Portal vein thrombosis and pancreatic failure

We report a case of a child with portal vein thrombosis presenting with protein losing enteropathy. He later developed exocrine and endocrine pancreatic failure. This association has not been reported before.

Inhibition of retinal neovascularisation by gene transfer of soluble VEGF receptor sFlt-1

Retinal angiogenesis is a central feature of the leading causes of blindness. Current treatments for these conditions are of limited efficacy and cause significant adverse effects. In this study, we evaluated the angiostatic effect of gene transfer of the soluble VEGF receptor sFlt-1 in a mouse model of ischaemia-induced retinal neovascularisation using adenovirus and adeno-associated virus (AAV) vectors. We induced proliferative retinopathy in mice by exposure to 75% oxygen from postnatal day 7 (p7) to p12 and injected intravitreally recombinant viral vectors expressing the reporter green fluorescent protein (GFP) or vectors expressing the VEGF inhibitor sFlt-1. Efficient adenovirus-mediated GFP expression was evident in cells of the corneal endothelium and iris pigment epithelium. AAV-mediated GFP expression was evident in ganglion cells and cells of the inner nuclear layer of the retina. Vector-mediated sFlt-1 expression was confirmed by ELISA of pooled homogenised whole eyes. Injection of either vector expressing sFlt-1 resulted in a reduction in the number of neovascular endothelial cells by 56% and 52% for adenovirus and AAV vectors, respectively (P < 0.05). Local gene transfer of sFlt-1 consistently inhibits experimental retinal neovascularisation by approximately 50% and offers a powerful novel approach to the clinical management of retinal neovascular disorders.

The effects of a roster schedule change from 8- to 12-hour shifts on health and safety in a mining operation

The current study examined the impact on employee health and safety of changes to the roster system of an Australian coal mine. Absenteeism and incident frequency rate data were collected over a 33-month period that covered three different roster schedules, an 8-hour system, a 12-hour system and a 12-hour system incorporating unregulated overtime. The first change was implemented after consultation with the employee population, whereas the second was not. There were no significant negative effects of the 12-hour pattern, when compared to the 8-hour system. However, when unregulated and excessive overtime was introduced as part of the second round of changes, absenteeism rates were increased in one sector of the mine. The maintenance sector was subject to a significant increase in absenteeism rates, which may have been attributable to the excessive overtime required of the workers in that area. It is important that overtime be strictly monitored and that the employee population are involved in the process of roster change.

Catalytic oligodeoxynucleotides define a key regulatory role for early growth response factor-1 in the porcine model of coronary in-stent restenosis

Early growth response factor-1 (Egr-1) controls the expression of a growing number of genes involved in the pathogenesis of atherosclerosis and postangioplasty restenosis. Egr-1 is activated by diverse proatherogenic stimuli. As such, this transcription factor represents a key molecular target in efforts to control vascular lesion formation in humans. In this study, we have generated DNAzymes targeting specific sequences in human EGR-1 mRNA. These molecules cleave in vitro transcribed EGR-1 mRNA efficiently at preselected sites, inhibit EGR-1 protein expression in human aortic smooth muscle cells, block serum-inducible cell proliferation, and abrogate cellular regrowth after mechanical injury in vitro. These DNAzymes also selectively inhibit EGR-1 expression and proliferation of porcine arterial smooth muscle cells and reduce intimal thickening after stenting pig coronary arteries in vivo. These findings demonstrate that endoluminally delivered DNAzymes targeting EGR-1 may serve as inhibitors of in-stent restenosis.

Deaths from antidepressants in England and Wales 1993-1997: analysis of a new national database

BACKGROUND

The prescription of antidepressants has increased substantially over the last 10 years. It is therefore timely to examine trends in mortality associated with overdoses of antidepressants and to compare the relative mortality associated with different antidepressants.

METHODS

Data were derived from a newly developed national database of deaths from overdose and poisoning in England and Wales between 1993 and 1997. Age and sex specific death rates associated with overdose and poisoning with antidepressants were calculated together with numbers of deaths per 100,000 prescriptions of individual antidepressants.

RESULTS

Twenty per cent (2,503) of all deaths from overdose or poisoning were antidepressant related. The number of deaths increased by 18% between 1993 and 1997. Ninety-five per cent of deaths from antidepressants were associated with tricyclic antidepressants, particularly dothiepin and amitriptyline. Tricyclic antidepressants were associated with 5.3 deaths per 100,000 prescriptions, 4.4 for monoamine oxidase inhibitors and 0.4 for selective serotonin reuptake inhibitors. Annual death rates were highest in men aged 30-44 years (18.2 per million) and women aged 45-59 years (14.8). Death rates from antidepressants were 2.5 times higher in the most deprived fifth than in the least deprived fifth of enumeration districts.

CONCLUSIONS

Antidepressants are an important cause of death from poisoning and overdose. SSRIs and newer antidepressants are associated with <10% of the risk of death than the older antidepressants. There is a strong association between area deprivation and deaths from antidepressants.

Hemodynamic response to continuous infusion of dobutamine in Alagille's syndrome

BACKGROUND

Alagille's syndrome is a rare condition that is characterized by paucity of interlobular bile ducts and peripheral pulmonary artery stenosis. Liver transplantation in the setting of peripheral pulmonary stenosis and right ventricular hypertension seems to be associated with a higher mortality, which raises the concern that these patients are unable to increase their cardiac output in the immediate posttransplantation period to meet the demands of reperfusion and early graft dysfunction and cope with further increases in pulmonary vascular resistance.

METHOD

Cardiac catheterization was performed in 15 children with Alagille's syndrome and peripheral pulmonary artery stenosis to measure the cardiac output response to dobutamine infusion. The cardiac output was measured before and during each increment of infusion of dobutamine at 10 microg/kg/min and 20 microg/kg/min by using a thermodilution catheter placed in the pulmonary artery.

RESULTS

There was a significant change in the baseline cardiac index (P<0.001) with an infusion of 20 microg/kg/min of dobutamine with an increase from 4.4(1.0) L/min/m2 to 6.4(1.5) L/min/m2. There was, however, a wide variation between individuals in the increase in cardiac index, ranging from 7.3-95%. There was no correlation between the baseline systolic right ventricular/aortic pressure ratios and the increase in cardiac index (r=0.1086).

CONCLUSION

The increase in cardiac index, in response to dobutamine in patients with Alagille's syndrome, is independent of the more conventional measurement of the right ventricular pressure. This method of producing a hemodynamic response is closer to the response that results after liver transplantation, and thus, it may be a better way of predicting the outcome of liver transplantation in these patients.

Predictor index of mortality in dementia patients upon entry into long-term care

BACKGROUND

The purpose of this study was to develop an algorithm that predicts survival in patients with dementia upon entry into long-term care. There are, as yet, no predictive equations developed for those in the late stages of Alzheimer's disease (AD).

METHODS

This was a prospective, observational study of 132 patients with dementia (61% with AD) followed for up to 5.0 years (median of 41.0 months) after admission to a long-term care facility for dementia patients. Information on demographic characteristics, physical health, and cognitive, emotional, and behavioral characteristics was collected shortly after admission and entered as predictors of time until death in Cox regressions. Findings were used to derive an index predicting mortality.

RESULTS

There were 60 deaths among the 132 patients (45.4% mortality), with an average survival of 22.4 months in those who died. Better physical health and the presence of delusions were associated with longer survival. These two variables were aggregated into the Copper Ridge Index (CRI). Each one-point increase on the CRI was associated with a four-fold greater likelihood of death over 5 years.

CONCLUSIONS

A predictive equation incorporating measures of general physical health and delusions accurately predicted time to death in dementia patients in long-term care.

Fluorescence of dissolved organic matter as a natural tracer of ground water

The fluorescence properties of dissolved organic matter (DOM) in ground water in the Permian limestone of northeast England is determined from six monitoring boreholes, a private water supply well and from a natural resurgence in a flooded collapse doline in the environs of Darlington, County Durham, northeast England. Measurements of both protein and "fulvic-like" fluorescence was undertaken from January to December 1999. The wavelengths of fulvic-like fluorescence excitation and emission and of protein fluorescence emission were all determined to be sensitive fingerprints of organic matter fluxes through the ground water, with water within the till and within both gypsum and limestone strata deep inside the Magnesian Limestone being differentiated by these parameters. Previous research has suggested that proteins in waters are "young" in age, hence our seasonal variations suggest that we are sampling recently formed DOM. The rapid response of all deep borehole samples suggests relatively rapid ground water flow, probably through karstic cave systems developed in the gypsum and solution widened features in the dolomitic limestone. Our results suggest that use of both protein and fulvic-like fluorescence wavelength variations provides a DOM signature that can be used as a natural tracer.

Trends in deaths from drug overdose and poisoning in England and Wales 1993-1998

BACKGROUND

The study examines time trends and sociodemographic aspects of drug poisoning deaths in England and Wales.

METHODS

Socio-demographic data from the four drug groups most commonly used in poisoning were extracted, and annual age- and sex-specific mortality rates calculated. Enumeration districts were ranked into five groups on the basis of their Carstairs scores, and the number of deaths in each of the five groups was calculated.

RESULTS

There were 15720 deaths from drug poisoning between 1993 and 1998. More deaths occurred in men than in women (10 223 versus 5497). Opiates were the most commonly used drugs in deaths from drug poisoning (32 per cent of deaths); mortality rates increased twofold for these drugs. Males had higher number of deaths from opiate poisoning than females (4523 versus 1221). Highest mortality rates from opiate poisoning (77.4 per million) occurred in men aged 24-35 years. Deaths from drug poisoning were strongly associated with deprivation.

CONCLUSION

There are substantial socio-demographic differences in mortality rates from drug poisoning.

Randomized controlled trial of brief cognitive-behavioural interventions among regular users of amphetamine

AIMS

To identify whether brief cognitive-behavioural interventions are feasible among regular users of amphetamine, to assess the effectiveness of intervention overall and to pilot two- and four-session interventions.

DESIGN

Subjects were assigned randomly to individually receive a cognitive-behavioural intervention (n = 32) of either two or four sessions' duration or a self-help booklet (control condition; n = 32).

SETTING

Subjects were volunteers recruited from needle exchange schemes and treatment centres in Newcastle, Australia.

PARTICIPANTS

Regular (at least monthly) users of amphetamine were recruited.

INTERVENTION

Either four sessions of cognitive-behaviour therapy, consisting of a motivational interview and skills training in avoidance of high-risk situations, coping with craving and relapse prevention, or two sessions consisting of a motivational interview and discussion of skills.

MEASUREMENTS

The Opiate Treatment Index was the main measure at pre-treatment and 6-month follow-up.

FINDINGS

There was a significant reduction in amphetamine use among the sample as a whole, with inconclusive differences between intervention subgroups. There was a moderate overall intervention effect, with the intervention group reporting over twice the reduction in daily amphetamine use as the control group. Significantly more people in the cognitive-behavioural intervention condition abstained from amphetamine at 6-month follow-up compared to the control condition.

CONCLUSION

Brief cognitive-behavioural interventions appear feasible among regular users of amphetamine. A larger randomised controlled trial of the effectiveness of such interventions appears warranted.

Perforin-low memory CD8+ cells are the predominant T cells in normal humans that synthesize the beta -chemokine macrophage inflammatory protein-1beta

The synthesis of antiviral beta-chemokines has joined cytolysis as a potential mechanism for the control of HIV-1 infection by CD8(+) T cells. Recent evidence suggests that these two effector functions can diverge in some individuals infected with HIV-1; however, little is known about the CD8(+) T cell subsets in normal individuals that synthesize antiviral beta-chemokines. In this report, we have used mutliparameter flow cytometry to characterize the T cell subsets that secrete the antiviral beta-chemokine macrophage inflammatory protein (MIP)-1beta. These studies have shown: (i) CD8(+) cells are the predominant T cell subset that synthesizes MIP-1beta; (ii) MIP-1beta and IFN-gamma are synthesized congruently in most CD8(+) T cells; however, significant numbers of these cells synthesize only one of these effector molecules; (iii) approximately 60% of the CD8(+) T cells that synthesize MIP-1beta lack perforin; (iv) MIP-1beta is synthesized with approximately equal frequency by CD28(+) and CD28(-) subpopulations of CD8(+) T cells; (v) MIP-1beta is synthesized by three distinct CD8(+) T cell subsets defined by the expression of CD45R0 and CD62L; and (vi) MIP-1beta is not synthesized in short-term cultures of naive CD8(+) T cells. These results demonstrate substantial subset heterogeneity of MIP-1beta synthesis among CD8(+) T cells and suggest that these subsets should be evaluated as correlates of protective immunity against HIV-1.

Perceptions of labour pain by mothers and their attending midwives

AIMS

The aim of the current study was to examine the perception of pain by labouring women and their attendant midwife, from the onset of labour to delivery.

RATIONALE

Accurate measurement and appropriate management of pain is a significant problem for attendant medical and nursing personnel. Both the experience and perception of pain are regarded as subjective and are therefore difficult to measure objectively. Indeed, much of the literature reports that pain is often under- or over-estimated by nursing staff who as a consequence consistently fail to administer adequate analgesia. Few studies have specifically examined the ability of midwives to assess the pain of labouring women.

DESIGN

The short form McGill Pain Questionnaire (SF-MPQ), routinely used to assess pain in obstetric environments, was used to determine pain perception. Thirteen labouring women and nine midwives completed the SF-MPQ every 15 minutes beginning at the time of admittance to the delivery suite. Peak pain ratings for the preceding 15 minutes were obtained without reference to prior ratings or each other's scores. Further, midwives in the maternity unit of The Queen Elizabeth Hospital (TQEH), Adelaide, South Australia completed a survey investigating the cues they use to assess pain during labour.

RESULTS

On each measure of pain on the SF-MPQ, the midwives scores correlated with the mothers' scores across the entire pain range. Further analysis showed that mothers' and midwives' pain scores were similar at mild-moderate pain levels, but midwives significantly underestimated pain intensity at levels that mothers described as severe. The survey responses indicated that midwives rely on both verbal and nonverbal cues to assess pain levels.

CONCLUSIONS

The cues used by midwives to differentiate pain intensities and qualities are similar to those used in other clinical settings, but may have limited discriminatory value as pain levels become severe.

No effect of copper supplementation on biochemical markers of bone metabolism in healthy young adult females despite apparently improved copper status

OBJECTIVE

To investigate the effects of increasing Cu intakes, above the usual dietary intake, on biomarkers of bone metabolism in healthy young adult females (aged 21-28 y) over a 4 week period.

DESIGN

A double-blind, placebo-controlled randomised repeat crossover Cu supplementation trial.

SETTING

The study was conducted at the Royal Veterinary and Agricultural University (RVAU), Copenhagen, Denmark.

SUBJECTS

Sixteen healthy young adult females aged 20-28 y were recruited from among students at the RVAU.

INTERVENTION

During the 4 week intervention periods in this randomised, crossover trial (3x4 weeks with a minimum 3 week wash-out period), each subject received, in addition to their usual diet, either 3 or 6 mg elemental Cu/day as CuSO4 or a matching placebo. On the last 3 days of each dietary period 24 h urines were collected. In addition, blood was collected on the last day of each dietary period.

RESULTS

Serum Cu and erythrocyte superoxide dismutase (but not caeruloplasmin protein concentration or activity (putative indices of Cu status)) were significantly increased (P<0.05) after daily Cu supplementation with 3 and 6 mg/day for 4 weeks. Serum osteocalcin (biomarker of bone formation), urinary creatinine (Cr) concentration, urinary pyridinoline (Pyr)/Cr or deoxypyridinoline (Dpyr)/Cr excretion, or daily urinary Pyr or Dpyr excretion (biomarkers of bone resorption) were unaffected by Cu supplementation.

CONCLUSION

Copper supplementation of the usual diet in healthy young adult females, while apparently improving Cu status, had no effect on biochemical markers of bone formation or bone resorption over 4 week periods.

SPONSORSHIP

Funding from the European Commission.

Veno-occlusive disease with multi-organ involvement following actinomycin-D

Actinomycin-D (Act-D) is a rare cause of veno-occlusive disease (VOD). Between 1993 and 1998, we managed 6 patients, all male, median age 19 months (range 6-48 months) who received Act-D for Wilms' tumour (n=4), clear cell sarcoma (n=1) or rhabdomyosarcoma (n=1). VOD presented with a median platelet count of 12 x 10(9)/l, INR 3.8, fibrinogen 16 mg/l, fibrinogen degradation products (FDPs) > or =80 microg/l, aspartate aminotransferase (AST) 6922 IU/l, bilirubin 47 micromol/l. In 3 cases, transient liver dysfunction and thrombocytopenia without neutropenia had been observed after a previous course of Act-D. All six children developed encephalopathy, hepatomegaly, ascites, reversed portal flow and renal impairment. All received mechanical ventilation and two required haemofiltration. The treatment was supportive. Severe Adult Respiratory Distress Syndrome developed in 3 patients, all of whom died. 3 patients recovered. The outcome of VOD with multi-organ failure is poor. Intravascular coagulopathy precedes and characterises severe VOD during Act-D treatment.

A multicenter study of lamivudine treatment in 33 patients with hepatitis B after liver transplantation

Hepatitis B virus (HBV) infection after liver transplantation (LT) may lead to severe and rapidly progressive graft failure. Antiviral treatment may be of benefit in selected patients with recurrent hepatitis B post-LT. The aim of this prospective open-label study is to determine the safety and efficacy of lamivudine in 33 liver transplant recipients with active HBV infection. The median time from LT to study enrollment was 51 months, all patients were hepatitis B surface antigen positive, and 75% and 94% of subjects had detectable hepatitis B e antigen (HBeAg) and HBV DNA at entry, respectively. The median duration of lamivudine treatment on study was 85 weeks, during which time median HBV DNA levels became undetectable by 16 weeks and 9% of patients lost previously detectable HBeAg. Serum alanine aminotransferase (ALT) levels improved in most patients and normalized in 27% of patients with elevated values pretreatment. Serum bilirubin and albumin levels significantly improved in patients with abnormal values at entry (P <.05). Virological breakthrough was detected in 13 subjects after a median of 61 weeks of lamivudine treatment and was confirmed to be caused by YMDD mutants in all patients tested. None of the patients with virological breakthrough showed a complete loss of clinical response to lamivudine. Serum ALT and bilirubin levels in patients with and without virological breakthrough were not significantly different at last study follow-up. Study results show that lamivudine is safe and effective in liver transplant recipients with recurrent hepatitis B. However, the high rate of virological breakthrough with prolonged therapy indicates the need for further studies of combination antiviral therapy in this patient population. Our results and others further establish the improving long-term outcomes with LT for patients with hepatitis B through advances in prevention of reinfection, as well as the availability of safe and effective antiviral therapies to treat patients with HBV recurrence.

Identification and characterisation of PEX6 orthologues from plants

The sunflower (Helianthus annuus) orthologue of PEX6, an AAA ATPase essential for the biogenesis of peroxisomes in yeasts and mammals, was isolated. HaPex6p is immunologically related to Pichia pastoris Pex6p. Like other genes involved in peroxisome biogenesis and function HaPEX6 mRNA and protein levels peak in early post-germinative growth and mRNA levels also increase in senescent tissue. HaPEX6 identifies probable orthologues in Arabidopsis and rice.

Biochemical and molecular approaches to understanding protein import into peroxisomes

Peroxisomes are eukaryotic organelles that perform diverse and variable functions. Although genetic studies in yeasts and mammals have identified approximately 20 genes (PEX genes) required for the biogenesis of this important organelle, biochemical studies of protein targeting and import have lagged behind and in many cases we have no idea of the function of the PEX gene products (peroxins). Using an import assay in vitro derived from sunflower cotyledon cells and recombinant proteins, we have obtained translocation intermediates on the peroxisome import pathway and are using cross-linking to identify interacting partners. We have also used antibodies raised against human PEX14 to inhibit the import of matrix proteins in this system. To obtain homologous antibodies for inhibition experiments, to immunoprecipitate cross-linked products and to enable us to study the import pathways of peroxins we have cloned and characterized plant orthologues of three PEX genes, PEX6, PEX10 and PEX14.

Microtubule-independent motility and nuclear targeting of adenoviruses with fluorescently labeled genomes

A novel adenovirus system for analyzing the adenovirus entry pathway has been developed that contains green fluorescent protein bound to the encapsidated viral DNA (AdLite viruses). AdLite viruses enter host cells and accumulate around the nuclei and near the microtubule organizing centers (MTOC). In live cells, individual AdLite particles were observed trafficking both toward and away from the nucleus. Depolymerization of microtubules during infection prevented AdLite accumulation around the MTOC; however, it did not abolish perinuclear localization of AdLite particles. Furthermore, depolymerization of microtubules did not affect AdLite motility and did not affect gene expression from wild-type adenovirus and adenovirus-derived vectors. These data revealed that adenovirus intracellular motility and nuclear targeting can be supported by a mechanism that does not rely on the microtubule network.

Fluorescence excitation-emission matrix characterization of some sewage-impacted rivers

Fluorescence excitation-emission matrix (EEM) spectrophotometry was applied to 10 sample sites in six rivers in northeastern England, some of which were adversely impacted by sewage treatment works (STW) discharges, with the aim to investigate whether STW discharge has a significantly distinct fluorescence signature. Upstream, downstream, and STW discharge samples for two STWs demonstrated that treated sewage has a distinct fluorescence EEM, with high tryptophan and fulvic-like fluorescence intensities that are of approximately equal ratio. This signature could be seen in downstream samples. When all 10 sample locations were compared, two trend lines were apparent where STW impacted rivers plotted separately from the other sample locations. Fluorescence EEM signatures were compared to absorption at 254 nm and demonstrated to provide a better fingerprint of sewage-impacted water. It is suggested that fluorescence EEM spectrophotometry can provide a useful tool for the analysis of grab samples taken for both routine and investigative monitoring and has the potential for on-line monitoring of STW impacts on river systems.