Comparative effectiveness and cost-effectiveness of natalizumab and fingolimod in rapidly evolving severe relapsing-remitting multiple sclerosis in the United Kingdom

AIM

To evaluate the real-world comparative effectiveness and the cost-effectiveness, from a UK National Health Service perspective, of natalizumab versus fingolimod in patients with rapidly evolving severe relapsing-remitting multiple sclerosis (RES-RRMS).

METHODS

Real-world data from the MSBase Registry were obtained for patients with RES-RRMS who were previously either naive to disease-modifying therapies or had been treated with interferon-based therapies, glatiramer acetate, dimethyl fumarate, or teriflunomide (collectively known as BRACETD). Matched cohorts were selected by 3-way multinomial propensity score matching, and the annualized relapse rate (ARR) and 6-month-confirmed disability worsening (CDW6M) and improvement (CDI6M) were compared between treatment groups. Comparative effectiveness results were used in a cost-effectiveness model comparing natalizumab and fingolimod, using an established Markov structure over a lifetime horizon with health states based on the Expanded Disability Status Scale. Additional model data sources included the UK MS Survey 2015, published literature, and publicly available sources.

RESULTS

In the comparative effectiveness analysis, we found a significantly lower ARR for patients starting natalizumab compared with fingolimod (rate ratio [RR] = 0.65; 95% confidence interval [CI], 0.57-0.73) or BRACETD (RR = 0.46; 95% CI, 0.42-0.53). Similarly, CDI6M was higher for patients starting natalizumab compared with fingolimod (hazard ratio [HR] = 1.25; 95% CI, 1.01-1.55) and BRACETD (HR = 1.46; 95% CI, 1.16-1.85). In patients starting fingolimod, we found a lower ARR (RR = 0.72; 95% CI, 0.65-0.80) compared with starting BRACETD, but no difference in CDI6M (HR = 1.17; 95% CI, 0.91-1.50). Differences in CDW6M were not found between the treatment groups. In the base-case cost-effectiveness analysis, natalizumab dominated fingolimod (0.302 higher quality-adjusted life-years [QALYs] and £17,141 lower predicted lifetime costs). Similar cost-effectiveness results were observed across sensitivity analyses.

CONCLUSIONS

This MSBase Registry analysis suggests that natalizumab improves clinical outcomes when compared with fingolimod, which translates to higher QALYs and lower costs in UK patients with RES-RRMS.

Active Brownian particles in random and porous environments

The transport of active particles may occur in complex environments, in which it emerges from the interplay between the mobility of the active components and the quenched disorder of the environment. Here, we explore the structural and dynamical properties of active Brownian particles (ABPs) in random environments composed of fixed obstacles in three dimensions. We consider different arrangements of the obstacles. In particular, we consider two particular situations corresponding to experimentally realizable settings. First, we model pinning particles in (non-overlapping) random positions and, second, in a percolating gel structure and provide an extensive characterization of the structure and dynamics of ABPs in these complex environments. We find that the confinement increases the heterogeneity of the dynamics, with new populations of absorbed and localized particles appearing close to the obstacles. This heterogeneity has a profound impact on the motility induced phase separation exhibited by the particles at high activity, ranging from nucleation and growth in random disorder to a complex phase separation in porous environments.

Pyrocumulonimbus affect average stratospheric aerosol composition

Pyrocumulonimbus (pyroCb) are wildfire-generated convective clouds that can inject smoke directly into the stratosphere. PyroCb have been tracked for years, yet their apparent rarity and episodic nature lead to highly uncertain climate impacts. In situ measurements of pyroCb smoke reveal its distinctive and exceptionally stable aerosol properties and define the long-term influence of pyroCb activity on the stratospheric aerosol budget. Analysis of 13 years of airborne observations shows that pyroCb are responsible for 10 to 25% of the black carbon and organic aerosols in the "present-day" lower stratosphere, with similar impacts in both the North and South Hemispheres. These results suggest that, should pyroCb increase in frequency and/or magnitude in future climates, they could generate dominant trends in stratospheric aerosol.

Reducing Implant Infection in Orthopaedics (RIIiO): Results of a pilot study comparing the influence of forced air and resistive fabric warming technologies on postoperative infections following orthopaedic implant surgery

BACKGROUND

Active warming during surgery prevents perioperative hypothermia but the effectiveness and postoperative infection rates may differ between warming technologies.

AIM

To establish the recruitment and data management strategies needed for a full trial comparing postoperative infection rates associated with forced air warming (FAW) versus resistive fabric warming (RFW) in patients aged >65 years undergoing hemiarthroplasty following fractured neck of femur.

METHODS

Participants were randomized 1:1 in permuted blocks to FAW or RFW. Hypothermia was defined as a temperature of <36°C at the end of surgery. Primary outcomes were the number of participants recruited and the number with definitive deep surgical site infections.

FINDINGS

A total of 515 participants were randomized at six sites over a period of 18 months. Follow-up was completed for 70.1%. Thirty-seven participants were hypothermic (7.5% in the FAW group; 9.7% in the RFW group). The mean temperatures before anaesthesia and at the end of surgery were similar. For the primary clinical outcome, there were four deep surgical site infections in the FAW group and three in the RFW group. All participants who developed a postoperative infection had antibiotic prophylaxis, a cemented prosthesis, and were operated under laminar airflow; none was hypothermic. There were no serious adverse events related to warming.

CONCLUSION

Surgical site infections were identified in both groups. Progression from the pilot to the full trial is possible but will need to take account of the high attrition rate.

Septic pericarditis and pericardial abscess secondary to a migrating foreign body in a dog

Abscess formation in the pericardial space has been described as a rare complication of trauma, congenital defects, penetrating foreign body, or extension of local myocardial infection in the dog. Presented here is a case of a juvenile dog with septic pericardial effusion secondary to an isolated intrapericardial abscess. Surgical pericardiectomy was successful in removing the abscess and nidus for septic effusion in this patient, and histopathology of the abscess tissue was suggestive of foreign plant material migration as the nidus for abscess formation. Recheck echocardiogram at the six-month postoperative period showed no recurrence of pericardial effusion or abscessation. Although abscess formation and septic pericarditis secondary to foreign body migration is an uncommon cause for large volume pericardial effusion, this should be considered as a differential particularly in a young and previously healthy dog.

Chemical evidence of inter-hemispheric air mass intrusion into the Northern Hemisphere mid-latitudes

The East Asian Summer Monsoon driven by temperature and moisture gradients between the Asian continent and the Pacific Ocean, leads to approximately 50% of the annual rainfall in the region across 20–40°N. Due to its increasing scientific and social importance, there have been several previous studies on identification of moisture sources for summer monsoon rainfall over East Asia mainly using Lagrangian or Eulerian atmospheric water vapor models. The major source regions for EASM previously proposed include the North Indian Ocean, South China Sea and North western Pacific. Based on high-precision and high-frequency 6-year measurement records of hydrofluorocarbons (HFCs), here we report a direct evidence of rapid intrusion of warm and moist tropical air mass from the Southern Hemisphere (SH) reaching within a couple of days up to 33°N into East Asia. We further suggest that the combination of direct chemical tracer record and a back-trajectory model with physical meteorological variables helps pave the way to identify moisture sources for monsoon rainfall. A case study for Gosan station (33.25°N, 126.19°E) indicates that the meridional transport of precipitable water from the SH accompanying the southerly/southwesterly flow contributes most significantly to its summer rainfall.

Fumarase Deficiency: A Safe and Potentially Disease Modifying Effect of High Fat/Low Carbohydrate Diet

Fumarate hydratase deficiency (FHD) caused by biallelic alterations of the FH (fumarate hydratase) gene is a rare disorder of the tricarboxylic acid cycle, classically characterized by encephalopathy, profound psychomotor retardation, seizures, a spectrum of brain abnormalities and early death in childhood. Less common milder phenotypes with moderate cognitive impairment and long-term survival have been reported. In addition, heterozygous mutations of the FH gene are responsible for hereditary leiomyomatosis and renal cell cancer (HLRCC). There is currently no recommended disease modifying treatment for FHD and only isolated reports of unsuccessful dietary modifications. Herein, we describe the safe and possibly disease modifying effect of a high fat, low carbohydrate diet in a 14-year-old female with severe FHD.

Erratum to: 2016 WSES guidelines on acute calculous cholecystitis

[This corrects the article DOI: 10.1186/s13017-016-0082-5.].

2016 WSES guidelines on acute calculous cholecystitis

Acute calculus cholecystitis is a very common disease with several area of uncertainty. The World Society of Emergency Surgery developed extensive guidelines in order to cover grey areas. The diagnostic criteria, the antimicrobial therapy, the evaluation of associated common bile duct stones, the identification of “high risk” patients, the surgical timing, the type of surgery, and the alternatives to surgery are discussed. Moreover the algorithm is proposed: as soon as diagnosis is made and after the evaluation of choledocholitiasis risk, laparoscopic cholecystectomy should be offered to all patients exception of those with high risk of morbidity or mortality. These Guidelines must be considered as an adjunctive tool for decision but they are not substitute of the clinical judgement for the individual patient.

Potential Health Risk of Herbal Distillates and Decoctions Consumption in Shiraz, Iran

Concentration of 26 elements in 16 different herbal distillates and 5 herbal decoctions, were determined using inductively coupled plasma-mass spectrometry (ICP-MS). The elemental content of five raw herbal materials used for making decoctions and seven distilled and boiled residues were also evaluated by inductively coupled plasma optical emission spectrometry (ICP-OES). The results indicated that herbal products display a wide range of elemental concentrations. Compared with world health regulations, the concentrations of the elements in herbal distillates and decoctions did not exceed the recommended limits. The analysis of herbal extracts did not show a significant transfer of toxic elements during decoction preparation. Comparison of elemental content among fresh herbal material and herbal distillate and decoction of the same herb showed that, besides the elemental abundance of herbal organs, the ionic potential of elements also play an important role in elemental content of herbal products. Based on the results of the research, it seems that most health benefits attributed to herbal products (especially herbal distillates) are more related to their organic compounds rather than elemental composition. Calculated hazard quotient (HQ) and hazard index (HI) were used to evaluate the noncarcinogenic health risk from individual and combined metals via daily consumption of 100 ml of herbal distillates and 250 ml of herbal decoctions. Both HQs and HI through consumption of herbal distillates and herbal decoctions (except Valerian) were below 1. Apparently, daily consumption of herbal distillates and decoctions at the indicated doses poses no significant health risk to a normal adult.

Ecotoxicological risk of polycyclic aromatic hydrocarbons (PAHs) in urban soil of Isfahan metropolis, Iran

Concentration, distribution, probable sources, and health risks of 16 polycyclic aromatic hydrocarbons (PAHs) were investigated in 52 soil samples collected within a radius 50 km from Isfahan metropolis center. Total concentration of PAHs ranged from 57.70 to 11,730.08 μg/kg averaging 2,000.56 μg/kg. Spatial PAH profiles were site-specific and higher concentration of PAHs was observed in the vicinity of industrial zones within Isfahan metropolis. The molecular indices, ring classes, and principal component analysis indicated that the sources of PAHs were both geogenic and pyrogenic. The incremental lifetime cancer risks of exposure to soil PAHs for adults and children living in the study area were 2.3×10(-2) and 2.2×10(-3), respectively. The results suggest that current PAHs levels in Isfahan metropolis soil are highly carcinogenic and may hold a serious health risk for local resident.

Heavy metals fractionation in surface sediments of Gowatr bay--Iran

In this study, the chemical speciation of heavy metals and their distribution in surface sediments of Gowatr bay, southeast Iran, are investigated. Modified Bureau Commune de Reference of the European Commission (BCR) sequential extraction technique was applied to assess Cu, Pb, Zn, Mn, Ni, Co, Cr, V, and Fe in the four fractions of five surface sediment samples. Calculated contamination factors (C(i)f) indicate considerable to very high degree of contamination for Cu and Cr, and very high degree for Zn and Ni. Maximum contamination degree (Cd) also suggests serious anthropogenic pollution at two sites. The dominance of average concentration of Cu, Pb, Zn, and Mn in non-residual fractions indicates higher ecological risk within Gowatr bay. Conversely, Ni, Co, Cr, Fe, and V mainly exist in residual phase and hence pose no immediate ecological risk. Calculated individual contamination factors (ICFs) indicate the highest risk of Cu, Pb, Zn, and Mn at two investigated sites. Global contamination factor (GCF) reveals that Pasabandar harbor is highly impacted by metal pollutants.

Fluctuations of MS births and UV-light exposure

BACKGROUND

Patients with multiple sclerosis (MS) are more frequently born in spring when compared to autumn. Fluctuation of UV-light has been hypothesized to drive this phenomenon.

AIM

To assess the correlation between fluctuation of sunlight and birth season in persons with MS.

METHODS

For this record-linkage study, we collected from the international MSBase and the Italian MS iMed-web databases the dates of birth of 11,415 patients with MS from 36 centres from 15 countries worldwide and compared these to dates of live-births from national registries. From all participating sites, we collected data on UV-light fluctuation and assessed its correlation with seasonal fluctuation in MS births.

RESULTS

Compared with the reference cohort, an increased proportion of persons with MS were born in spring and a decreased proportion in autumn (odds ratio (OR) to be born in spring versus autumn = 1.158, χ² = 36.347, P < 0.001). There was no significantly increased fluctuation of MS births with increased quartile of ambient UV-light fluctuation (Ptrend = 0.086).

CONCLUSION

Seasonal fluctuation of MS births as found in this worldwide cohort of patients with MS did not correlate with variation in seasonal fluctuation of UV-light. Most likely, it results from a complex interplay between fluctuation of sunlight, behavioural factors, other environmental factors and (epi)genetic factors.

Evaluation of potentially toxic metals pollution in the sediments of the Kor river, southwest Iran

This study is carried out to evaluate potentially toxic metal concentrations (As, Cd, Cr, Cu, Hg, Mo, Ni, Pb, and Zn) together with their spatial distribution, degree of pollution, and potential ecological risk in Kor river sediments (southwest Iran) using sediment quality guidelines, geoaccumulation index (I geo), Hakanson potential ecological risk index (RI), and standard methods of statistical analysis. The study area stretches some 140 km from the Drodzan Dam to Bakhtegan Lake, a stretch of river where different industrial and domestic activities (e.g., petrochemical complex, oil refinery, industrial meat processing complex, Marvdasht city sewage) and ecological value overlap with each other. Calculated geoaccumulation index indicate that 50 % of the stations are moderately to very extremely polluted. The potential ecological risk for nine investigated metals in Kor river is Hg (948) > Mo (51.9) > Ni (37.8) > Cd (29.8) > As (22) > Cu (16.6) > Pb (13.3) > Zn (3.3) > Cr (1). Results show that sediments in parts of Kor river sediments are heavily affected by effluents discharged from industrial plants and other parts are affected by agriculture and urban runoff from nearby lands. These phenomena may cause a risk of secondary water pollution under sediment disturbance and/or changes in the physical-chemical characteristics of the aquatic system.

The frequency of CSF oligoclonal banding in multiple sclerosis increases with latitude

BACKGROUND

With the advent of MRI scanning, the value of lumbar puncture to assess oligoclonal band (OCB) status-for the diagnosis of multiple sclerosis (MS) is increasingly uncertain. One major issue is that the reported frequency of cerebrospinal fluid (CSF)-restricted oligoclonal banding for the diagnosis of MS varies considerably in different studies. In addition, the relationship between OCB positivity and disease outcome remains uncertain, as reported studies are generally too small to assess comparative disability outcomes with sufficient power.

METHODS

In order to further investigate variation of OCB positivity in patients with MS, we utilized MSBase, a longitudinal, Web-based collaborative MS outcomes registry following clinical cohorts in several continents and latitudes. We also assessed whether OCB positivity affects long-term disability outcome.

RESULTS

A total of 13,242 patient records were obtained from 37 MS specialist centres in 19 different countries. OCB status was documented in 4481 (34%) patients and 80% of these were OCB positive. The presence of OCB was associated with degree of latitude (p = 0.02). Furthermore, the outcome of patients negative for CSF-specific OCB was significantly better in comparison to the OCB positive patients, as assessed by Expanded Disability Status Scale change (p < 0.001).

CONCLUSIONS

The results of this study indicate that latitude could explain some of the inconsistencies in OCB status reported in different populations. The study confirms that OCB positivity in MS is associated with a worse long-term prognosis.

Speciation and phytoavailability of heavy metals in contaminated soils in Sarcheshmeh area, Kerman Province, Iran

Heavy metal content in soil and the most abundant indigenous plant species (Artemisia sieberi) in Sarcheshmeh area is investigated. Sequential extraction analysis is carried out and phytoavailable fractions of selected heavy metals are also determined. The results show that heavy metals in the study area are potentially bioavailable. Calculated transfer factor (mean value for Cu: 5.7; As: 8.9; Pb: 4.1; Mo: 7.2; Cd: 1.9; and Zn: 1.8) and heavy metal concentration in plant species indicate that metal contamination is already transferred to Artemisia sieberi which proved to behave like an accumulator plant and hence poses a serious threat to local population. Contamination is mostly the result of three decades of ore smelting at the Sarcheshmeh copper complex.

Mcl-1 downregulation by pro-inflammatory cytokines and palmitate is an early event contributing to β-cell apoptosis

Pancreatic β-cell apoptosis is a key feature of diabetes mellitus and the mitochondrial pathway of apoptosis is a major mediator of β-cell death. We presently evaluated the role of the myeloid cell leukemia sequence 1 (Mcl-1), an antiapoptotic protein of the Bcl-2 family, in β-cells following exposure to well-defined β-cell death effectors, for example, pro-inflammatory cytokines, palmitate and chemical endoplasmic reticulum (ER) stressors. All cytotoxic stresses rapidly and preferentially decreased Mcl-1 protein expression as compared with the late effect observed on the other antiapoptotic proteins, Bcl-2 and Bcl-xL. This was due to ER stress-mediated inhibition of translation through eIF2α phosphorylation for palmitate and ER stressors and through the combined action of translation inhibition and JNK activation for cytokines. Knocking down Mcl-1 using small interference RNAs increased apoptosis and caspase-3 cleavage induced by cytokines, palmitate or thapsigargin, whereas Mcl-1 overexpression partly prevented Bax translocation to the mitochondria, cytochrome c release, caspase-3 cleavage and apoptosis induced by the β-cell death effectors. Altogether, our data suggest that Mcl-1 downregulation is a crucial event leading to β-cell apoptosis and provide new insights into the mechanisms linking ER stress and the mitochondrial intrinsic pathway of apoptosis. Mcl-1 is therefore an attractive target for the design of new strategies in the treatment of diabetes.

Assessment of heavy metal concentration in the Khoshk River water and sediment, Shiraz, Southwest Iran

Heavy metal contents and contamination characteristics of the water and sediment of the Khoshk River, Shiraz, Southwest Iran were investigated. The abundance of heavy metals decreases as Zn > Mn > Cr > Ni >Pb > Cu > Cd in water samples and Mn > Cr > Pb > Ni > Zn > Cu > Cd in sediments, respectively. Based on the enrichment factor and geoaccumulation index values, sediments were loaded with Cr, Zn, Pb, Cu, and Cd. Pearson correlation matrix as well as cluster and principal components analyses and analysis of variance were implemented on data from sampling sites. Based on the locations of sampling sites in clusters and variable concentrations at these stations, it was concluded that municipal, industrial, and domestic discharges in the Shiraz urban area strongly affected heavy metals concentrations in the Khoshk River water and sediment. Results obtained from principal components analysis of sediment samples showed that the high concentration of Ni was mainly from natural origin, related to the composition of parent rocks, while the elevated values of Cr, Zn, Pb, Cd, and Cu were due to anthropogenic activities.

Monitoring deterioration of vegetation cover in the vicinity of smelting industry, using statistical methods and TM and ETM(+) imageries, Sarcheshmeh copper complex, Central Iran

Simple statistical methods on Normalized Difference Vegetation Index (NDVI) and bands 3 and 4 data of relatively coarse resolution Thematic Mapper (TM) and Enhanced Thematic Mapper plus (ETM(+)) imageries were used to investigate the impacts of air pollution on the deterioration of the vegetation cover in the Sarcheshmeh copper complex of central Iran. Descriptive statistics and k-means cluster analysis indicated that vegetation deterioration had already started in the prevailing wind directions. The results show that combination of simple statistical methods and satellite imageries can be used as effective monitoring tools to indicate vegetation stress even in regions of sparse vegetation. Despite various possible perturbing factors upon NDVI, this index remains to be a valuable quantitative vegetation monitoring tool.

The Immediate Management of the Patient with Rupture: Open Versus Endovascular repair (IMPROVE) aneurysm trial--ISRCTN 48334791 IMPROVE trialists

BACKGROUND

Systematic reviews have suggested a survival advantage for patients with ruptured abdominal aortic aneurysm (AAA), who are managed by endovascular repair. These reviews are based on single centre experiences of selected patients.

OBJECTIVE

To determine whether a policy of endovascular repair improves the survival of all patients with ruptured AAA.

METHODS

A randomized controlled trial, IMPROVE (ISRCTN 48334791) will randomize patients with a clinical diagnosis of rAAA, made in hospital, either to immediate CT scan and endovascular repair whenever anatomically suitable (endovascular first), or to open repair, with CT scan being optional (normal care), The trial is set on a background of guidelines for emergency care, CT scanning and anaesthesia, which incorporate the protocol of permissive hypotension. Recruitment started in October 2009 and 600 patients are required to show a 14% survival benefit at 30 days (primary outcome) for the endovascular first policy. Recruitment will be from the UK and Europe. Secondary outcomes include 24h, in-hospital and 1 year survival, complications, major morbidities, costs and quality of life.

DISCUSSION

This is a "real life" trial that will answer the fundamental relevant clinical dilemma, namely, do patients who present with ruptured AAA derive benefit from treatment in a system, which offers a preferential strategy of endovascular repair? The trial addresses whether the anticipated reduced mortality and morbidity associated with endovascular repair is offset by the relatively greater ease of access and speed to conventional surgery. This issue is pivotal to future patient care and provision of services.

Interferon regulatory factor-1 is a key transcription factor in murine beta cells under immune attack

AIMS/HYPOTHESIS

IFN-gamma, together with other inflammatory cytokines such as IL-1beta and TNF-alpha, contributes to beta cell death in type 1 diabetes. We analysed the role of the transcription factor interferon regulatory factor (IRF)-1, a downstream target of IFN-gamma/signal transducer and activator of transcription (STAT)-1, in immune-mediated beta cell destruction.

METHODS

Islets from mice lacking Irf-1 (Irf-1 (-/-)) and control C57BL/6 mice were transplanted in overtly diabetic NOD mice. Viability and functionality of islets were evaluated in vitro. Chemokine expression by Irf-1 (-/-) islets and INS-1E cells transfected with Irf-1 short interfering RNA (siRNA) was measured by real-time PCR as well as in functional assays in vitro.

RESULTS

IRF-1 deletion in islets was associated with higher prevalence of primary non-function (63% vs 25%, p <or= 0.05) and shorter functioning graft survival (6.0 +/- 2.6 vs 10.4 +/- 4.8 days, p <or= 0.05) in contrast to similar skin graft survival. Although Irf-1 (-/-) islets were resistant to cytokine-induced cell death, insulin secretion by them was lower than that of control C57BL/6 islets under medium and cytokine conditions. IL-1 receptor antagonist partly restored the cytokine-induced secretory defect in vitro and completely prevented primary non-function in vivo. Cytokine-exposed Irf-1 (-/-) islets and INS-1E cells transfected with Irf-1 siRNA showed increased expression of Mcp-1 (also known as Ccl2), Ip-10 (also known as Cxcl10), Mip-3alpha (also known as Ccl20) and Inos (also known as Nos2) mRNA and elevated production of monocyte chemoattractant protein-1 (MCP-1) and nitrite compared with controls. In vivo, Irf-1 (-/-) islets displayed a higher potential to attract immune cells, reflected by more aggressive immune infiltration in the grafted islets.

CONCLUSIONS/INTERPRETATION

These data indicate a key regulatory role for IRF-1 in insulin and chemokine secretion by pancreatic islets under inflammatory attack.

Lessons learned engaging Hispanic communities in cancer research

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Background: Community involvement is critical to advance cancer education and prevention in minority communities. Researchers must be knowledgeable of the target community's basic cultural beliefs and linguistic needs. This study sought to identify the best approach for conducting community based cancer research in South Texas Hispanic communities. We report our experiences and lessons learned with participants and site recruitment and retention. Methods: We introduced a community based, culturally relevant breast and cervical cancer screening and early detection program, Esperanza y Vida, to address barriers and disparities in four border communities (urban, rural, colonia, and small border town). These areas represent the diverse South Texas Mexican American population in terms of language use, immigration status, and length of time in the US. Within these communities we recruited a grassroots community organization, faith-based health center, rural hospital district, and federally qualified health center. Results: Focus groups were conducted with women and men to assess knowledge, attitudes, and beliefs about women's cancers. To successfully recruit participants, we implemented various techniques to engage the community and establish sustainable relationships. These included community health worker recruitment of community members, traditional recruitment (flyers, posters, word of mouth), key community and cultural leader support, and discussions with local groups and health organizations. We and our community partners identified and overcame investigator/community barriers (lack of community knowledge, community integration into the research process, community understanding of research methods, reluctance to develop innovative approaches). Consequently, participants are eager to remain with the program and are individually and collectively mobilizing others to create a sustainable and durable program. Conclusions: 1. Cultural leader engagement worked best for participant recruitment in the small border town and colonia settings, while key community leader engagement was most effective in the small city urban and rural settings. 2. Research/community partners must identify and discuss project barriers regardless of the fear of creating discordance to reach solutions.

No significant financial relationships to disclose.

Induction of nuclear factor-kappaB and its downstream genes by TNF-alpha and IL-1beta has a pro-apoptotic role in pancreatic beta cells

AIMS/HYPOTHESIS

IL-1beta and TNF-alpha contribute to pancreatic beta cell death in type 1 diabetes. Both cytokines activate the transcription factor nuclear factor-kappaB (NF-kappaB), but recent observations suggest that NF-kappaB blockade prevents IL-1beta + IFN-gamma- but not TNF-alpha + IFN-gamma-induced beta cell apoptosis. The aim of the present study was to compare the effects of IL-1beta and TNF-alpha on cell death and the pattern of NF-kappaB activation and global gene expression in beta cells.

METHODS

Cell viability was measured after exposure to IL-1beta or to TNF-alpha alone or in combination with IFN-gamma, and blockade of NF-kappaB activation or protein synthesis. INS-1E cells exposed to IL-1beta or TNF-alpha in time course experiments were used for IkappaB kinase (IKK) activation assay, detection of p65 NF-kappaB by immunocytochemistry, real-time RT-PCR and microarray analysis.

RESULTS

Blocking NF-kappaB activation protected beta cells against IL-1beta + IFNgamma- or TNFalpha + IFNgamma-induced apoptosis. Blocking de novo protein synthesis did not increase TNF-alpha- or IL-1beta-induced beta cell death, in line with the observations that cytokines induced the expression of the anti-apoptotic genes A20, Iap-2 and Xiap to a similar extent. Microarray analysis of INS-1E cells treated with IL-1beta or TNF-alpha showed similar patterns of gene expression. IL-1beta, however, induced a higher rate of expression of NF-kappaB target genes putatively involved in beta cell dysfunction and death and a stronger activation of the IKK complex, leading to an earlier translocation of NF-kappaB to the nucleus.

CONCLUSIONS/INTERPRETATION

NF-kappaB activation in beta cells has a pro-apoptotic role following exposure not only to IL-1beta but also to TNF-alpha. The more marked beta cell death induced by IL-1beta is explained at least in part by higher intensity NF-kappaB activation, leading to increased transcription of key target genes.

The gut in systemic inflammatory response syndrome and sepsis. Enzyme systems fighting multiple organ failure

The prognosis and care of critically ill ICU patients has improved over recent years, but the development of multiple organ failure (MOF) continues to cause significant morbidity and mortality. Shock, with resultant organ ischemia, appears to play a critical role in the development of MOF. It is our global hypothesis that MOF is a gut-derived phenomenon and that novel interventions can improve outcome in shock-induced gut inflammation and dysfunction in critically ill patients. We have found that the anesthetic agent ketamine has a profound impact on the response to endotoxic shock. This review summarizes our findings on the mechanisms of action by which ketamine is able to modulate the nitric oxide, cyclo-oxygenase and heme-oxygenase enzyme systems to attenuate endotoxin-induced organ dysfunction.

Aldose reductase inhibitors for the treatment of diabetic polyneuropathy

BACKGROUND

Polyneuropathy, a common complication of diabetes mellitus, causes pain and sensory and motor deficits in the limbs, and is also an important independent predictor of foot ulceration. Inhibiting the metabolism of glucose by the polyol pathway using aldose reductase inhibitors is a potential mechanism to slow or reverse the neuropathy's progression.

OBJECTIVES

To assess the effects of aldose reductase inhibitors on the progression of symptoms, signs or functional disability in diabetic polyneuropathy.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to May 2007), EMBASE (from January 1980 to May 2007) and LILACS (from 1982 to May 2007). We reviewed bibliographies of randomized trials identified, and contacted authors and experts in the field.

SELECTION CRITERIA

We included randomized controlled trials comparing an aldose reductase inhibitor with control, and lasting at least six months. The primary outcome measure was change in neurological function, measured in various ways, including strength testing, sensory examination, and composite scores of neurological examination. Secondary outcome measures were nerve conduction studies, neuropathic symptoms, quality of life, occurrence of foot ulcers and adverse effects.

DATA COLLECTION AND ANALYSIS

Trials included in the review were selected and assessed independently by at least two of us. Methodological criteria and study results were recorded on data extraction forms.

MAIN RESULTS

Thirty-two randomized controlled trials meeting the inclusion criteria were identified. Many had significant methodological flaws. Change in neurological function, our primary outcome measure, was assessed in 29 trials, but sufficient data for meta-analysis were only available in 13 studies, involving 879 treated participants and 909 controls. There was no overall significant difference between the treated and control groups (SMD -0.25, 95% CI -0.56 to 0.05), although one subgroup analysis (four trials using tolrestat) favored treatment. A benefit for neuropathic symptoms was suggested by a group of trials using a dichotomized endpoint (improvement or not), but this was contradicted by another group of trials which measured symptoms on a continuous scale. There was no overall benefit on nerve conduction parameters (27 studies) or foot ulceration (one study). Quality of life was not assessed in any of the studies. While most adverse events were infrequent and minor, three compounds had dose limiting adverse events that lead to their withdrawal from human use: severe hypersensitivity reactions with sorbinil, elevation of creatinine with zenarestat, and alteration of liver function with tolrestat.

AUTHORS' CONCLUSIONS

We found no statistically significant difference between aldose reductase inhibitors and placebo in the treatment of diabetic polyneuropathy. Any future clinical trials of aldose reductase inhibitors should be restricted to compounds proven to have substantial biological or preclinical advantages over previously tested agents.

Physician Response Unit—A feasibility study of an initiative to enhance the delivery of pre-hospital emergency medical care

OBJECTIVES

To describe the rationale, development and initial results of a collaborative pre-hospital pilot project designed to enhance the emergency care needs of an inner city population.

METHODS

Retrospective descriptive analysis of emergency calls attended by a rapid response car staffed by a pre-hospital care physician and ambulance service technician or paramedic.

RESULTS

Seven hundred and forty-eight consecutive patients over a 13-month period are described. Six hundred and thirty-eight (82%) patients underwent clinical consultation with a physician within 8 min of emergency call. The Physician Response Unit (PRU) also provided an additional vehicle responding to emergency calls, reaching the national 8 min target response time in 638 (82%) of all cases. Two hundred and eighty-nine (39%) of the patients attended had medical therapy initiated by the PRU physician. Nearly two-thirds of this group, 189 (65%), received medical therapy outside current ambulance service protocols. A physician medical escort was provided for 142 (25%) of patients attending hospital. Of all patients seen 577 (77%) attended the emergency department via ambulance, and 136 (18%) patients were assessed, treated and prevented from attending the emergency department.

CONCLUSIONS

The PRU provided clinical care beyond that delivered by the ambulance service. It also contributed positively to local ambulance service response times. The service was able to prevent unnecessary ambulance journeys and attendance at hospital. It demonstrates that traditional working practices can be altered to improve the delivery of emergency medical care.

Hearing half the message? A re-audit of the care of patients with acute asthma by emergency ambulance crews in London

PROBLEM

An initial audit of the care provided to emergency asthma patients by the ambulance service was carried out in 1996. Some under-recognition and under-treatment of severe asthma was found as well as a lack of documentation of patient condition on scene. A re-audit was undertaken in 1999.

DESIGN

A multidisciplinary advisory group was reconvened. The same method was adopted as for the first audit. Patients included were those administered nebulised salbutamol by crews in the catchment areas of four hospitals and those diagnosed with asthma at the Accident & Emergency (A&E) departments of those hospitals between January and March 1999.

SETTING

London Ambulance Service.

KEY MEASURES FOR IMPROVEMENT

(1) Accuracy of diagnosis and appropriateness of treatment, and (2) adherence to protocol.

STRATEGIES FOR CHANGE

Following the first audit, treatment protocols were widened and brought into line with the British Thoracic Society guidelines for care of acute asthma patients. The results were widely disseminated within the service and training was initiated for all operational staff.

EFFECTS OF CHANGE

The number of patients included in the re-audit more than doubled (audit 1: n = 252, audit 2: n = 532). The increase occurred exclusively in those administered nebulised salbutamol by ambulance crews but diagnosed with conditions other than asthma in A&E (audit 1: n = 15, audit 2: n = 161). The proportion of patients diagnosed with asthma in A&E who were administered nebulised salbutamol by their attending crew rose from 58% to 75%. However, 43 asthma patients were not treated; several of these were not recognised as suffering from asthma and others fell within the changed protocols for treatment. Adherence to protocol for administration of salbutamol remained high. Pre-hospital documentation of key observations did not improve.

LESSONS LEARNT

Messages from the first audit seem to have been acted upon selectively. Implementing change is complex, and re-audit is necessary to understand the effects of the changes made.

Unexpected effects of viral interleukin-10-secreting dendritic cells in vivo: preferential inhibition of TH2 responses

Viral interleukin (IL)-10 (vIL-10) has been widely described as an immunoregulatory cytokine that does not possess the T-cell costimulatory activities of cellular IL-10; it was therefore believed to be a more potent tolerogenic mediator. The immunosuppressive properties of this cytokine are partly attributed to its capacity to render dendritic cells (DCs) unable to undergo full maturation and to activate T cells. We reported here that myeloid DCs retrovirally transduced with vIL-10 had an impaired production of IL-12 and a decreased expression of MHC class II molecules but had minor defects in costimulatory molecule expression and no alteration on CCR5 and CCR7 expression. In mixed leukocyte reaction, vIL-10-transduced C57BL/6 bm12 (MHC class II mismatch) DCs had a reduced capacity to stimulate C57BL/6 wild-type CD4+ T-cell proliferation. We show that bm12 vIL-10-transduced DC administration in CD8-/- C57BL/6 mice promoted IFN-gamma production, down-regulated TH2-type cytokine production, and did not induce skin graft tolerance. These findings suggest that vIL-10-transduced DC may surprisingly facilitate Th1-type inflammatory responses in vivo.

Primary Dural Mucosa-Associated Lymphoid Tissue-Type Lymphoma: Case Report and Review of the Literature

A 47-year-old Hispanic male presented with visual field disturbances, memory impairment, and a seizure. CT and MRI were consistent with meningioma. Both neurologic exam and routine laboratory tests were within normal limits. The patient underwent craniotomy and subtotal resection of the tumor. On H&E, the lesion was composed of a lymphoid mass with well-defined irregularly shaped follicles surrounded by a monomorphic population of small lymphocytes. Marginal zones stained for B-cell markers, CD20 and CD79a, one T-cell marker, CD43, and kappa light chains. While other markers did not stain the majority of tumor cells, they did identify other lymphoid and plasma cell elements. A diagnosis of marginal zone B-cell lymphoma of dura, mucosa-associated lymphoid tissue (MALT)-type (extranodal) was made. MALT-type lymphomas are unusual in the nervous system; this is the first such case reported in a male and serves to emphasize the wide diversity of presentation of a neoplasm originally described in the GI tract and thus far described in the CNS only in females.

True Winter Range of the Veery (Catharus Fuscescens): Lessons for Determining Winter Ranges of Species That Winter in The Tropics

Most recent references describe the winter range of the Veery (Catharus fuscescens) as including an extensive area from northern Colombia, Venezuela, and Guyana south to south-central Brazil. Analysis of seasonal distribution of specimen records in South America, however, shows that 91 of 105 specimens were taken during spring and fall, not winter; the remaining 14, taken from 2 December to 20 February, are all from three small areas at the periphery or south of the Amazon basin. Thus, the true winter range is almost completely south and east of the area generally described. The seasonal distribution of specimen records is consistent with observational data from South America and banding data from the Neotropics. Although those data must be treated cautiously, it appears that the true winter range of the Veery is in south-central and southeastern Brazil, an area where habitat destruction threatens many natural habitats, rather than in the relatively undisturbed areas of western Amazonia. Widespread erroneous portrayal of the winter range of the Veery seems to have been caused largely by the assumption that the species winters in South America wherever it has been recorded and by overlooking a previously published analysis of its winter distribution.

Developing an integrated nursing team approach

Nursing Standard recently published a literature search that explored different models of integrated nursing and more traditional models of community nursing in primary care (Baileff 2000). Models of change for implementing integrated nursing were also examined. This article aims to explore the development of an integrated nursing team in a healthcare centre in Northampton.

Myosin light chain kinase and the onset of labour in humans

Myosin light chain kinase (MLCK) is essential for myometrial contractions induced by calcium-mobilizing agonists. From the gene of vertebrate smooth muscle/non-muscle MLCK there are at least four proteins expressed. We have found that both a > 200 and a 137 kDa MLCK are equally expressed in human non-pregnant (NP) and term pregnant (P) uterine smooth muscle and confirmed that 19 kDa telokin (TK) is only expressed in P myometrium. In addition, we have observed that a MLCK immunogen at approximately 60 kDa is only expressed in NP myometrium, suggesting that its expression is inhibited during normal pregnancy in a hormonally dependent manner. However, when we compared pregnant myometrium from patients delivered preterm (PT) (< 34 weeks gestation), but not in labour (NIL), with PT patients in labour (IL) we found that PT(IL) samples expressed the approximately 60 kDa MLCK immunogen and thus displayed a NP phenotype whereas PT(NIL) samples did not express the protein and retained a pregnant phenotype. We hypothesize that the novel approximately 60 kDa MLCK immunogen contributes to the aberrent contractility associated with preterm labour. Experimental Physiology (2001) 86.2, 313-318.