DeltaHbA (1c)= -0.78% and -0.86%, respectively; treatment difference =0.09%, 95% CI=-0.08, 0.25). The HbA (1c) reductions with RSG+MET, but not SU+MET, were accompanied by significant improvements in measures of beta-cell function including proinsulin:insulin ratio. The degree of beta-cell failure was significantly greater with SU+MET compared to RSG+MET as measured by the coefficient of failure (0.543 vs. 0.055 HbA (1c)%/year, respectively, p=0.0002). The proportion of individuals who experienced hypoglycaemic events was significantly (p<0.0001) lower with RSG+MET (6%) than with SU+MET (30%). Diastolic ambulatory blood pressure and cardiovascular biomarkers (high-sensitivity C-reactive protein and plasminogen activator inhibitor-1) were also reduced following one year of treatment with RSG+MET but not SU+MET. Both treatments were generally well tolerated.

CONCLUSION

Fixed-dose combination therapy with rosiglitazone/metformin is non-inferior to sulphonylurea plus metformin combination therapy in reducing HbA (1c) over one year of treatment. Improvements in measures of beta-cell function suggest that the improvements in glycaemic control may be better maintained in long-term therapy with the rosiglitazone/metformin combination.

Non-invasive measurement of stress in dairy cows using infrared thermography

The possibility that changes in eye temperature, measured using infrared thermography (IRT), can detect stress in dairy cattle was examined by six different stimulations of the stress axis. Six cows were given six treatments in a random Latin-square design: 1) Control (saline) 2) ACTH (0.05 mg Synacthen) 3) bCRH (20 mug) 4) bCRH (40 mug) 5) epinephrine (1.4 mug /kg liveweight) and 6) social isolation. Treatments were administered at time 0 and blood samples were taken at -30, -15, 0, 5, 10, 15, 20, 30, 40, 50, 60, 75, 90, 120, 180 and 240 min except for epinephrine which was sampled at -30, -15, -10, -5, 0, 2, 5, 10, 15, 20, 30, 45, 60, 90 and 120 min. Core body temperature was recorded every 10 min and eye images collected every 2 min. Eye temperature and cortisol increased following catheterization (P<0.05). ACTH increased following bCRH, cortisol increased following ACTH and bCRH (P<0.001) and NEFA increased following epinephrine (P<0.001). Core body temperature was unaffected by treatments. Eye temperature was unaffected by CRH and epinephrine but was higher 30 and 60 min following control and ACTH (P<0.001). Our results provide evidence that exogenous HPA stimulation does not increase eye temperature. The increases in eye temperature following catheterization however raise the possibility that a cognitive component may be required for an eye temperature response to occur.

Drug resistance and neurotransmitter receptors of nematodes: recent studies on the mode of action of levamisole

Here we review recent studies on the mode of action of the cholinergic anthelmintics (levamisole, pyrantel etc.). We also include material from studies on the free living nematode Caenorhabditis elegans. The initial notion that these drugs act on a single receptor population, while attractive, has proven to be an oversimplification. In both free living and parasitic nematodes there are multiple types of nicotinic acetylcholine receptor (nAChR) on the somatic musculature. Each type has different (sometimes subtly so) pharmacological properties. The implications of these findings are: (1) combinations of anthelmintic that preferentially activate a broad range of nAChR types would be predicted to be more effective; (2) in resistant isolates of parasite where a subtype has been lost, other cholinergic anthelmintics may remain effective. Not only are there multiple types of nAChR, but relatively recent research has shown these receptors can be modulated; it is possible to increase the response of a parasite to a fixed concentration of drug by altering the receptor properties (e.g. phosphorylation state). These findings offer a potential means of increasing efficacy of existing compounds as an alternative to the costly and time consuming development of new anthelmintic agents.

Epigenetic regulation of tumor necrosis factor alpha

Tumor necrosis factor alpha (TNF-alpha) is a potent cytokine which regulates inflammation via the induction of adhesion molecules and chemokine expression. Its expression is known to be regulated in a complex manner with transcription, message turnover, message splicing, translation, and protein cleavage from the cell surface all being independently regulated. This study examined both cell lines and primary cells to understand the developmental regulation of epigenetic changes at the TNF-alpha locus. We demonstrate that epigenetic modifications of the TNF-alpha locus occur both developmentally and in response to acute stimulation and, importantly, that they actively regulate expression. DNA demethylates early in development, beginning with the hematopoietic stem cell. The TNF-alpha locus migrates from heterochromatin to euchromatin in a progressive fashion, reaching euchromatin slightly later in differentiation. Finally, histone modifications characteristic of a transcriptionally competent gene occur with myeloid differentiation and progress with differentiation. Additional histone modifications characteristic of active gene expression are acquired with stimulation. In each case, manipulation of these epigenetic variables altered the ability of the cell to express TNF-alpha. These studies demonstrate the importance of epigenetic regulation in the control of TNF-alpha expression. These findings may have relevance for inflammatory disorders in which TNF-alpha is overproduced.

Evaluation of the core outcome measure in whiplash

STUDY DESIGN

Reanalysis of data derived from longitudinal cohort studies.

OBJECTIVE

To comprehensively evaluate the psychometric properties of a 5-item version of the Core Outcome Measure in people with whiplash.

SUMMARY OF BACKGROUND DATA

The 7-item Core Outcome Measure was initially proposed as a brief health outcome measure for use in low back pain. To date, this measure has not been comprehensively assessed in a whiplash population. METHOD.: Data were sourced from 3 separate whiplash cohorts (total 481) encompassing acute, early chronic, and late-chronic whiplash among primary care and insurance populations. Subjects completed a 5-item version of the Core Outcome Measure for whiplash (Core Whiplash Outcome Measure [CWOM]), the Functional Rating Index, Neck Disability Index, SF-36, and perceived recovery questionnaires at baseline and short and long-term follow-up periods. Psychometric evaluation of the CWOM included assessing questionnaire responses, internal consistency, construct validity, and internal and external responsiveness.

RESULTS

Internal consistency was excellent at all stages of whiplash (Cronbach alpha = 0.76 in the acute stage and 0.83 in the late-chronic stage). Convergent validity was observed between the CWOM and Functional Rating Index (Pearson r = 0.81), Neck Disability Index (Pearson r = 0.76), and SF-36 physical health summary measure (Pearson r = -0.65). Divergent validity was observed between the CWOM and SF-36 mental health summary measure (Pearson r = -0.45). The internal and external responsiveness of the CWOM was similar to other neck-specific outcome measures.

CONCLUSIONS

We recommend the 5-item CWOM as a brief clinical measure for whiplash because it is quick to administer and score, and has excellent measurement properties. The CWOM may need to be supplemented with other questionnaires (e.g., when assessment of psychological or emotional health is required).

Responsiveness of pain and disability measures for chronic whiplash

STUDY DESIGN

Cohort study.

OBJECTIVE

To evaluate the responsiveness of common pain and disability measures in a cohort of patients with chronic whiplash.

SUMMARY OF BACKGROUND DATA

Pain and disability are routinely measured in clinical practice and clinical research. However, to date, a head-to-head comparison of competing measures for whiplash patients has not been performed.

METHODS

Pain (pain intensity, bothersomeness, and SF-36 bodily pain score) and disability (Patient Specific Functional Scale, Neck Disability Index, Functional Rating Index, Copenhagen Scale, and SF-36 physical summary) measures were completed by 132 patients with chronic whiplash at baseline and then again after 6 weeks together with an 11-point global perceived effect scale. Internal responsiveness was evaluated by calculating effect sizes and standardized response means, and external responsiveness by correlating change scores with global perceived effect scores and by ROC curves.

RESULTS

The ranking of responsiveness was consistent across the different analyses. Pain bothersomeness was more responsive than pain intensity, which was more responsive than the SF-36 pain measure. The Patient Specific Functional Scale was the most responsive disability measure, followed by the spine-specific measures, with the SF-36 physical summary measure the least responsive.

CONCLUSION

Pain bothersomeness and the Patient Specific Functional Scale provide the most responsive measures of pain and disability, respectively, in patients with chronic whiplash.

Determinants of neuropsychological and behavioural outcomes in early childhood survivors of congenital heart disease

AIMS

To evaluate the relative effect of cyanosis, surgical interventions and family processes on neuropsychological and behavioural outcomes in 4-year-old survivors of serious congenital heart disease (CHD).

METHODS

90 children with a range of cyanotic and acyanotic conditions, who underwent either corrective or palliative surgery, completed a neuropsychological and behavioural evaluation. Families of participants were also profiled by evaluation of maternal mental health, worry, social support, parenting style and family functioning.

RESULTS

Compromised neuropsychological outcomes were associated with a combination of cyanotic conditions and open-heart surgery, but this was not exacerbated by having a complex, palliative, status. Both cyanotic and acyanotic conditions were associated with specific sensorimotor delays, regardless of method of the correction. Only children with complex conditions and palliative interventions seemed at risk of poor behavioural outcomes; indeed, children with cyanosis with complete repair showed favourable behavioural outcomes compared with controls. Multivariate analyses highlighted the sometimes greater relevance of family processes (eg parenting style, maternal mental health and worry), rather than disease or surgical factors, in predicting especially behavioural outcomes.

CONCLUSIONS

The findings (1) suggest a more complex relationship between cyanosis, surgical methods of correction, neuropsychological and behavioural outcomes than previously charted, (2) highlight that family processes may be aetiologically more important than disease and surgical factors, and (3) indicate specific targets for secondary prevention programmes for this at-risk population.

Calibration of base flow separation methods with streamflow conductivity

The conductivity mass-balance (CMB) method can be used to calibrate analytical base flow separation methods. The principal CMB assumptions are base flow conductivity is equal to streamflow conductivity at lowest flows, runoff conductivity is equal to streamflow conductivity at highest flows, and base flow and runoff conductivities are assumed to be constants over the period of record. To test the CMB assumptions, fluid conductivities of ground water, surface runoff, and streamflow were measured during wet and dry conditions in a 12-km(2) stream basin. Ground water conductivities at wells varied an average of 6% from dry to wet conditions, while stream conductivities varied 58%. Shallow ground water conductivity varied significantly with distance from the stream, with lowest conductivities of 87 microS/cm near the divide, a maximum of 520 microS/cm 59 m from the stream, and 215 microS/cm 22 m from the stream. Runoff conductivities measured in three rain events remained nearly constant, with lower conductivities of 35 microS/cm near the divide and 50 microS/cm near the stream. The CMB method was applied to the records from 10 USGS stream-gauging stations in Texas, Kentucky, Georgia, and Florida to calibrate the USGS base flow separation technique, HYSEP, by varying the time parameter 2N*. There is a statistically significant relationship between basin areas and calibrated values of 2N*, expressed as N = 0.46A(0.44), with N in days and A in km(2). The widely accepted relationship N = 0.83A(0.2) is not valid for these basins. Other analytic methods can also be calibrated with the CMB method.

Indwelling trans-anastomotic rectal tubes in colorectal surgery: a survey of usage in UK and Ireland

BACKGROUND

The use of rectal tubes in colorectal surgery appears to be a matter of individual choice, with little documented evidence to support their use. This study assesses the current practice of rectal tubes amongst consultant members of the Association of Coloproctology of Great Britain & Ireland (ACPGBI).

METHODS

A piloted questionnaire was sent to practising ACPGBI consultant members listed in the 2003-04 directory. Statistical analysis was performed using SPSS software and Fishers exact test.

RESULTS

Three hundred and thirty-nine replies were received from 579 posted questionnaires (response rate = 58.5%). Rectal tubes were used by 116 (35%) of responding surgeons. Rectal tubes were more commonly used by surgeons with less than 10 years practice as a consultant (P < 0.005). The main indications for tube placement were following ileo-anal or colonic pouch surgery (73%), after any anterior resection (36%) (rectal tubes were reserved for only low anterior resections by 16% of surgeons) and in the rectal stump after total or subtotal colectomy for acute colitis (11%). Twenty-three percent of these practising surgeons would use a rectal tube as an alternative to a diverting stoma, predominantly in selected patients following ileo-anal pouch surgery. A Foley catheter was the commonest type of tube used (70%) and this was usually placed above the anastomosis (80%). Rectal tubes were left in situ for a median of 5 days (range = 1-13 days). Three surgeons (2.6%) reported serious complications including tube perforation of the bowel or anastomosis. Several different mechanisms were suggested for the purpose and functioning of the rectal tube, the commonest being to decompress the rectum and/or pouch.

CONCLUSION

Rectal tube placement is simple and safe and is used by a third of colorectal surgeons in UK and Ireland. Given their simplicity, the efficacy of rectal tubes in reducing local anastomotic complications requires further evaluation within the confines of a randomised controlled trial.

Hemispheric differences in protein kinase C betaII levels in the rat amygdala: baseline asymmetry and lateralized changes associated with cue and context in a classical fear conditioning paradigm

The amygdala is critically important for fear learning, and specific kinases have been implicated as contributors to the mechanisms that underlie learning. We examined levels of protein kinase C betaII (PKC betaII) in the left and right lateral and basolateral nuclei (LA/BLA) of the amygdala from animals that were classically fear conditioned with tones as cues and footshocks. Groups consisted of animals that received neither tones nor shocks, paired tones and shocks, or unpaired tones and shocks. At 1 h after conditioning, some animals from each group were used for biochemical measurements of PKC betaII levels and other animals were given probe trials to assess freezing behavior to cue and context. The levels of PKC betaII were greater in the left hemisphere in animals receiving neither tones nor shocks and animals receiving paired tones and shocks. PKC betaII levels were greater in the right hemisphere of animals receiving randomly presented tones and shocks. Freezing times to cue were long (>80% of probe trial time) in both the paired tone/shock and randomly unpaired tone/shock groups. Freezing times to context were long in the unpaired tone/shock group, but not the paired tone/shock group. Correlational analyses showed that freezing times to context, but not cue, precisely predicted the right/left relation of PKC betaII levels in the LA/BLA: the greater the time spent freezing to context, the greater the increase in right hemisphere PKC betaII levels. We conclude that fear conditioning causes hemisphere and input specific increases in PKC betaII in the rat LA/BLA.

Structural basis for the nuclear protein import cycle

Transport of macromolecules between the nuclear and cytoplasmic compartments through NPCs (nuclear pore complexes) is mediated by soluble transport factors that are commonly members of the importin-β superfamily. In the nuclear protein import cycle, importin-β binds cargo in the cytoplasm (usually via the importin-α adaptor) and transports it through NPCs with which it interacts transiently by way of NPC proteins (‘nucleoporins’) that contain distinctive FG (Phe-Gly) sequence repeats. In the nucleus, Ran-GTP binds to importin-β, dissociating the import complex. The importin-β–Ran-GTP complex recycles to the cytoplasm, whereas importin-α is recycled by the importin-β family member CAS (cellular apoptosis susceptibility protein) complexed with Ran-GTP. Cytoplasmic RanGAP (Ran GTPase-activating protein) dissociates these complexes, freeing the importins for another import cycle. Crystallography and biochemical and cellular studies have enabled a molecular description of the transport cycle to be developed and tested using protein engineering and computer modelling. Importin-β family members are elongated flexible molecules that adapt their shape to encircle their cargoes. Ran-GTP binds at three sites along importin-β and CAS, locking the molecules into a rigid conformation that is unable to bind cargoes effectively. Interactions between transport factors and key nucleoporins (such as Nup1p, Nup2p and Nup50) accelerate the formation and dissolution of many of these complexes.

Repeatable focal seizure suppression: A rat preparation to study consequences of seizure activity based on urethane anesthesia and reversible carotid artery occlusion

Seizures can be associated with serious systemic complications (even death) due to autonomic nervous system or respiratory dysfunction. Clinical and laboratory studies examining the relationship between seizures and autonomic dysfunction have not resolved important questions, such as whether autonomic changes result primarily from muscle activation or from limbic cortical seizure activity, because correlational studies are limited by opportunities to observe seizures and study seizure spread. We describe a rat preparation that will greatly facilitate such studies. First, we show that systemic kainic acid in urethane anesthetized animals causes a period of status epilepticus as it does in ketamine/xylazine anesthetized or awake animals, but with a critical distinction: limbic cortical seizures occur without neocortical involvement. No paralytic agents are necessary to keep animals "safely" in a stereotaxic frame because there are not motor convulsions, yet animals continue to breathe on their own. Second, we describe the construction of a simple device to permit remote reversible unilateral or bilateral common carotid artery occlusion, and show that seizure activity in dorsal hippocampal regions can be unilaterally or bilaterally suppressed during periods of occlusion. Using this preparation, we found an increase in vagus nerve activity and a decrease in mean arterial pressure during suppression of right dorsal hippocampal seizures. By contrast, suppression of left dorsal hippocampal seizures caused no changes in vagus nerve activity and a small increase in mean arterial pressure. This preparation will be invaluable for defining the dynamic interactions of limbic brain regions and the interactions of limbic brain regions with autonomic brain regions.

Continuous stimulation of transected distal nerves fails to prolong action potential propagation

Wallerian degeneration of the distal portion of a cut nerve is considered irreversible. A possible reason for degeneration is lack of axon stimulation in the distal, cut nerves. We hypothesized greater rates of stimulation of distal nerve stumps would prolong time to action potential propagation failure, and uncut nerves would not be damaged by implanted nerve stimulators. We also hypothesized that action potentials measured from the body of the sciatic nerve would show similar response as motor-evoked potentials measured in the muscles innervated by branches of the sciatic nerve. We implanted a nerve stimulator onto distal cut sciatic nerves of rats and recorded motor-evoked potentials. Three groups were stimulated at 1 Hz (once per second), 0.1 Hz (once per 10 seconds), and 0.01 Hz (once per 100 seconds) respectively. Motor-evoked potentials progressively declined after nerve transection, failing faster at 1 Hz (26.8 hours +/- 108 minutes) and 0.1 Hz (22 hours +/- 66 minutes) compared with stimulation at 0.01 Hz (36.75 hours +/- 83 minutes). Intact axons were not damaged by implanted nerve stimulators. Action potentials recorded directly from nerves were equivalent to motor- evoked potentials. Failure of motor-evoked potential transmission in a transected nerve is accelerated by a greater rate of continuous stimulation of the distal stump.

Endoscopic alternatives in managing anastomotic strictures of the colon and rectum

BACKGROUND

The development of anastomotic strictures following colorectal surgery is a frequent problem, but commonly used treatments (e.g. dilatation or revisional surgery) are often ineffective. This study assessed the efficacy of self-expanding metallic stents (SEMS) and endoscopic transanal resection of strictures (ETARS) in managing high-grade benign colorectal anastomotic strictures after the failure of first-line therapies.

METHODS

All patients with biopsy-proven benign anastomotic strictures (luminal diameter<7 mm) following colorectal surgery, seen in the period April 1995-October 2004, were treated with either SEMS or ETARS.

RESULTS

In the study period, we treated 10 patients (7 men) of median age 71 years. Ten ETARS procedures were performed in six patients, with a mean operating time of 42 minutes and a median hospital stay of 1 day. Early complications of ETARS included: re- operation for bleeding, asymptomatic anastomotic perforation and technical failure in an acutely angulated stricture. SEMS were successfully inserted into five patients (including two with failed ETARS) without any early complications. Overall, nine patients have had satisfactory longterm outcomes (median follow-up, 29 months; range, 3-75 months).

CONCLUSIONS

SEMS and ETARS are simple, safe and effective methods in treating high-grade anastomotic strictures.

Self-expanding metallic stents in the treatment of benign colorectal disease: indications and outcomes

OBJECTIVE

The use of stents for benign colorectal obstruction is considered controversial because of a lack of data and perceived high failure and complication rates. The aim of this study was to evaluate the indications and outcomes following stent placement for benign colorectal disease in a UK district general hospital and to review the published literature.

PATIENTS AND METHODS

Between 1997 and 2004, 11 of 90 attempted stent insertions were performed for benign colorectal disease (diverticular disease, 4; anastomotic strictures, 4; idiopathic rectal stricture, 1; rectal endometriosis, 1; caecal volvulus, 1). Complications and outcomes were analysed from a prospective database.

RESULTS

Stent insertion was successful in nine patients. Early complications occurred in two patients (both with diverticular disease): one patient failed to decompress and needed a colostomy and laparotomy was performed in a second patient who developed peritonitis after five days although no stent perforation of the bowel was identified. Two patients were successfully decompressed and underwent subsequent elective surgery with full bowel preparation. Stent placement resulted in symptomatic improvement in three out of four patients with anastomotic strictures (allowing closure of defunctioning stomas) and in the one patient with an idiopathic rectal stricture. Stent migration occurred in two of these patients without recurrence of symptoms. Stent fracture occurred in one patient, who remained symptomatic.

CONCLUSIONS

Self-expanding metallic stents are an effective treatment for benign colorectal obstructions, especially anastomotic strictures with long-term patency. Stents should be avoided in acute diverticular disease because of a higher incidence of complications.