Unlocking the Potential of Acetazolamide: A Literature Review of an Adjunctive Approach in Heart Failure Management

Background: Heart failure (HF) patients often experience persistent fluid overload despite standard diuretic therapy. The adjunctive use of acetazolamide, a carbonic anhydrase inhibitor, in combination with loop diuretics has shown promise in improving decongestion and diuretic efficacy. This literature review aims to analyze six studies evaluating the effectiveness of acetazolamide as an additive treatment for acute decompensated heart failure (ADHF) and its impact on various outcomes. Methods: We searched the PubMed database using the terms "acetazolamide heart failure". We refined our search with specific filters (as shown our PRISMA flow diagram) and exclusion criteria, narrowing down our results to five studies. We included an extra study via expert recommendation, ultimately including six studies for comprehensive analysis. Results: The review highlights the positive effects of acetazolamide on decongestion, natriuresis, and diuresis in HF patients. However, it also showcases the limitations of these trials. Discussion: While the reviewed studies demonstrate the potential benefits of acetazolamide in enhancing decongestion and diuretic efficiency, there are limitations to consider, including small sample sizes, lack of blinding, and limited external validity. Further research is needed to confirm these findings, compare acetazolamide with other diuretic combinations, and explore its effects in a broader population of heart failure patients, including those in the United States. The use of acetazolamide in HF management warrants continued investigation to optimize its role in improving decongestion and patient outcomes.

Quantum sensing for gravity cartography

The sensing of gravity has emerged as a tool in geophysics applications such as engineering and climate research1-3, including the monitoring of temporal variations in aquifers4 and geodesy5. However, it is impractical to use gravity cartography to resolve metre-scale underground features because of the long measurement times needed for the removal of vibrational noise6. Here we overcome this limitation by realizing a practical quantum gravity gradient sensor. Our design suppresses the effects of micro-seismic and laser noise, thermal and magnetic field variations, and instrument tilt. The instrument achieves a statistical uncertainty of 20 E (1 E = 10-9 s-2) and is used to perform a 0.5-metre-spatial-resolution survey across an 8.5-metre-long line, detecting a 2-metre tunnel with a signal-to-noise ratio of 8. Using a Bayesian inference method, we determine the centre to ±0.19 metres horizontally and the centre depth as (1.89 -0.59/+2.3) metres. The removal of vibrational noise enables improvements in instrument performance to directly translate into reduced measurement time in mapping. The sensor parameters are compatible with applications in mapping aquifers and evaluating impacts on the water table7, archaeology8-11, determination of soil properties12 and water content13, and reducing the risk of unforeseen ground conditions in the construction of critical energy, transport and utilities infrastructure14, providing a new window into the underground.

A community challenge to evaluate RNA-seq, fusion detection, and isoform quantification methods for cancer discovery

The accurate identification and quantitation of RNA isoforms present in the cancer transcriptome is key for analyses ranging from the inference of the impacts of somatic variants to pathway analysis to biomarker development and subtype discovery. The ICGC-TCGA DREAM Somatic Mutation Calling in RNA (SMC-RNA) challenge was a crowd-sourced effort to benchmark methods for RNA isoform quantification and fusion detection from bulk cancer RNA sequencing (RNA-seq) data. It concluded in 2018 with a comparison of 77 fusion detection entries and 65 isoform quantification entries on 51 synthetic tumors and 32 cell lines with spiked-in fusion constructs. We report the entries used to build this benchmark, the leaderboard results, and the experimental features associated with the accurate prediction of RNA species. This challenge required submissions to be in the form of containerized workflows, meaning each of the entries described is easily reusable through CWL and Docker containers at https://github.com/SMC-RNA-challenge. A record of this paper's transparent peer review process is included in the supplemental information.

Crowdsourced mapping of unexplored target space of kinase inhibitors

Despite decades of intensive search for compounds that modulate the activity of particular protein targets, a large proportion of the human kinome remains as yet undrugged. Effective approaches are therefore required to map the massive space of unexplored compound-kinase interactions for novel and potent activities. Here, we carry out a crowdsourced benchmarking of predictive algorithms for kinase inhibitor potencies across multiple kinase families tested on unpublished bioactivity data. We find the top-performing predictions are based on various models, including kernel learning, gradient boosting and deep learning, and their ensemble leads to a predictive accuracy exceeding that of single-dose kinase activity assays. We design experiments based on the model predictions and identify unexpected activities even for under-studied kinases, thereby accelerating experimental mapping efforts. The open-source prediction algorithms together with the bioactivities between 95 compounds and 295 kinases provide a resource for benchmarking prediction algorithms and for extending the druggable kinome.

PBRM1 Deficiency Confers Synthetic Lethality to DNA Repair Inhibitors in Cancer

Inactivation of Polybromo 1 (PBRM1), a specific subunit of the PBAF chromatin remodeling complex, occurs frequently in cancer, including 40% of clear cell renal cell carcinomas (ccRCC). To identify novel therapeutic approaches to targeting PBRM1-defective cancers, we used a series of orthogonal functional genomic screens that identified PARP and ATR inhibitors as being synthetic lethal with PBRM1 deficiency. The PBRM1/PARP inhibitor synthetic lethality was recapitulated using several clinical PARP inhibitors in a series of in vitro model systems and in vivo in a xenograft model of ccRCC. In the absence of exogenous DNA damage, PBRM1-defective cells exhibited elevated levels of replication stress, micronuclei, and R-loops. PARP inhibitor exposure exacerbated these phenotypes. Quantitative mass spectrometry revealed that multiple R-loop processing factors were downregulated in PBRM1-defective tumor cells. Exogenous expression of the R-loop resolution enzyme RNase H1 reversed the sensitivity of PBRM1-deficient cells to PARP inhibitors, suggesting that excessive levels of R-loops could be a cause of this synthetic lethality. PARP and ATR inhibitors also induced cyclic GMP-AMP synthase/stimulator of interferon genes (cGAS/STING) innate immune signaling in PBRM1-defective tumor cells. Overall, these findings provide the preclinical basis for using PARP inhibitors in PBRM1-defective cancers. SIGNIFICANCE: This study demonstrates that PARP and ATR inhibitors are synthetic lethal with the loss of PBRM1, a PBAF-specific subunit, thus providing the rationale for assessing these inhibitors in patients with PBRM1-defective cancer. GRAPHICAL ABSTRACT: http://cancerres.aacrjournals.org/content/canres/81/11/2888/F1.large.jpg.

Key Parameters of Tumor Epitope Immunogenicity Revealed Through a Consortium Approach Improve Neoantigen Prediction

Many approaches to identify therapeutically relevant neoantigens couple tumor sequencing with bioinformatic algorithms and inferred rules of tumor epitope immunogenicity. However, there are no reference data to compare these approaches, and the parameters governing tumor epitope immunogenicity remain unclear. Here, we assembled a global consortium wherein each participant predicted immunogenic epitopes from shared tumor sequencing data. 608 epitopes were subsequently assessed for T cell binding in patient-matched samples. By integrating peptide features associated with presentation and recognition, we developed a model of tumor epitope immunogenicity that filtered out 98% of non-immunogenic peptides with a precision above 0.70. Pipelines prioritizing model features had superior performance, and pipeline alterations leveraging them improved prediction performance. These findings were validated in an independent cohort of 310 epitopes prioritized from tumor sequencing data and assessed for T cell binding. This data resource enables identification of parameters underlying effective anti-tumor immunity and is available to the research community.

Abstract 1058: Targeting chromatin remodeling-associated genetic vulnerabilities in cancer: PBRM1 defects are synthetic lethal with PARP and ATR inhibitors

Aim: Polybromo-1 (PBRM1), a specific subunit of the pBAF chromatin remodeling complex, is frequently inactivated in cancer. For example, 40% of clear cell Renal Cell Carcinoma (ccRCC) and 15% of cholangiocarcinoma present deleterious PBRM1 mutations. There is currently no precision medicine-based therapeutic approach that targets PBRM1 defects. To identify novel, targeted therapeutic strategies for PBRM1-defective cancers, we carried out high-throughput functional genomics and drug screenings followed by in vitro and in vivo validation studies.

Methods: High-throughput siRNA-drug sensitization and drug sensitivity screens evaluating > 150 cancer-relevant small molecules in dose-response were performed in Pbrm1 siRNA-transfected mouse embryonic stem cells (mES) and isogenic PBRM1-KO or -WT HAP1 cells, respectively. After identification of PBRM1-selective small molecules, revalidation was carried out in a series of in-house-generated isogenic models of PBRM1 deficiency - including 786-O (ccRCC), A498 (ccRCC), U2OS (osteosarcoma) and H1299 (non-small cell lung cancer) human cancer cell lines - and non-isogenic ccRCC models, using multiple clinical compounds. Mechanistic dissection was performed using immunofluorescence, RT-qPCR, western blotting, DNA fiber assay, transcriptomics, proteomics and DRIP-sequencing to evaluate markers of DNA damage response (DDR), replication stress and cell-autonomous innate immune signaling. Preclinical data were integrated with TCGA tumor data.

Results: Parallel high-throughput drug screens independently identified PARP inhibitors (PARPi) as being synthetic lethal with PBRM1 defects - a cell type-independent effect which was exacerbated by ATR inhibitors (ATRi) and which we revalidated in vitro in isogenic and non-isogenic systems and in vivo in a xenograft model. PBRM1 defects were associated with increased replication fork stress (higher γH2AX and RPA foci levels, decreased replication fork speed and increased ATM checkpoint activation), R-loop accumulation and enhanced genomic instability in vitro; these effects were exacerbated upon PARPi exposure. In patient tumor samples, we also found that PBRM1-mutant cancers possessed a higher mutational load. Finally, we found that ATRi selectively activated the cGAS/STING cytosolic DNA sensing pathway in PBRM1-deficient cells, resulting in increased expression of type I interferon genes.

Conclusion: PBRM1-defective cancer cells present increased replication fork stress, R-loop formation, genome instability and are selectively sensitive to PARPi and ATRi through a synthetic lethal mechanism that is cell type-independent. Our data provide the pre-clinical rationale for assessing PARPi as a monotherapy or in combination with ATRi or immune-modulating agents in molecularly-selected patients with PBRM1-defective cancers.

Citation Format: Roman Merial Chabanon, Daphné Morel, Léo Colmet-Daage, Thomas Eychenne, Nicolas Dorvault, Ilirjana Bajrami, Marlène Garrido, Suzanna Hopkins, Cornelia Meisenberg, Andrew Lamb, Theo Roumeliotis, Samuel Jouny, Clémence Astier, Asha Konde, Geneviève Almouzni, Jyoti Choudhary, Jean-Charles Soria, Jessica Downs, Christopher J. Lord, Sophie Postel-Vinay. Targeting chromatin remodeling-associated genetic vulnerabilities in cancer: PBRM1 defects are synthetic lethal with PARP and ATR inhibitors [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 1058.

Integrative Genomics Analysis Identifies ACVR1B as a Candidate Causal Gene of Emphysema Distribution

Genome-wide association studies (GWAS) have identified multiple associations with emphysema apicobasal distribution (EABD), but the biological functions of these variants are unknown. To characterize the functions of EABD-associated variants, we integrated GWAS results with 1) expression quantitative trait loci (eQTL) from the Genotype Tissue Expression (GTEx) project and subjects in the COPDGene (Genetic Epidemiology of COPD) study and 2) cell type epigenomic marks from the Roadmap Epigenomics project. On the basis of these analyses, we selected a variant near ACVR1B (activin A receptor type 1B) for functional validation. SNPs from 168 loci with P values less than 5 × 10^-5 in the largest GWAS meta-analysis of EABD were analyzed. Eighty-four loci overlapped eQTL, with 12 of these loci showing greater than 80% likelihood of harboring a single, shared GWAS and eQTL causal variant. Seventeen cell types were enriched for overlap between EABD loci and Roadmap Epigenomics marks (permutation P < 0.05), with the strongest enrichment observed in CD4⁺, CD8⁺, and regulatory T cells. We selected a putative causal variant, rs7962469, associated with ACVR1B expression in lung tissue for additional functional investigation, and reporter assays confirmed allele-specific regulatory activity for this variant in human bronchial epithelial and Jurkat immune cell lines. ACVR1B expression levels exhibit a nominally significant association with emphysema distribution. EABD-associated loci are preferentially enriched in regulatory elements of multiple cell types, most notably T-cell subsets. Multiple EABD loci colocalize to regulatory elements that are active across multiple tissues and cell types, and functional analyses confirm the presence of an EABD-associated functional variant that regulates ACVR1B expression, indicating that transforming growth factor-β signaling plays a role in the EABD phenotype. Clinical trial registered with www.clinicaltrials.gov (NCT00608764).

PARP inhibition enhances tumor cell-intrinsic immunity in ERCC1-deficient non-small cell lung cancer

The cyclic GMP-AMP synthase/stimulator of IFN genes (cGAS/STING) pathway detects cytosolic DNA to activate innate immune responses. Poly(ADP-ribose) polymerase inhibitors (PARPi) selectively target cancer cells with DNA repair deficiencies such as those caused by BRCA1 mutations or ERCC1 defects. Using isogenic cell lines and patient-derived samples, we showed that ERCC1-defective non-small cell lung cancer (NSCLC) cells exhibit an enhanced type I IFN transcriptomic signature and that low ERCC1 expression correlates with increased lymphocytic infiltration. We demonstrated that clinical PARPi, including olaparib and rucaparib, have cell-autonomous immunomodulatory properties in ERCC1-defective NSCLC and BRCA1-defective triple-negative breast cancer (TNBC) cells. Mechanistically, PARPi generated cytoplasmic chromatin fragments with characteristics of micronuclei; these were found to activate cGAS/STING, downstream type I IFN signaling, and CCL5 secretion. Importantly, these effects were suppressed in PARP1-null TNBC cells, suggesting that this phenotype resulted from an on-target effect of PARPi on PARP1. PARPi also potentiated IFN-γ-induced PD-L1 expression in NSCLC cell lines and in fresh patient tumor cells; this effect was enhanced in ERCC1-deficient contexts. Our data provide a preclinical rationale for using PARPi as immunomodulatory agents in appropriately molecularly selected populations.

Abstract B051: Facilitating translational research with interactive tools for immuno-oncology data

With the explosive growth in data and results from immuno-oncology (IO) studies, improved ways to easily share, integrate and explore available data and results are needed. The Cancer Research Institute (CRI) iAtlas (www.cri-iatlas.org) is an interactive web-based platform and set of analytic tools for studying interactions between tumors and the immune microenvironment. These tools allow researchers to explore associations among a variety of immune characterizations as well as with genomic and clinical phenotypes. The initial version of CRI iAtlas is based on an analysis performed by The Cancer Genome Atlas (TCGA) Research Network on the TCGA data set comprising over 10,000 tumor samples and 33 tumor types (Thorsson et al., 2018). The platform will be expanded to include other immunogenomic data sets and workflows. In the TCGA analysis, each tumor sample was scored for a variety of computationally estimated immune-based readouts, including immune cell composition, adaptive cell receptor repertoire, neoantigen load, and expression of genes coding for immunomodulatory proteins. Immune-based subtypes, spanning multiple tumor types, were identified. The web tool allows researchers to explore the data readouts as well as the relation between them in individual TCGA tumor types and across the global immune subtypes identified in the study. CRI iAtlas is made possible through a collaboration between CRI, Sage Bionetworks, and the Institute for Systems Biology. The main feature of the iAtlas web tool is the iAtlas Explorer, which provides several Analysis Modules to explore and visualize results. Each module presents information organized by theme, with multiple views and interactive controls to enhance and extend the information included in the original manuscript figures. Sample Group Overview: summaries of selected groups (including six immune subtypes that span cancer tissue types and molecular subtypes); Tumor Microenvironment: overall immune infiltrate and relative immune cell proportions in selected sample groups; Immune Feature Trends: distributions of immune readouts across selected groups, and associations between readouts within groups; Clinical Outcomes: trends of and associations with survival outcomes across sample groups based on immune characteristics; Immunomodulators: expression trends of genes that code for immunomodulating proteins, including checkpoint proteins. In response to community feedback, we are extending the iAtlas portal with two modules, one allowing researchers to classify their own RNAseq samples into immune subtypes, and the other allowing researchers to upload their own sample categories for analysis with the tool. As the resource evolves, we expect that the CRI iAtlas will help to accelerate discovery and improve patient outcomes by providing researchers greater access to immunogenomics data to better understand the immunologic characteristics of the tumor microenvironment and its potential impact on patient responses to immunotherapy. Reference: Thorsson et al. The immune landscape of cancer. Immunity 2018;48(4):812-30.e14. doi: 10.1016/j.immuni.2018.03.023.

Citation Format: Vesteinn Thorsson, James A. Eddy, Andrew Lamb, David L. Gibbs, Ilya Shmulevich, Justin Guinney. Facilitating translational research with interactive tools for immuno-oncology data [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr B051.

Blood eosinophil count thresholds and exacerbations in patients with chronic obstructive pulmonary disease

BACKGROUND

Eosinophilic airway inflammation in patients with chronic obstructive pulmonary disease (COPD) is associated with exacerbations and responsivity to steroids, suggesting potential shared mechanisms with eosinophilic asthma. However, there is no consistent blood eosinophil count that has been used to define the increased exacerbation risk.

OBJECTIVE

We sought to investigate blood eosinophil counts associated with exacerbation risk in patients with COPD.

METHODS

Blood eosinophil counts and exacerbation risk were analyzed in patients with moderate-to-severe COPD by using 2 independent studies of former and current smokers with longitudinal data. The Genetic Epidemiology of COPD (COPDGene) study was analyzed for discovery (n = 1,553), and the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) study was analyzed for validation (n = 1,895). A subset of the ECLIPSE study subjects were used to assess the stability of blood eosinophil counts over time.

RESULTS

COPD exacerbation risk increased with higher eosinophil counts. An eosinophil count threshold of 300 cells/μL or greater showed adjusted incidence rate ratios for exacerbations of 1.32 in the COPDGene study (95% CI, 1.10-1.63). The cutoff of 300 cells/μL or greater was validated for prospective risk of exacerbation in the ECLIPSE study, with adjusted incidence rate ratios of 1.22 (95% CI, 1.06-1.41) using 3-year follow-up data. Stratified analysis confirmed that the increased exacerbation risk associated with an eosinophil count of 300 cells/μL or greater was driven by subjects with a history of frequent exacerbations in both the COPDGene and ECLIPSE studies.

CONCLUSIONS

Patients with moderate-to-severe COPD and blood eosinophil counts of 300 cells/μL or greater had an increased risk exacerbations in the COPDGene study, which was prospectively validated in the ECLIPSE study.

The Immune Landscape of Cancer

We performed an extensive immunogenomic analysis of more than 10,000 tumors comprising 33 diverse cancer types by utilizing data compiled by TCGA. Across cancer types, we identified six immune subtypes-wound healing, IFN-γ dominant, inflammatory, lymphocyte depleted, immunologically quiet, and TGF-β dominant-characterized by differences in macrophage or lymphocyte signatures, Th1:Th2 cell ratio, extent of intratumoral heterogeneity, aneuploidy, extent of neoantigen load, overall cell proliferation, expression of immunomodulatory genes, and prognosis. Specific driver mutations correlated with lower (CTNNB1, NRAS, or IDH1) or higher (BRAF, TP53, or CASP8) leukocyte levels across all cancers. Multiple control modalities of the intracellular and extracellular networks (transcription, microRNAs, copy number, and epigenetic processes) were involved in tumor-immune cell interactions, both across and within immune subtypes. Our immunogenomics pipeline to characterize these heterogeneous tumors and the resulting data are intended to serve as a resource for future targeted studies to further advance the field.

RNA sequencing identifies novel non-coding RNA and exon-specific effects associated with cigarette smoking

BACKGROUND

Cigarette smoking is the leading modifiable risk factor for disease and death worldwide. Previous studies quantifying gene-level expression have documented the effect of smoking on mRNA levels. Using RNA sequencing, it is possible to analyze the impact of smoking on complex regulatory phenomena (e.g. alternative splicing, differential isoform usage) leading to a more detailed understanding of the biology underlying smoking-related disease.

METHODS

We used whole-blood RNA sequencing to describe gene and exon-level expression differences between 229 current and 286 former smokers in the COPDGene study. We performed differential gene expression and differential exon usage analyses using the voom/limma and DEXseq R packages. Samples from current and former smokers were compared while controlling for age, gender, race, lifetime smoke exposure, cell counts, and technical covariates.

RESULTS

At an adjusted p-value <0.05, 171 genes were differentially expressed between current and former smokers. Differentially expressed genes included 7 long non-coding RNAs that have not been previously associated with smoking: LINC00599, LINC01362, LINC00824, LINC01624, RP11-563D10.1, RP11-98G13.1, AC004791.2. Secondary analysis of acute smoking (having smoked within 2-h) revealed 5 of the 171 smoking genes demonstrated an acute response above the baseline effect of chronic smoking. Exon-level analyses identified 9 exons from 8 genes with significant differential usage by smoking status, suggesting smoking-induced changes in isoform expression.

CONCLUSIONS

Transcriptomic changes at the gene and exon levels from whole blood can refine our understanding of the molecular mechanisms underlying the response to smoking.

A portable magneto-optical trap with prospects for atom interferometry in civil engineering

The high precision and scalable technology offered by atom interferometry has the opportunity to profoundly affect gravity surveys, enabling the detection of features of either smaller size or greater depth. While such systems are already starting to enter into the commercial market, significant reductions are required in order to reach the size, weight and power of conventional devices. In this article, the potential for atom interferometry based gravimetry is assessed, suggesting that the key opportunity resides within the development of gravity gradiometry sensors to enable drastic improvements in measurement time. To push forward in realizing more compact systems, techniques have been pursued to realize a highly portable magneto-optical trap system, which represents the core package of an atom interferometry system. This can create clouds of 10⁷ atoms within a system package of 20 l and 10 kg, consuming 80 W of power.This article is part of the themed issue 'Quantum technology for the 21st century'.

C₁-Pathways in Methyloversatilis universalis FAM5: Genome Wide Gene Expression and Mutagenesis Studies

Methyloversatilis universalis FAM5 utilizes single carbon compounds such as methanol or methylamine as a sole source of carbon and energy. Expression profiling reveals distinct sets of genes altered during growth on methylamine vs methanol. As expected, all genes for the N-methylglutamate pathway were induced during growth on methylamine. Among other functions responding to the aminated source of C₁-carbon, are a heme-containing amine dehydrogenase (Qhp), a distant homologue of formaldehyde activating enzyme (Fae3), molybdenum-containing formate dehydrogenase, ferredoxin reductase, a set of homologues to urea/ammonium transporters and amino-acid permeases. Mutants lacking one of the functional subunits of the amine dehydrogenase (ΔqhpA) or Δfae3 showed no growth defect on C₁-compounds. M. universalis FAM5 strains with a lesion in the H₄-folate pathway were not able to use any C₁-compound, methanol or methylamine. Genes essential for C₁-assimilation (the serine cycle and glyoxylate shunt) and H₄MTP-pathway for formaldehyde oxidation showed similar levels of expression on both C₁-carbon sources. M. universalis FAM5 possesses three homologs of the formaldehyde activating enzyme, a key enzyme of the H₄MTP-pathway. Strains lacking the canonical Fae (fae1) lost the ability to grow on both C₁-compounds. However, upon incubation on methylamine the fae1-mutant produced revertants (Δfae1^R), which regained the ability to grow on methylamine. Double and triple mutants (Δfae1^RΔfae3, or Δfae1^RΔfae2 or Δfae1^RΔfae2Δfae3) constructed in the revertant strain background showed growth similar to the Δfae1^R phenotype. The metabolic pathways for utilization of methanol and methylamine in Methyloversatilis universalis FAM5 are reconstructed based on these gene expression and phenotypic data.

Trauma experience in the UK and Ireland: analysis of orthopaedic training using the FHI eLogbook

Surgical trainees routinely provide evidence of their training and operative experience for assessment. National comparative data on the number of procedures performed during training was previously unavailable in the UK. Since 2003 every trainee in Trauma and Orthopaedics (T&O) in the UK and Ireland has submitted data recording their operative experience electronically via the Faculty of Health Informatics (FHI) eLogbook. This provides detailed data on trainee, trainer, hospital and training programme performance. This data has been analysed for trauma surgery. By March 2007 there were 1053 T&O Specialist Registrars with operations logged. Trauma operations performed and uploaded during the previous 3 years have been included. Each trainee's work is analysed by 'year-in-training' (YIT, 1-6). Data on levels of supervision and potentially missed opportunities (where the trainee was present but assisted rather than performed the operation) was analysed. The mean number of trauma operations performed annually by trainees was 109, 120, 110, 122, 98 and 84 (total 643) for YIT 1-6, respectively. 22% of the operations at which a trainee was present were potentially missed opportunities. A high level of experience is gained in hip fracture surgery (121 operations performed), intramedullary nailing (38) and ankle (47) stabilisation over the 6 years of training. However, the mean number of tendon repairs (18), tension band wires (13), external fixators (12) and children's supracondylar fracture procedures (9) performed is low. We also report figures for complex fracture stabilisation. The eLogbook remains a powerful tool which can provide accurate information to support in-depth analysis of trainees, trainers, and training programmes. Based on this analysis, we suggest 'standard setting' to identify trainees performing fewer operations than required during their training. We have also established a baseline which can be used to identify the consequences of changes to length of training and working hours.

Large mammal turnover in Africa and the Levant between 1.0 and 0.5 Ma

Faunal change at the Early-Middle Pleistocene boundary in Europe has long been a topic for discussion. However, analyses of large mammal turnover at this time in Africa have been lacking, largely because of the low number of sites dated to this interval. Recent work, particularly in the last 10 years, has resulted in a much larger published sample of sites and we synthesize these data in this paper. In our multivariate (TWINSPAN) analyses of African and Levantine large mammal faunas we found that localities were subdivided by geographic regions, not by age. There were some small-scale changes with the appearance or extinction of particular taxa, but there was no large-scale turnover such as that seen in Europe. The Levant was included as a possible route for faunal interchange with east Africa, but no similarities were found between these areas. It therefore appears that the modern zoogeographic separation of the Levant and north Africa into the Palaearctic region and sub-Saharan Africa into the African region can be traced back to at least the Early-Middle Pleistocene boundary.

Differential deficits in expression recognition in gene-carriers and patients with Huntington's disease

Previous studies in symptomatic patients and asymptomatic gene-carriers of Huntington's disease (HD) reported a differential deficit in the recognition of facial expressions of disgust. This impairment may point to involvement of the basal ganglia in the recognition of disgust. In this study, we compared the performance of 20 patients with symptoms of HD, 20 gene-carriers of HD and 20 healthy controls on two tests of facial expressions in order to further investigate the role of the basal ganglia in disgust recognition. Recognition of fear, rather than disgust, was most severely impaired in the patients, who were also impaired at recognising expressions of anger, disgust and sadness. Direct testing for a differential deficit in disgust at the group level (and at the level of individual HD cases) revealed that the patients were in fact significantly more impaired on the other negative expressions than on disgust. The gene-carriers were not impaired on any expression, although there was a trend for the gene-carriers to be poorer at recognising fearful faces than the controls. We argue that the expression recognition performance of the patients and gene-carriers simply reflects differences in task difficulty, rather than dysfunction of any mechanisms dedicated to specific emotions. In contrast to previous studies in patients or gene-carriers of HD, our findings provide no evidence for a role of the basal ganglia in the recognition of disgust and cast doubt on whether results from HD patients and gene-carriers can be used in support of a double dissociation between recognition of disgust and fear.

Experience with an XML/HTTP-based federative approach to develop a hospital-wide clinical information system

The authors present a two-year experience with an approach aimed at federating applications into a component-based hospital-wide clinical information system. Recognizing the need for better integration, clearer separation of knowledge from applications, as well as the necessity to respect and integrate the diversity of roles in a healthcare network, a strategy was implemented that included the development of a shared vision, organizational changes to promote appropriation at all levels, and the elaboration and maintenance of a common architecture and terminology by an instrumental technical group. Choices for federative technologies were in part based on their level of acceptance and potential to evolve. XML was used as the syntactic framework and HTTP as the transfer protocol. Within twelve months, the shared vision was developed, the architecture was specified, the key central components implemented, incorporated into the applications, and applications teams started producing shareable services using XML and HTTP.

Rapid prenatal diagnosis of chromosome aneuploidies by interphase fluorescence in situ hybridization: a one-year clinical experience with high-risk and urgent fetal and postnatal samples

OBJECTIVES

To evaluate the clinical utility of rapid prenatal and postnatal detection of common chromosome aneuploidies by interphase fluorescence in situ hybridization (FISH) analysis with DNA probes.

DESIGN

Four hundred and seventy-seven high-risk and/or urgent amniotic fluid, chorionic villus and fetal and postnatal blood samples were prospectively examined by FISH with probes specific for chromosomes 13, 18, 21, X, and Y and results were reported within 48 hours. All FISH results were followed by conventional chromosome analysis, if possible.

SETTING

Cytogenetic service laboratory at the tertiary referral center, Rigshospitalet in Copenhagen.

MAIN OUTCOME MEASURES

The fraction of clinically significant chromosome aneuploidies that was detected by FISH analysis, and the fraction of terminations that was based on FISH and ultrasound results rather than on conventional cytogenetic results.

RESULTS

The FISH assay detected 76% of the clinically significant chromosome abnormalities as determined by subsequent cytogenetic analysis. Seventy-two percent of the terminations of the chromosomally abnormal pregnancies were based on FISH and ultrasound results rather than on conventional cytogenetic results.

CONCLUSION

FISH analysis is a clinically useful adjunctive tool to conventional pre- and postnatal cytogenetic analysis. The assay rapidly detects the majority of clinically significant chromosome abnormalities, thus facilitating difficult pre- and postnatal clinical decisions.

Patients' perceptions of the Odstock Dropped Foot Stimulator (ODFS)

OBJECTIVE

To determine the perceived benefit, pattern and problems of use of the Odstock Dropped Foot Stimulator (ODFS) and the users' opinion of the service provided.

DESIGN

Questionnaire sent in a single mailshot to current and past users of the ODFS. Returns were sent anonymously.

SETTING

Outpatient-based clinical service.

SUBJECTS

One hundred and sixty-eight current and 123 past users with diagnoses of stroke (CVA), multiple sclerosis (MS), incomplete spinal cord injury (SCI), traumatic brain injury (TBI) and cerebral palsy (CP).

INTERVENTION

Functional electrical stimulation (FES) to correct dropped foot in subjects with an upper motor neuron lesion, using the ODFS.

MAIN OUTCOME MEASURES

Purpose-designed questionnaire.

RESULTS

Return rate 64% current users (mean duration of use 19.5 months) and 43% past users (mean duration of use 10.7 months). Principal reason cited for using equipment was a reduction in the effort of walking. Principal reasons identified for discontinuing were an improvement in mobility, electrode positioning difficulties and deteriorating mobility. There were some problems with reliability of equipment. Level of service provided was thought to be good.

CONCLUSION

The ODFS was perceived by the users to be of considerable benefit. A comprehensive clinical follow-up service is essential to achieve the maximum continuing benefit from FES-based orthoses.