Synergism of Anti-CGRP Monoclonal Antibodies and OnabotulinumtoxinA in the Treatment of Chronic Migraine: A Real-World Retrospective Chart Review

BACKGROUND

Many patients with chronic migraine do not achieve clinically meaningful improvement in their headache frequency with monotherapy. The burden associated with chronic migraine calls for a multifaceted treatment approach targeting multiple aspects of migraine pathophysiology.

OBJECTIVE

The aim of this study was to evaluate the effect of concurrent anti-calcitonin gene-related peptide (CGRP) monoclonal antibody (mAb) and onabotulinumtoxinA (onabot) treatment on median monthly migraine days (MMD) in patients with chronic migraine, through a retrospective study.

METHODS

The electronic medical records of Cleveland Clinic patients either concurrently (dual therapy) or consecutively (monotherapy) treated with anti-CGRP mAbs and onabot between June 2018 and November 2021 were extracted. Only adult patients (≥ 18 years of age) were included in this study. MMDs for 194 concurrently treated (86.6% female and a median [interquartile range] age of 51 [41-61] years) and 229 consecutively treated (88.2% female and median age of 47 [IQR 39-57] years) patients were examined at baseline, after first therapy of either anti-CGRP mAb or onabot, and following dual therapy for 3 consecutive months. The reduction of MMDs for each treatment group were compared. The same approach was utilized to compare consecutive monotherapy at separate times (n = 229) and dual-therapy groups.

RESULTS

The initial treatment of the dual-therapy group reduced the median (IQR) MMDs from 30 (30-30) to 15 (12-30) [p < 0.0001]. After initiation of dual therapy, the median MMDs was further decreased from 15 (12-30) to 8 (3-22) [p < 0.0001]. A majority [132/194 (68.0%)] of the dual-therapy patients reported a ≥ 50% reduction in MMD and 90/194 (46.4%) reported a ≥ 75% reduction. For the consecutive monotherapy group, median MMDs changed from a baseline of 30 (25-30) to 15 (8-25) from onabot monotherapy and decreased from 25 (15-30) to 12 (4-25) after anti-CGRP mAb monotherapy. Almost half (113/229 [49.3%] from onabot, and 104/229 [45.4%] from anti-CGRP mAb) of these patients achieved a ≥ 50% reduction in MMDs and a minority (38/229 [16.6%] from onabot, and 45/229 [19.7%] from anti-CGRP mAb) achieved a reduction of ≥ 75%. Additionally, dual therapy showed significant improvement in MMDs compared with monotherapy of either treatment (p < 0.0001).

CONCLUSION

Dual therapy of anti-CGRP mAbs and onabot may be more efficacious than monotherapy, possibly due to their synergistic mechanisms of action.

Is breastfeeding in infancy predictive of child mental well-being and protective against obesity at 9 years of age?

BACKGROUND

Preventing child mental health problems and child obesity have been recognized as public health priorities. The aim of the present study was to examine whether being breastfed (at all or exclusively) in infancy was a predictor of mental well-being and protective against risk of obesity at age 9.

METHODS

Cross-sectional data from a large, nationally representative cohort study in the Republic of Ireland was used (n = 8357). Data on breastfeeding were retrospectively recalled. Child mental well-being was assessed using a parent-completed Strengths and Difficulties Questionnaire (SDQ). Child's height and weight were measured using scientifically calibrated instruments.

RESULTS

Logistic regression analyses indicated that, after controlling for a wide range of potential confounding variables, being breastfed in infancy was associated with a 26% (P < 0.05) reduction in the risk of an abnormal SDQ score at 9 years. Being breastfed remained a significant predictor of child mental well-being when child obesity was controlled for, indicating that being breastfed, independent of child obesity, is a predictor of child mental well-being. The results of a second logistic regression indicated that, after controlling for a wide range of potential confounding variables, being breastfed for between 11 and 25 weeks was associated with a 36% (P < 0.05) reduction in the risk of obesity at 9 years, while being breastfed for 26 weeks or longer was associated with a 48% (P < 0.01) reduction in the risk of obesity at 9 years.

CONCLUSIONS

Breastfeeding in infancy may protect against both poor mental well-being and obesity in childhood.

An investigation into the reporting and management of late terminations of pregnancy (between 22 +0 and 26 +6 weeks of gestation) within NHS Hospitals in England in 2006: the EPICure preterm cohort study

OBJECTIVE

To review all late terminations of pregnancy, between 22(+0) and 26(+6) weeks of gestation, collected as part of the EPICure2 study.

DESIGN

Prospective cohort study.

SETTING

All National Health Service (NHS) hospitals providing perinatal services for extremely preterm infants.

POPULATION

All births between 22(+0) and 26(+6) weeks of gestation in England during 2006.

METHODS

Data were collected for the defined cohort of births, including terminations of pregnancy, by designated unit staff using a standardised questionnaire. Rigorous validation processes were established to ensure comprehensive data collection. Gestational age was validated using a hierarchical classification of scan dates, certain date of last menstrual period and working gestation. Data for terminations of pregnancy (TOPs) were categorised into two groups, terminations for fetal abnormality and for maternal or fetal compromise, and were analysed in terms of their reporting, management and outcomes.

MAIN OUTCOME MEASURES

Classification, rate of feticide and outcome following TOP.

RESULTS

Of 3782 births between 22(+0) and 26(+6) weeks of gestation, 647 (17.1%) were TOPs; of these 584 (90.3%) were for fetal abnormality and 63 (9.7%) for maternal or fetal compromise. Feticide was carried out in 489 of 584 (83.7%) TOPs for fetal abnormality, and in 38 of 63 (60.3%) of the TOPs for maternal or fetal compromise. Live births resulted following 2.2% TOPs for fetal abnormality and 4.8% TOPs for maternal or fetal compromise.

CONCLUSION

Terminations of pregnancy represent a relatively large proportion of very preterm births. Fetal abnormalities are the main cause for these terminations, and most include feticide. Better screening strategies are required to avoid the need for late terminations of pregnancy for fetal abnormalities.

Gastric emptying disorder in children and adolescents with diabetes mellitus type 1

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Relationship between CCL5 and transforming growth factor-β1 (TGFβ1) in breast cancer

PURPOSE

Investigate circulating CCL5 in breast cancer patients and healthy controls, along with gene expression levels in corresponding tumour tissue and isolated primary stromal cells. Hormonal control of CCL5, and a potential relationship with TGFβ1, was also investigated.

METHODS

Circulating levels of CCL5 and TGFβ1 were measured in 102 breast cancer patients and 66 controls using ELISA. Gene expression levels (CCL5, CCR5, TGFβ1, TGFβRII) were quantified in corresponding tumour tissue (n = 43), normal tissue (n = 16), and isolated tumour (n = 22) and normal (n = 3) stromal cells using RQ-PCR. CCL5 and circulating menstrual hormones (LH, FSH, Oestradiol, Progesterone) were analysed in serum samples from healthy, premenopausal volunteers (n = 60).

RESULTS

TGFβ1 was significantly higher in breast cancer patients (Mean(SEM) 27.4(0.9)ng/ml) compared to controls (14.9(0.9)ng/ml). CCL5 levels decreased in the transition from node negative (59.6(3.7)ng/ml) to node positive disease (40.5(6.3)ng/ml) and increased again as the number of positive lymph nodes increased (⩾3 positive 50.95(9.8)ng/ml). A significant positive correlation between circulating CCL5 and TGFβ1 (r = 0.423, p<0.0001) was observed, and mirrored at the gene expression level in tumour tissue from the same patients (r = 0.44, p<0.001). CCL5, CCR5 and TGFβ1 expression was significantly higher in tumour compared to normal breast tissue (p < 0.001). A significant negative correlation was observed between circulating CCL5, Oestradiol and Progesterone (r = -0.50, r = -0.39, respectively, p < 0.05).

CONCLUSION

CCL5 expression is elevated in the tumour microenvironment. The data support a role for hormonal control of circulating CCL5 and also highlight a potentially important relationship between CCL5 and TGFβ1 in breast cancer.

Accuracy of bacterial DNA testing for central venous catheter-associated bloodstream infection in children with cancer

BACKGROUND

Central venous catheters (CVCs) are widely used for children with cancer and are a major risk factor for bloodstream infection. Early and specific diagnosis of CVC-associated bloodstream infection allows early targeted treatment, reducing the risk of CVC removal and avoiding the operative risks and trauma of reinsertion, but peripheral vein sampling, as used in adults, improves specificity but is not usually acceptable in children.

OBJECTIVE

To improve the detection and treatment of CVC-associated bloodstream infection in children (aged 0-18 years) with cancer admitted with fever.

METHODS

There were four main studies: (1) evaluation of the diagnostic accuracy of a quantitative molecular method for the detection of bacterial deoxyribonucleic acid (DNA), based solely on blood samples drawn through the CVC; (2) analysis of the prognostic risk of CVC removal and duration of intravenous (i.v.) antibiotic treatment days in relation to presenting clinical features, blood culture results and bacterial DNA test results; (3) systematic reviews of treatment options for CVC-associated infection and a questionnaire survey of current practice in paediatric oncology centres; (4) evaluation of the clinical effectiveness of different test-treatment strategies to reduce i.v. antibiotic treatment days and unnecessary CVC removals.

RESULTS

(1) The bacterial DNA test detected two-thirds [95% confidence interval (CI) 44% to 83%] of children classified with probable CVC-associated infection - specificity was 88% (95% CI 84% to 92%). Although high bacterial DNA concentrations were associated with subsequent CVC removal and long duration of i.v. antibiotic treatment, the test did not improve the prediction of these outcomes over and above clinical signs of CVC-associated infection combined with blood culture results. (2) High DNA load was predictive of CVC removal and i.v. treatment duration, before blood culture results became available at 48 hours after sampling. (3) There was limited evidence that antibiotic lock treatment reduces the risk of recurrent CVC-associated infection or CVC removal (pooled relative risk 0.7, 95% CI 0.47 to 1.05), but prophylactic use of antimicrobial locks halved the risk of bloodstream infection (pooled incidence rate ratio 0.43, 95% CI 0.36 to 0.51). Contrary to this, the national survey of paediatric oncology centres found that locks are being used for treatment rather than prevention and that problems related to the formulation of lock solutions currently impede a shift to their prophylactic use in children. (4) Most i.v. treatment days would be saved by early stopping of treatment for children at low risk of infection.

LIMITATIONS

The accuracy study was limited primarily by the lack of an adequate reference standard, and the main limitation of the series of systematic reviews was the poor quality of included studies and lack of randomised controlled trials of CVC removal or antimicrobial locks for treatment of infection.

CONCLUSIONS

There is strong evidence to support the use of antimicrobial locks for prevention of CVC-associated infection; however, few of these studies involved children with cancer. The analysis does not support routine bacterial DNA testing on admission to detect CVC-associated infection, but repeated testing (as a marker of microbial load) should be evaluated in high-risk groups. Further research should determine the effectiveness of antibiotic locks for treating CVC-associated infection.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN68138140.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 15, No. 7. See the HTA programme website for further project information.

MicroRNA-21 and PDCD4 expression in colorectal cancer

INTRODUCTION

MiRNAs regulate gene expression by binding to target sites and initiating translational repression and/or mRNA degradation. Studies have shown that miR-21 exerts its oncogenic activity by targeting the PDCD4 tumour suppressor 3'-UTR. However, the mechanism of this regulation is poorly understood. In colorectal cancer, loss of PDCD4 has been reported in association with increased tumour aggressiveness and poor prognosis. The purpose of this study was to delineate the interaction between PDCD4 and its oncogenic modulator miR-21 in colorectal cancer.

METHODS

A cohort of 48 colorectal tumours, 61 normal tissues and 7 polyps were profiled for miR-21 and PDCD4 gene expression. A subset of 48 specimens (31 tumours and 17 normal tissues) were analysed for PDCD4 protein expression by immunohistochemistry.

RESULTS

A significant inverse relationship between miR-21 and PDCD4 gene expression (p < 0.001) was identified by RT-qPCR. In addition, significant reduction of PDCD4 (p < 0.001) expression and reciprocal upregulation of miR-21 (p = 0.005) in a progressive manner from tumour-polyp-normal mucosae was identified. Analysis of protein expression by IHC revealed loss of PDCD4 staining in tumour tissue. Patients with disease recurrence had higher levels of miR-21.

CONCLUSION

This study demonstrates the inverse relationship between miR-21 and PDCD4, thus suggesting that miR-21 post-transcriptionally modulates PDCD4 via mRNA degradation. Pharmacological manipulation of the miR-21/PDCD4 axis could represent a novel therapeutic strategy in the treatment of colorectal cancer.

Development of the Children's Attributions about Psychological Problems in their Peers Scale

BACKGROUND

Research has shown that children's beliefs about the causes of psychological problems are related to their attitudes and reactions towards affected peers. This study describes the development of the Children's Attributions about Psychological Problems in their Peers (CAPPP) Scale, which assesses children's beliefs about the causes of an internalizing and an externalizing condition.

METHODS

The 16 items comprising the CAPPP are derived from previous qualitative research findings. Five hundred and ninety-five young people, drawn from five different age groups spanning early childhood to late adolescence, completed a CAPPP Scale for each of two vignettes describing the behaviour of hypothetical peers with attention deficit hyperactivity disorder (ADHD) and depression.

RESULTS

Modifications following consideration of psychometric properties and conceptual fit resulted in a 12-item scale. For both the ADHD and depression conditions, the components that emerged were 'Volition', 'Recent Life Stress', 'Family Factors' and 'School Factors'.

CONCLUSIONS

The present study represents the first field trial of the CAPPP. Results suggest that children's and adolescents' beliefs about the causes of psychological problems are multidimensional and incorporate both individual and environmental factors.

Nature and severity of lung function abnormalities in extremely pre-term children at 11 years of age

Advances in neonatal care have resulted in increased survival of children born extremely pre-term (EP). Nevertheless the incidence of bronchopulmonary dysplasia and long-term respiratory morbidity remains high. We investigated the nature of pathophysiological changes at 11 yrs of age to ascertain whether respiratory morbidity in EP children primarily reflects alterations in the lung periphery or more centralised airway function in this population. Spirometry, plethysmography, diffusing capacity, exhaled nitric oxide, multiple-breath washout, skin tests and methacholine challenge were used during laboratory-based assessments in a subgroup of the 1995 EPICure cohort and in controls. Results were obtained in 49 EP and 52 control children. Lung function abnormalities were found in 78% of EP children, with evidence of airway obstruction, ventilation inhomogeneity, gas trapping and airway hyperresponsiveness. Levels of atopy and exhaled nitric oxide were similar between the groups. Prior wheeze was associated with significant reductions in forced flows and volumes. By contrast, abnormalities of the lung periphery appear to be mediated primarily through EP birth per se. The prevalence of lung function abnormalities, which is largely obstructive in nature and likely to have long-term implications, remains high among 11-yr-old children born EP. Spirometry proved an effective means of detecting these persistent abnormalities.

Potential role of mesenchymal stem cells (MSCs) in the breast tumour microenvironment: stimulation of epithelial to mesenchymal transition (EMT)

Bone marrow-derived mesenchymal stem cells (MSCs) are known to specifically migrate to and engraft at tumour sites. Understanding interactions between cancer cells and MSCs has become fundamental to determining whether MSC-tumour interactions should be harnessed for delivery of therapeutic agents or considered a target for intervention. Breast Cancer Cell lines (MDA-MB-231, T47D & SK-Br3) were cultured alone or on a monolayer of MSCs, and retrieved using epithelial specific magnetic beads. Alterations in expression of 90 genes associated with breast tumourigenicity were analysed using low-density array. Expression of markers of epithelial-mesenchymal transition (EMT) and array results were validated using RQ-PCR. Co-cultured cells were analysed for changes in protein expression, growth pattern and morphology. Gene expression and proliferation assays were also performed on indirect co-cultures. Following direct co-culture with MSCs, breast cancer cells expressed elevated levels of oncogenes (NCOA4, FOS), proto-oncogenes (FYN, JUN), genes associated with invasion (MMP11), angiogenesis (VEGF) and anti-apoptosis (IGF1R, BCL2). However, universal downregulation of genes associated with proliferation was observed (Ki67, MYBL2), and reflected in reduced ATP production in response to MSC-secreted factors. Significant upregulation of EMT specific markers (N-cadherin, Vimentin, Twist and Snail) was also observed following co-culture with MSCs, with a reciprocal downregulation in E-cadherin protein expression. These changes were predominantly cell contact mediated and appeared to be MSC specific. Breast cancer cell morphology and growth pattern also altered in response to MSCs. MSCs may promote breast cancer metastasis through facilitation of EMT.

Academic attainment and special educational needs in extremely preterm children at 11 years of age: the EPICure study

AIM

To assess academic attainment and special educational needs (SEN) in extremely preterm children in middle childhood.

METHODS

Of 307 extremely preterm (< or =25 weeks) survivors born in the UK and Ireland in 1995, 219 (71%) were re-assessed at 11 years of age and compared to 153 classmates born at term, using standardised tests of cognitive ability and academic attainment and teacher reports of school performance and SEN. Multiple imputation was used to correct for selective dropout.

RESULTS

Extremely preterm children had significantly lower scores than classmates for cognitive ability (-20 points; 95% CI -23 to -17), reading (-18 points; -22 to -15) and mathematics (-27 points; -31 to -23). Twenty nine (13%) extremely preterm children attended special school. In mainstream schools, 105 (57%) extremely preterm children had SEN (OR 10; 6 to 18) and 103 (55%) required SEN resource provision (OR 10; 6 to 18). Teachers rated 50% of extremely preterm children as having below average attainment compared with 5% of classmates (OR 18; 8 to 41). Extremely preterm children who entered compulsory education an academic year early due to preterm birth had similar academic attainment but required more SEN support (OR 2; 1.0 to 3.6).

CONCLUSIONS

Extremely preterm survivors remain at high risk for learning impairments and poor academic attainment in middle childhood. A significant proportion require full-time specialist education and over half of those attending mainstream schools require additional health or educational resources to access the national curriculum. The prevalence and impact of SEN are likely to increase as these children approach the transition to secondary school.

Topical or oral ibuprofen for chronic knee pain in older people. The TOIB study

OBJECTIVES

To determine whether GPs should advise their older patients with chronic knee pain to use topical or oral non-steroidal anti-inflammatory drugs (NSAIDs).

DESIGN

An equivalence study was designed to compare the effect of advice to use preferentially oral or topical ibuprofen (an NSAID) on knee pain and disability, NSAID-related adverse effects and NHS/societal costs, using a randomised controlled trial (RCT) and a patient preference study (PPS). Reasons for patient preferences for topical or oral preparations, and attitudes to adverse effects, were explored in a qualitative study.

SETTING

Twenty-six general practices in the UK.

PARTICIPANTS

Participants comprised 585 people with knee pain, aged 50 years or over; 44% were male, mean age 64 years. The RCT had 282 participants: 144 in the oral group and 138 in the topical group. The PPS had 303 participants: 79 in the oral group and 224 in the topical group.

INTERVENTIONS

Advice to use preferentially oral or topical NSAIDs for knee pain.

OUTCOME MEASURES

The primary outcome measure was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcome measures were the Short Form with 36 Items (SF-36), perceived troublesomeness of knee pain, satisfaction with health status, major adverse effects (unplanned hospital admissions and deaths) and minor adverse events over 12 months. The health economic analysis measured the comparative cost per quality-adjusted life-year (QALY) from both an NHS and a societal perspective over 1 and 2 years.

RESULTS

Changes in the global WOMAC score at 12-months were equivalent in both studies: topical - oral, RCT difference=2 [95% confidence interval (CI) -2 to 6], PPS difference=1 (95% CI -4 to 6). There were no differences in the secondary outcomes, except for a suggestion, in the RCT, that those in the topical group were more likely to have more severe overall pain and disability as measured by the chronic pain grade, and more likely to report changing treatment because of inadequate pain relief. There were no differences in the rate of major adverse effects but some differences in the number of minor ones. In the RCT, 17% and 10% in the oral and the topical group, respectively, had a defined respiratory adverse effect (95% CI of difference -17% to -2.0%); after 12 months, the change in serum creatinine was 3.7 mmol/l (95% CI 0.9 to 6.5) less favourable in the oral than in the topical group, and 11% of those in the oral group reported changing treatment because of adverse effects compared with 1% in the topical group (p=0.02). None of these differences were seen in the PPS. Oral NSAIDs cost the NHS 191 pounds and 72 pounds more per participant over 1 year in the RCT and PPS respectively. In the RCT the cost per QALY in the oral group, from an NHS perspective, was in the range 9000-12,000 pounds. In the PPS it was 2564 pounds over 1 year, but over 2 years the oral route was more cost-effective. Patient preference for medication type was affected by previous experience of medication (including adverse reactions), other illness, pain elsewhere, anecdotes, convenience, severity of pain and perceived degree of degeneration. Lack of understanding about knee pain and the action of medication led to increased tolerance of symptoms. Potentially important symptoms may inadvertently have been disregarded, increasing participants' risk of suffering a major adverse effect.

CONCLUSIONS

Advice to use either oral or topical preparations has an equivalent effect on knee pain, but oral NSAIDs appear to produce more minor adverse effects than topical NSAIDs. Generally, these results support advising older people with knee pain to use topical rather than oral NSAIDS. However, for patients who prefer oral NSAID preparations rather than a topical NSAID, particularly those with more widespread or severe pain, the oral route is a reasonable treatment option, provided that patients are aware of the risks of potentially serious adverse effects from oral medication. Further research is needed into strategies to change prescribing behaviour and ensure that older patients are aware of the potential risks and benefits of using NSAIDs. Observational studies are needed to estimate rates of different predefined minor adverse effects associated with the use of oral NSAIDs in older people as are long-term studies of topical NSAIDs in those for whom oral NSAIDs are not appropriate.

Prospective matched-pair comparison of outcome after treatment for lobular and ductal breast carcinoma

Background

Whether the prognosis of invasive lobular carcinoma is different from that of other invasive breast cancers is controversial. The aim of this study was to compare the outcome in age- and stage-matched patients with lobular carcinoma and those with invasive breast cancer, and in particular to compare predictors of outcome.

Methods

Data were obtained from a prospectively maintained database that included patients who had breast surgery for invasive cancer. Patients were matched for International Union Against Cancer stage and age at diagnosis within 5 years. Two patients with invasive ductal carcinoma were matched to each patient with invasive lobular carcinoma.

Results

There was no significant difference between invasive ductal and lobular carcinomas in terms of overall survival. Oestrogen receptor (ER)-positive invasive ductal carcinoma had a better prognosis than ER-positive invasive lobular carcinoma (P = 0·011). Similarly, ER-negative invasive ductal carcinoma was associated with worse survival than ER-negative invasive lobular carcinoma (P = 0·054).

Conclusion

These results suggested that the differences in outcome between invasive ductal and lobular carcinomas may be determined by ER status.

Children's understanding of psychological problems displayed by their peers: a review of the literature

BACKGROUND

There is a widespread consensus in the literature that children who have psychological problems are more likely than other children to be excluded or rejected by their peers. The existence of this phenomenon has been established, primarily with the use of research on their sociometric status within groups of peers. Much less research has been performed on the way in which children develop attitudes and behavioural intentions towards peers with problems.

AIMS

The primary aim of this article is to introduce readers to research on children's understanding of the nature of common childhood psychological problems, with a view to exploring the factors that might contribute to the development of negative attitudes and behaviour.

METHOD

Relevant publications were identified through searches of electronic databases and articles in print.

RESULTS

From the early years of primary school, children are able to identify peers whose behaviour deviates from the norm and to suggest causes for the behaviour of peers with psychological problems. Furthermore, their beliefs about peers' personal responsibility for these problems appear to be a significant determinant of attitudes and behavioural intentions. The article identifies the need for more research on the role of factors such as gender and personal contact in determining children's understanding of, and attitudes towards, peers with psychological problems. In addition, the article calls for more research on mental health education programmes and the extension of these programmes to younger children, given the fact that even young primary school children appear to have beliefs about the causes of psychological problems and negative attitudes to peers who display such problems.

CONCLUSIONS

Research on children's understanding of mental health can make an important contribution to our understanding of why children with problems are so much more likely to be excluded from their peer group.

Monocyte chemotactic protein-1 secreted by primary breast tumors stimulates migration of mesenchymal stem cells

PURPOSE

Major barriers to effective adenovirus-based gene therapy include induction of an immune response and tumor-specific targeting of vectors. The use of mesenchymal stem cells (MSC) as systemic delivery vehicles for therapeutic genes has been proposed as a result of their combined ability to home in on the tumor site and evade the host immune response. This study is aimed at investigating factors mediating homing of human MSCs to breast cancer primary cultures and cell lines in vitro and in vivo.

EXPERIMENTAL DESIGN

Fluorescently labeled MSCs were given to mice bearing breast cancer xenografts, and tumor tissue was harvested to detect MSC engraftment. MSC migration in response to primary breast tumors in vitro was quantified, and chemokines secreted by tumor cells were identified. The role of monocyte chemotactic protein-1 (MCP-1) in cell migration was investigated using antibodies and standards of the chemokine. Serum MCP-1 was measured in 125 breast cancer patients and 86 healthy controls.

RESULTS

Engrafted MSCs were detected in metastatic breast tumors in mice after systemic administration. There was a significant increase in MSC migration in response to primary breast tumor cells in vitro (6-fold to 11-fold increase). Tumor explants secreted a variety of chemokines including GROalpha, MCP-1, and stromal cell-derived factor-1alpha. An MCP-1 antibody caused a significant decrease (37-42%) in MSC migration to tumors. Serum MCP-1 levels were significantly higher in postmenopausal breast cancer patients than age-matched controls (P < 0.05).

CONCLUSIONS

These results highlight a role for tumor-secreted MCP-1 in stimulating MSC migration and support the potential of these cells as tumor-targeted delivery vehicles for therapeutic agents.

Use of quantitative 16S ribosomal DNA detection for diagnosis of central vascular catheter-associated bacterial infection

Many central vascular catheters (CVCs) are removed unnecessarily because current diagnostic methods for CVC-associated infection are unreliable. A quantitative PCR assay using primers and probe targeted to bacterial 16S ribosomal DNA was used to measure the levels of bacterial DNA in blood samples drawn through the CVC in a population of patients receiving intravenous nutrition. Bacterial DNA concentrations were raised in 16 of 16 blood samples taken during episodes of probable bacterial CVC-associated infection. Bacterial DNA concentrations were raised in 4 of 29 episodes in which bacterial CVC-associated infection was unlikely. The use of this technique has the potential to substantially reduce the unnecessary removal of CVCs.

Designing a community-based fourth-year obstetrics and gynaecology module: an example of innovative curriculum development

INTRODUCTION

This paper describes the design and evaluation of the community-based obstetrics and gynaecology module at St Bartholomew's and the Royal London School of Medicine and Dentistry. This module sets out to comply with the General Medical Council's recommendations of encouraging students to consider the community perspective, and places less emphasis on a disease-orientated approach.

OBJECTIVES

The development of the module, issues of improving student acceptance of the course, staff development and the benefits of community teaching in obstetrics and gynaecology are discussed.

MODULE ORGANIZATION

The 2-week module precedes the 8-week hospital obstetrics and gynaecology firms that occur in the fourth undergraduate year. The course is organized into three components: general practice, departmental teaching, and self-directed learning. Students are allocated to general practices for their clinical teaching, for eight sessions. Seven departmental sessions are run by the Academic Department of General Practice and Primary Care. These include a review of the students' self-directed learning.

EVALUATION AND CONCLUSION

Evaluation data are reported for the three components of the course. Overall the majority of students rated the module as useful, GP attachments being most favourably received. The majority of students have grasped the basic obstetric and gynaecological history and examination skills and found this useful before starting their hospital firms. Aspects of a specialist subject, such as, obstetrics and gynaecology, can be taught successfully in the community and GP tutors are, as yet, an untapped source of excellent obstetric and gynaecology teaching.

Randomized trial of folic acid supplementation and serum homocysteine levels

BACKGROUND

Lowering serum homocysteine levels with folic acid is expected to reduce mortality from ischemic heart disease. Homocysteine reduction is known to be maximal at a folic acid dosage of 1 mg/d, but the effect of lower doses (relevant to food fortification) is unclear.

METHODS

We randomized 151 patients with ischemic heart disease to 1 of 5 dosages of folic acid (0.2, 0.4, 0.6, 0.8, and 1.0 mg/d) or placebo. Fasting blood samples for serum homocysteine and serum folate analysis were taken initially, after 3 months of supplementation, and 3 months after folic acid use was discontinued.

RESULTS

Median serum homocysteine level decreased with increasing folic acid dosage, to a maximum at 0.8 mg of folic acid per day, when the homocysteine reduction (placebo adjusted) was 2.7 micromol/L (23%), similar to the known effect of folic acid dosages of 1 mg/d and above. The higher a person's initial serum homocysteine level, the greater was the response to folic acid, but there were statistically significant reductions regardless of the initial level. Serum folate level increased approximately linearly (5.5 nmol/L for every 0.1 mg of folic acid). Within-person fluctuations over time in serum homocysteine levels, measured in the placebo group, were large compared with the effect of folic acid, indicating that monitoring of the reduction in an individual is impractical.

CONCLUSIONS

A dosage of folic acid of 0.8 mg/d appears necessary to achieve the maximum reduction in serum homocysteine level across the range of homocysteine levels in the population. Current US food fortification levels will achieve only a small proportion of the achievable homocysteine reduction.

Changing patterns of sedation use for routine out-patient diagnostic gastroscopy between 1989 and 1998

BACKGROUND

Knowledge of sedation trends for upper gastrointestinal endoscopy is important for health service planning, particularly in view of rapidly increasing demands on endoscopy services. However, no data are available on sedation trends in Britain over the past 10 years.

AIM

To determine sedation use for routine gastroscopy in a single endoscopy unit between 1989 and 1998.

METHODS

This was a retrospective study of 9795 consecutive adults (mean age 56 years, range 18-100 years; 4512 females) who had undergone a gastroscopy between 1989 and 1998. Clinical, pharmacological and endoscopic data were retrieved from a computerized database.

RESULTS

Over the 10-year study period, the sedation rate remained constant for patients undergoing therapeutic endoscopy (P=0.99) and those undergoing in-patient diagnostic examinations (P=0.63). In contrast, the sedation rate for out-patient diagnostic endoscopy decreased by 54%, from a high of 70% in 1990 to 32% in 1998 (P < 0.0001). Logistic regression analysis showed that the decline in sedation use was greater in females (P < 0.0001) than males and in procedures performed by non-consultant compared to consultant staff (P=0.01).

CONCLUSIONS

If our results form part of a national trend, they will have important implications for cardiopulmonary monitoring strategies, recovery room practices and for complication rates due to the use of sedation for upper gastrointestinal endoscopy.

High group A streptococcal carriage in the Orthodox Jewish community of north Hackney

BACKGROUND

General practitioners and the microbiologist serving north Hackney in north east London formed the impression, that of throat swabs sent to the laboratory, a disproportionate number of those positive for group A streptococcus appeared to come from Orthodox Jewish patients.

AIM

To confirm the clinical impression that the pharyngeal carriage of group A streptococci was higher in the Orthodox Jewish population than in other members of the population in the same locality.

DESIGN OF STUDY

A general practice questionnaire survey of all patients aged three years or over attending two practices that are about one kilometre apart, over a five-week period.

SETTING

Two general practices in north London, one of which had a significant Orthodox Jewish patient list.

METHODS

Throat swabs were taken from eligible patients who were invited to participate by completing a questionnaire and having a throat swab taken.

RESULTS

Swabs were taken from 1223 people. After correction for age (child or adult) and history of recent sore throat, the Orthodox Jewish community had a significantly higher carriage rate of group A streptococci than the rest of the population (odds ratio = 5.0 [2.1 to 11.9]). The proportion of adults with group A streptococci with and without sore throats was 6.4% and 2.4% respectively in the Orthodox Jewish group and 0.45% and 1% respectively in the 'others' group. The proportion of children with group A streptococci with and without sore throats was 17.4% and 5.9% respectively and 3.4% and 0% respectively in the others. These differences were not explained by the larger family size and domestic overcrowding in the Orthodox Jewish group.

CONCLUSIONS

Orthodox Jews in north London have a higher pharyngeal carriage rate of group A streptococci than the neighbouring population. These results may have implications for the diagnosis and treatment of acute sore throat in Orthodox Jewish patients, especially children.

The EPICure study: outcomes to discharge from hospital for infants born at the threshold of viability

OBJECTIVE

To evaluate the outcome for all infants born before 26 weeks of gestation in the United Kingdom and the Republic of Ireland. This report is of survival and complications up until discharge from hospital.

METHODOLOGY

A prospective observational study of all births between March 1, 1995 and December 31, 1995 from 20 to 25 weeks of gestation.

RESULTS

A total of 4004 births were recorded, and 811 infants were admitted for intensive care. Overall survival was 39% (n = 314). Male sex, no reported chorioamnionitis, no antenatal steroids, persistent bradycardia at 5 minutes, hypothermia, and high Clinical Risk Index for Babies (CRIB) score were all independently associated with death. Of the survivors, 17% had parenchymal cysts and/or hydrocephalus, 14% received treatment for retinopathy of prematurity (ROP), and 51% needed supplementary oxygen at the expected date of delivery. Failure to administer antenatal steroids and postnatal transfer for intensive care within 24 hours of birth were predictive of major scan abnormality; lower gestation was predictive of severe ROP, while being born to a black mother was protective. Being of lower gestation, male sex, tocolysis, low maternal age, neonatal hypothermia, a high CRIB score, and surfactant therapy were all predictive of oxygen dependency. Intensive care was provided in 137 units, only 8 of which had >5 survivors. There was no difference in survival between institutions when divided into quintiles based on their numbers of extremely preterm births or admissions.

CONCLUSIONS

This study provides outcome data for this geographically defined cohort; survival and neonatal morbidity are consistent with previous data from the United Kingdom and facilitate comparison with other geographically based data.

Intergenerational influences affecting birth outcome. II. Preterm delivery and gestational age in the children of the 1958 British birth cohort

The 1958 British cohort study has data to investigate intergenerational effects on preterm delivery and on gestational age in non-preterm births, allowing for many confounders that may differ in the more pathological preterm babies. Previous results for all gestational ages-have been inconsistent. The strongest and only likely independent intergenerational effect on non-preterm gestational age found is parental gestational age (adjusted regression coefficient = 0.067 weeks per week in mothers and 0.045 in fathers). The preterm analysis has low power; however, reported history of hypertension in mothers (any), in fathers and in the maternal grandmother (measured in the 1958 pregnancy) all significantly and independently increased the risk of preterm birth [OR = 1.7, 2.0, 1.5 respectively]. The absolute risk was particularly high in hypertensive mothers who had been preterm themselves (21%). Other possible intergenerational influences of height, weight, fetal growth and gestation were not significant enough and/or consistent enough between parents to speculate whether they are truly intergenerational or confounded by other factors acting during the pregnancy. Excepting mother's weight for height, no genetic or environmental influence studied affects both gestational age and fetal growth in term births. However, many maternal factors that reduce either fetal growth or gestation in term births are associated with increased risk of preterm birth.

Intergenerational influences affecting birth outcome. I. Birthweight for gestational age in the children of the 1958 British birth cohort

There is considerable literature on intergenerational influences on birthweight. Few studies have been able to investigate such influences on the more basic measures of birthweight for gestational age and gestational age itself. This paper considers fetal growth. The investigations are derived from the 1958 British birth cohort followed from birth to age 33 years. Included were questions on physical and social characteristics of each parent and the grandparents, and birth details of parent and first child. In the present study, fetal growth in non-preterm babies, after adjustment for the known effects of smoking and sex of the child, is explained best by factors relating to the parent's own growth, primarily in utero, but also to adulthood. There are small additional effects of education or social class but not of parent's gestational age. Only 15% of the variability in the child's fetal growth can be explained by the mother's characteristics and approximately 7% by the father's. Parent's own fetal growth accounts for nearly half of the variability if unadjusted for other factors and nearly a third after adjustment for sex of child, smoking, parental height and weight, maternal age at menarche and paternal age at first birth. Parental fetal growth makes the greatest anthropometric contribution.

The effects of own fetal growth on reported hypertension in parous women aged 33

BACKGROUND

Data from the study of the British 1958 birth cohort, National Child Development Study (NCDS), has allowed wider investigation of the relationship between retarded fetal growth and risk of adult hypertension.

METHODS

A history of self-reported hypertension was related to fetal growth in 3308 parous cohort members. Fetal growth, the measure used, is the difference in actual birthweight from that expected for the gestational age and subsequent adult height. The relationships were investigated both linearly and non-linearly adjusting for potential confounders.

RESULTS

After adjustment for confounding factors, including adult weight for height, retarded fetal growth was associated with reported hypertension particularly when not confined to pregnancy. The latter was also associated with accelerated fetal growth, moderate or severe hypertension in the mother when pregnant with the cohort member, being relatively taller than your mother, and lack of educational qualifications. Hypertension confined to pregnancy was more likely among women who were themselves firstborn or older at childbirth. Neither maternal smoking during cohort's gestation nor cohort member's gestational age had a significant effect. The results are consistent with previous reports that fetal growth effects are less marked if gestation is short.

CONCLUSIONS

The relationships between fetal growth and subsequent hypertension are extremely complex and variable, and need to be studied allowing for deviations from growth potential. Adult weight for height remains the strongest predictor of hypertension. The results suggest that losing weight is likely to have the same proportional benefit in women with and without a history of retarded fetal growth.

Cerebral palsy: effects of twinning, birthweight, and gestational age

AIMS

To determine the effects of birthweight and gestational age on the risk of cerebral palsy for multiple and singleton births.

METHODS

Children on the North East Thames Regional Health Authority Interactive Child Health System, born between 1 January 1980 and 31 December 1986, and notified as having cerebral palsy, were included. Cases of postneonatal onset, of known progressive, or non-cerebral pathology and with only mild signs were excluded. Rates and relative risks were calculated using the most complete data, which related to 1985-86, and comprised 102,059 singletons and 2367 twins. Logistic regression was used to examine the associations between being a twin, gestational age, and birthweight.

RESULTS

The crude rate per 1000 survivors at 1 year of age was 1.0 in singletons and 7.4 in twins. The relative risk was greatest in twins weighing more than 2499 g (4.5). However, after adjusting for reduced birthweight of twins it was the relative risk of twins weighing less than 1400 g that was significantly increased. Logistic regression confirmed that lower fetal growth, lower gestational age, and being a twin are all independent risk factors for cerebral palsy.

CONCLUSION

The increased risk to twins of cerebral palsy is not entirely explained by their increased risk of prematurity and low birthweight.

Women's knowledge of emergency contraception

BACKGROUND

More widespread use of emergency contraception could help to reduce the number of unwanted pregnancies.

AIM

The objective of this study was to assess women's knowledge of emergency contraception.

METHOD

A questionnaire was distributed to 1290 women aged between 16 and 50 years attending 14 general practice surgeries in London over a two-week period in 1990.

RESULTS

The response rate was 70%. Over three quarters of the women had heard of emergency contraception; these were mainly women who used contraception, who had higher educational qualifications or who were not Muslim. Women who were the most likely to need and to use emergency contraception--those using barrier methods--had no more accurate knowledge than women using any other method of contraception. Only 53% of barrier method users knew emergency contraception could be used as a backup when other methods failed. Only one fifth of women had heard about this method from their general practitioner or any other health professional, while half had obtained their information from the media.

CONCLUSION

These results suggest that including information on emergency contraception in consultations with users of barrier methods of contraception is a small step which general practitioners and practice nurses could take to increase the use of emergency contraception.

Control of resting bronchial hemodynamics in the awake dog

In the resting awake dog a continuous-wave Doppler flow transducer on the right bronchoesophageal artery inscribes a sharp early systolic spike and low flow in late systole and throughout diastole, indicating a highly resistive bed. An analysis of autonomic factors using intravenous, cumulative, and randomly applied cholinoceptor, beta 1- and beta 2-adrenoceptor, and alpha 1- and alpha 2-adrenoceptor antagonists indicates that the low vascular conductance is due to cholinoceptor and alpha 1- and alpha 2-adrenoceptor effects in a ratio 3.6:1. No beta-adrenoceptor tone is present. Sighing behavior invokes a transient (< 2 s) fall in intrapleural pressure (and thus rise in bronchovascular transmural pressure) of 10-30 mmHg, which is followed by a two- to threefold increase over 30 s in bronchial flow and conductance, an effect simulated in 50% of dogs when bronchovascular transmural pressure is acutely raised and maintained over 40-60 s by inflating an intra-aortic balloon distal to the origin of the bronchial artery. Autonomic blockade has no effect on bronchovascular dilatation evoked either by sighing or by balloon inflation. It is concluded that, in the resting bronchial circulation, there exists strong cholinoceptor and alpha-adrenoceptor-based vasoconstrictor activity which can be overpowered by strong nonadrenergic noncholinergic local vasodilator reflexes evoked by sudden changes in intrathoracic transmural pressure possibly acting on stretch-sensitive sensory nerve endings containing substance P, calcitonin gene-related peptide, and neurokinins. The tonic vasoconstrictor but not the sigh-evoked vasodilator effects are sensitive to pentobarbital sodium anesthesia.

Incidence of rheumatoid arthritis in a genetically predisposed population

A follow-up study (mean duration five years) was undertaken on 370 previously unaffected first degree relatives from multicase rheumatoid arthritis (RA) families. The objectives were to determine the incidence of RA in this group and the possible predictors of disease development. In all, 14 individuals developed RA, equivalent to an incidence of 8/1000 person-years of observation. There was no control group included in this study as the intensive-follow-up required substantial compliance from highly motivated families. Population-based estimates, however, from a number of sources would suggest an annual incidence below 0.5/1000 per year, substantially less than the rate obtained in this study. The small number of incident cases precluded definitive conclusions about risk factors within these families but there were no important effects of age or sex. Possession of HLA-DR1 or DR4 explained only some of the increased risk. The increased incidence observed in the previously unaffected relatives of such families would suggest that this familial clustering did not for the most part arise by chance and that other shared genetic or environmental influences are relevant.

Cerebral palsy among children born during the Dublin randomised trial of intrapartum monitoring

In a randomised trial involving 13,079 liveborn children intrapartum care by electronic fetal heart rate monitoring, with scalp blood sampling when indicated, was associated with a 55% reduction in neonatal seizures. Reassessment, when aged 4, of the 9 children in the intensively monitored group and 21 in the control group who survived after neonatal seizures showed that 3 such children in each group had cerebral palsy. A fourth child in the intensively monitored group with cerebral palsy had had transient abnormal neurological signs during the neonatal period. 8 other children in the intensively monitored group and 7 in the control group who had not had abnormal neurological signs in the neonatal period also had cerebral palsy. 16 (78%) of the total of 22 cases of cerebral palsy had not shown clinical signs suggestive of intrapartum asphyxia. Thus, compared with intermittent intrapartum monitoring, intensive monitoring has little, if any, protective effect against cerebral palsy.

Co-segregation of HLA and rheumatoid arthritis in multicase families

Inheritance of parental HLA haplotypes was examined in the offspring of 95 multicase rheumatoid arthritis (RA) families. Overall, in these families there was no evidence of preferential transmission of one parental haplotype, although this might have been expected given the loading of these families with RA cases. However, there was a difference in inheritance when the affected and non-affected offspring were compared. A co-segregation analysis showed that the inheritance of parental HLA haplotypes was different between the affected and the unaffected offspring. Unlike a previous report, no difference was demonstrated in this study between the offspring of affected and non-affected parents. Similarly, the affected offspring of HLA DR4 heterozygote parents were more likely to inherit HLA DR4 than the non-affected offspring. It is concluded first that linkage studies of RA using the affected sib-pair method are not invalidated, which would have been the case in the presence of preferential transmission of HLA to all offspring. Secondly, HLA and specifically HLA-DR4 does co-segregate with RA, and, finally, parental RA status, independent of DR4, has little influence in explaining the genetic susceptibility to RA.

Uterine lavage in the diagnosis of endometrial malignancy and its precursors

A negative-pressure uterine lavage technique and simple cytologic processing were employed in the detection of endometrial disease in 1,606 patients, 366 of whom were postmenopausal and asymptomatic. Asymptomatic endometrial cancer and its precursors were detected by lavage in patients with negative cervical smear findings, while some symptomatic patients with negative cervical smears and curettage had persistent lavage cytologic abnormalities that preceded histologic confirmation. This technique detected 90.9% of the adenocarcinomas and 59.1% of the atypical/adenocarcinomatous hyperplasias, as compared with 52.3% and 27.3%, respectively, using cervical scraping. Detection rates for endometrial hyperplasia were improved by reporting as abnormal the presence of many clusters of otherwise-normal endometrial cells. In postmenopausal patients, representative endometrial material was obtained in 82.0%, and the procedure was abandoned in 4.1% due to cervical stenosis. Since intrauterine manipulation is unnecessary, the technique was well accepted by elderly asymptomatic women and appears suitable for routine cancer screening.