Accuracy of contrast-enhanced CT and predictive factors for extracapsular spread in unknown primary head and neck squamous cell cancer

AIM

To determine the accuracy of contrast-enhanced computed tomography (CECT) for nodal extracapsular spread (ECS) and identify predictive radiological signs and clinicopathological features for ECS in unknown-primary head and neck squamous cell cancer (UPHNSCC).

MATERIALS AND METHODS

The CECT imaging of patients who underwent primary neck dissection for UPHNSCC during 2011-2015 was analysed. The largest pathological-looking node at each radiologically involved level was evaluated in consensus by two head and neck radiologists. Parameters included longest diameter, margin sharpness, haziness in adjacent fat, necrosis, and loss of fat plane with adjacent structures. Independent assessment was also made regarding the presence/absence of ECS. Findings and clinicopathological parameters were correlated with histopathology.

RESULTS

Thirty-one patients with 39 neck levels had metastatic nodal involvement determined on CECT. Confirmed ECS was found at 26 levels in 23 patients. Sensitivity of radiological assessment for ECS by nodal level was 81-85% (95% confidence interval [CI]=65-93%) and specificity 46-54% (95% CI=19-81%); kappa 0.87. On univariate analysis based on the largest involved node per patient, longest diameter being ≥30 mm (p=0.007), haziness in adjacent fat (p=0.023), increasing age (p=0.006), and more advanced pathological nodal status (p=0.027) were statistically significantly associated with ECS. Haziness and increasing age were independent predictors on multivariate analysis (odds ratio [OR]=26.4 and 1.24).

CONCLUSION

Expert assessment of ECS on CECT had good sensitivity with excellent interobserver agreement. A longest nodal diameter of ≥30 mm, haziness in the surrounding fat on CECT, advanced pathological nodal status, and advancing patient age were significantly associated with ECS in UPHNSCC patients, findings not previously reported.

A Research Roadmap: Connected Health as an Enabler of Cancer Patient Support

The evidence that quality of life is a positive variable for the survival of cancer patients has prompted the interest of the health and pharmaceutical industry in considering that variable as a final clinical outcome. Sustained improvements in cancer care in recent years have resulted in increased numbers of people living with and beyond cancer, with increased attention being placed on improving quality of life for those individuals. Connected Health provides the foundations for the transformation of cancer care into a patient-centric model, focused on providing fully connected, personalized support and therapy for the unique needs of each patient. Connected Health creates an opportunity to overcome barriers to health care support among patients diagnosed with chronic conditions. This paper provides an overview of important areas for the foundations of the creation of a new Connected Health paradigm in cancer care. Here we discuss the capabilities of mobile and wearable technologies; we also discuss pervasive and persuasive strategies and device systems to provide multidisciplinary and inclusive approaches for cancer patients for mental well-being, physical activity promotion, and rehabilitation. Several examples already show that there is enthusiasm in strengthening the possibilities offered by Connected Health in persuasive and pervasive technology in cancer care. Developments harnessing the Internet of Things, personalization, patient-centered design, and artificial intelligence help to monitor and assess the health status of cancer patients. Furthermore, this paper analyses the data infrastructure ecosystem for Connected Health and its semantic interoperability with the Connected Health economy ecosystem and its associated barriers. Interoperability is essential when developing Connected Health solutions that integrate with health systems and electronic health records. Given the exponential business growth of the Connected Health economy, there is an urgent need to develop mHealth (mobile health) exponentially, making it both an attractive and challenging market. In conclusion, there is a need for user-centered and multidisciplinary standards of practice to the design, development, evaluation, and implementation of Connected Health interventions in cancer care to ensure their acceptability, practicality, feasibility, effectiveness, affordability, safety, and equity.

Exploring young women's perspectives of a targeted support programme for teenage parents

CONTEXT

Teenage parents and their children are at risk of poorer outcomes than older mothers, and their peers.

OBJECTIVE

Evaluate participants' experiences of a targeted teenage parent support programme.

DESIGN

A qualitative study was conducted to gain feedback from participants of a locally commissioned teenage parent support programme. Four focus groups were held with participants attending the programme in different areas of the county, and analysed using applied thematic analysis.

PARTICIPANTS

Teenage mothers aged 16-19 years from vulnerable backgrounds (n=18) attending a teenage parent support programme in County Durham.

RESULTS

Two major themes emerged from the analysis focusing on factors influencing enrolment and continued engagement and how the programme leads to personal development for mother and child.The majority of participants felt that the group fostered a supportive environment and led to a reduction in social isolation. The provision of free transport and childcare onsite was seen as a key component of the service without which many would not have been able to attend.

DISCUSSION

The programme appeared effective at increasing the emotional and social capabilities of teenage mothers. It had a positive impact on parents' engagement in education and employment, as well as impacting on children's social development.

CONCLUSIONS

Targeted support programmes have the ability to increase social and emotional capabilities of teenage mothers and their children. They can increase engagement in education and employment for teenage mothers. The provision of transport and free child care places can enhance engagement in such programmes.

Evaluation of a pilot police-led suicide early alert surveillance strategy in the UK

INTRODUCTION

Those bereaved by suicide are at increased risk of psychological harm, which can be reduced with the provision of timely support. This paper outlines an evaluation of a pilot police-led suicide strategy, in comparison to a coroner-led suicide strategy looking at the number, and length of time it takes for deaths to be recorded for each strategy. Additionally, the police-led strategy offers timely contact from support services for bereaved individuals. We examined what impact this offer of support had on the capacity of support services.

METHODS

A mixed methods evaluation compared how long it took for suspected suicides to be recorded using both strategies. The number of referrals received by support services during the pilot strategy were compared with those from previous years. A feedback focus group, and interviews, were held with key stakeholders.

RESULTS

The coroner strategy was more consistent at identifying suspected suicides; however, reports were filed quicker by the police. Bereaved individuals were willing to share contact details with police officers and consent for referral to support services which lead to increased referrals. The focus group and interviews revealed that the pilot police strategy needs better integration into routine police practice.

CONCLUSIONS

This strategy has the potential to deliver a real benefit to those bereaved by suicide; however, there are still aspects which could be improved.

A mixed-method outcome evaluation of a specialist Alcohol Hospital Liaison Team

AIMS

To evaluate the effectiveness of an Alcohol Hospital Liaison Team at reducing alcohol-specific hospital attendances and admissions.

METHODS

In a mixed-method evaluation, 96 patients who accessed the team were monitored using data for alcohol-specific hospital attendances and Accident and Emergency (A&E) admissions before, during, and after engaging with the team. A feedback survey was sent to patients and a focus group was held with staff from the team to identify barriers and facilitators to the successful delivery of this service.

RESULTS

No differences were observed when looking at alcohol admissions or A&E attendances before patients engaged with the service to those after discharge. While hospital admissions decreased slightly and A&E attendances increased slightly, these differences were not significant. Hospital admissions and A&E attendances increased significantly during engagement with the service. The focus group identified confusion over who should be delivering brief interventions and that the team was holding onto patients for too long.

CONCLUSION

The results of this evaluation demonstrated that this team was not effective at reducing alcohol attendances or admissions due to a number of factors. Policy makers should make note of the barriers to effectiveness highlighted in this article, before commissioning alcohol care teams in the future.

Calf Compartment Syndrome associated with the Use of an Intra-osseous Line in an Adult Patient: A Case Report

We present a case of a lower limb compartment syndrome associated with the use of an intra-osseous line inserted into the proximal tibia in an adult patient. An unconscious 59-year old male with multiple injuries presented to our Emergency Department after a road traffic accident. Bilateral proximal tibial intra osseous-lines were inserted due to poor venous access. After resuscitation his left leg was noted to be tense and swollen with absent pulses. Acute compartment syndrome was diagnosed both clinically and with compartment pressure measurement. Two incision fasciotomy on his left lower leg was performed. Intra osseous-lines in the proximal tibia are increasingly used in adult patients in the pre-hospital setting by paramedics and emergency physicians. Their use, along with the possible complications of these devices, such as the development of compartment syndrome or osteomyelitis leading to amputation, is well reported in the paediatric literature. To the best of our knowledge, there have not been any previous reports of complications in the adult patient. We present a case of lower leg compartment syndrome developing from the use of an intra-osseous line in the proximal tibia in an adult patient. With the increasing use of intra-osseous lines in adult patients, clinicians should be aware of the possibility of developing compartment syndrome which may lead to disability or amputation in severe cases.

A Coproduction Community Based Approach to Reducing Smoking Prevalence in a Local Community Setting

Research highlights that asset-based community development where local residents become equal partners in service development may help promote health and well-being. This paper outlines baseline results of a coproduction evaluation of an asset-based approach to improving health and well-being within a small community through promoting tobacco control. Local residents were recruited and trained as community researchers to deliver a smoking prevalence survey within their local community and became local health champions, promoting health and well-being. The results of the survey will be used to inform health promotion activities within the community. The local smoking prevalence was higher than the regional and national averages. Half of the households surveyed had at least one smoker, and 63.1% of children lived in a smoking household. Nonsmokers reported higher well-being than smokers; however, the differences were not significant. Whilst the community has a high smoking prevalence, more than half of the smokers surveyed would consider quitting. Providing smoking cessation advice in GP surgeries may help reduce smoking prevalence in this community. Work in the area could be done to reduce children's exposure to smoking in the home.

A rapid systematic review of what we know about alcohol use disorders and brief interventions in the criminal justice system

Purpose

– The purpose of this paper is to review the evidence of alcohol use disorders within the different stages of the criminal justice system in the UK. Furthermore it reviewed the worldwide evidence of alcohol brief interventions in the various stages of the criminal justice system.

Design/methodology/approach

– A rapid systematic review of publications was conducted from the year 2000 to 2014 regarding the prevalence of alcohol use disorders in the various stages of the criminal justice system. The second part of the work was a rapid review of effectiveness studies of interventions for alcohol brief interventions. Studies were included if they had a comparison group. Worldwide evidence was included that consisted of up to three hours of face-to-face brief intervention either in one session or numerous sessions.

Findings

– This review found that 64-88 per cent of adults in the police custody setting; 95 per cent in the magistrate court setting; 53-69 per cent in the probation setting and 5,913-863 per cent in the prison system and 64 per cent of young people in the criminal justice system in the UK scored positive for an alcohol use disorder. There is very little evidence of effectiveness of brief interventions in the various stages of the criminal justice system mainly due to the lack of follow-up data.

Social implications

– Brief alcohol interventions have a large and robust evidence base for reducing alcohol use in risky drinkers, particularly in primary care settings. However, there is little evidence of effect upon drinking levels in criminal justice settings. Whilst the approach shows promise with some effects being shown on alcohol-related harm as well as with young people in the USA, more robust research is needed to ascertain effectiveness of alcohol brief interventions in this setting.

Originality/value

– This paper provides evidence of alcohol use disorders in the different stages of the criminal justice system in the UK using a validated tool as well as reviewing the worldwide evidence for short ( < three hours) alcohol brief intervention in this setting.

Can a theoretical framework help to embed alcohol screening and brief interventions in an endoscopy day-unit?

INTRODUCTION AND AIMS

The National Institute for Health Care and Excellence recommend that alcohol screening and brief intervention (ASBI) should be routinely implemented in secondary care. This study used theoretical frameworks to understand how health professionals can be supported to adapt their behaviour and clinical practice.

DESIGN AND METHODS

Staff training and support was conducted using theoretical frameworks. A 12-week study, delivering ASBI was carried out as part of routine practice in an endoscopy day-unit. Anonymised patient data were collected using the Alcohol Use Disorders Identification Tool (AUDIT) and whether patients received a brief intervention. Staff completed the Shortened Alcohol and Alcohol Problems Perceptions Questionnaire at three time points and took part in a focus group both pre and post study.

RESULTS

For staff, levels or role adequacy, role legitimacy, motivation to discuss alcohol, security in their role, job satisfaction and commitment to working with patients who drink increased during the time of the study. 1598 individual patients were seen in the department in the timeframe. Of these, 1180 patients were approached (74%); 18% (n=207) of patients were AUDIT positive.

DISCUSSION

This study has shown that it is possible to reach a high number of patients in a busy hospital out-patient department and deliver ASBI by working with staff using theoretical frameworks for training. Embedding evidence-based public health interventions into routine clinical environments is complex. The social system in which professionals operate requires consideration alongside individual professionals' real and perceived barriers and facilitators to change.

Pharmacokinetics, Pharmacodynamics, and Safety of a Prostaglandin D2 Receptor Antagonist

Laropiprant is a selective antagonist of the prostaglandin D(2) (PGD(2)) receptor subtype 1 (DP1). Three double-blind, randomized, placebo-controlled studies evaluated the safety, tolerability, pharmacokinetics, and pharmacodynamics of single and multiple oral doses of laropiprant in healthy male volunteers. Single doses up to 900 mg and multiple doses up to 450 mg were generally well tolerated. Laropiprant exhibited dose-proportional pharmacokinetics. Oral absorption is rapid (T(max)=0.8-2.0 h) and the terminal half-life is approximately 12-18 h. The pharmacokinetics of laropiprant was not affected by food. Single doses of 6 mg and higher were effective in suppressing PGD(2)-induced cyclic AMP accumulation in platelets, demonstrating laropiprant target engagement with DP1. Laropiprant has detectable off-target antagonist effects at the thromboxane A(2) receptor but no clinically significant effect on collagen-induced platelet aggregation or bleeding times with multiple doses up to 200 mg.

Cervical extraskeletal Ewing's sarcoma: case report demonstrating radiological features and management

BACKGROUND

Extraskeletal Ewing's sarcoma is a rare tumour of mesenchymal origin, which is histologically similar to primary osseous Ewing's sarcoma. The majority of cases have been reported in the lower limb and paravertebral region, with a few cases reported in the neck.

METHODS

We report a patient with extraskeletal Ewing's sarcoma presenting with a right-sided neck mass, vocal fold palsy and T1 nerve root involvement. The detection of characteristic features on computed tomography and magnetic resonance imaging scans, in conjunction with histological analysis, was required to make the diagnosis.

RESULTS

Radiological imaging demonstrated that the tumour was infiltrating through the neural exit foramina of the lower cervical nerve roots, with encasement of the vertebral artery. The patient was managed with combination chemotherapy for systemic control and irradiation for local control.

CONCLUSION

Extraskeletal Ewing's sarcoma has a propensity to occur in a paravertebral location, being found rarely in the cervical region, and has a predilection to infiltrate through neural exit formina. Computed tomography and magnetic resonance imaging are helpful in the diagnosis of this rare tumour.

Suppression of Niacin-induced Vasodilation with an Antagonist to Prostaglandin D2 Receptor Subtype 1

Niacin (nicotinic acid) reduces cardiovascular events in patients with dyslipidemia. However, symptoms associated with niacin-induced vasodilation (e.g., flushing) have limited its use. Laropiprant is a selective antagonist of the prostaglandin D(2) receptor subtype 1 (DP1), which may mediate niacin-induced vasodilation. The aim of this proof-of-concept study was to evaluate the effects of laropiprant (vs placebo) on niacin-induced cutaneous vasodilation. Coadministration of laropiprant 30, 100, and 300 mg with extended-release (ER) niacin significantly lowered flushing symptom scores (by approximately 50% or more) and also significantly reduced malar skin blood flow measured by laser Doppler perfusion imaging. Laropiprant was effective after multiple doses in reducing symptoms of flushing and attenuating the increased malar skin blood flow induced by ER niacin. In conclusion, the DP1 receptor antagonist laropiprant was effective in suppressing both subjective and objective manifestations of niacin-induced vasodilation.

The relationship between patient physiology and cancer-specific survival following curative resection of colorectal cancer

The impact of patient physiology on cancer-specific survival is poorly documented. Patient physiology predicted overall, cancer-specific (Physiology Score>30; HR 8.64 (95% CI 3.00-24.92); P=0.0005) and recurrence-free survival (Physiology Score >30; HR 7.44 (95% CI 1.99-27.73); P=0.003) independent of Dukes stage following potentially curative surgery for colorectal cancer. This independent negative association with survival is a novel observation.

Neuroprotective agents for clinical trials in ALS: a systematic assessment

BACKGROUND

Riluzole is currently the only Food and Drug Administration-approved treatment for ALS, but its effect on survival is modest.

OBJECTIVE

To identify potential neuroprotective agents for testing in phase III clinical trials and to outline which data need to be collected for each drug.

METHODS

The authors identified 113 compounds by inviting input from academic clinicians and researchers and via literature review to identify agents that have been tested in ALS animal models and in patients with ALS. The list was initially narrowed to 24 agents based on an evaluation of scientific rationale, toxicity, and efficacy in previous animal and human studies. These 24 drugs underwent more detailed pharmacologic evaluation.

RESULTS

Twenty drugs were selected as suitable for further development as treatments for patients with ALS. Talampanel and tamoxifen have completed early phase II trials and have demonstrated preliminary efficacy. Other agents (ceftriaxone, minocycline, ONO-2506, and IGF-1 polypeptide) are already in phase III trials involving large numbers of patients with ALS. Remaining agents (AEOL 10150, arimoclomol, celastrol, coenzyme Q10, copaxone, IGF-1-viral delivery, memantine, NAALADase inhibitors, nimesulide, scriptaid, sodium phenylbutyrate, thalidomide, trehalose) require additional preclinical animal data, human toxicity and pharmacokinetic data including CNS penetration prior to proceeding to large scale phase III human testing. Further development of riluzole analogues should be considered.

CONCLUSIONS

Several potential neuroprotective compounds, representing a wide range of mechanisms, are available and merit further investigation in ALS.

Irish-1 and Irish-2: UK epidemic meticillin-resistant Staphylococcus aureus strains associated with Northern Ireland

Since 1998, an increasing number of meticillin-resistant Staphylococcus aureus (MRSA) isolates with one of two characteristic phage patterns have been referred to the authors' laboratory from Northern Ireland. These strains were designated 'Irish-1' and 'Irish-2'. Analysis of 956 submitted isolates classified as Irish-1 or Irish-2 showed that 97% of the former and 95% of the latter were from Northern Ireland. Only 0.2% and 3%, respectively, were from England. Eleven Irish-2 isolates had been referred from Western Australia as representatives of an epidemic strain originally isolated there in 1994. Ninety isolates with the Irish-1 phage pattern and 91 isolates with the Irish-2 phage pattern, from numerous hospitals, were characterized by SmaI pulsed-field gel electrophoresis (PFGE), toxin gene carriage and antibiotic susceptibility. PFGE showed that, within each collection, a few isolates represented unrelated strains, but the majority were within six band differences of the most common profiles. Half of the Irish-1 isolates were homogeneous, with 22 DNA profiles among the remainder. Irish-2 isolates had two common profiles, D1 and D2, equally divided between one-third of the isolates and differing from each other by two bands; the remaining isolates shared 31 DNA profiles. Cluster analysis showed some overlap in DNA profiles between the Irish-1 and Irish-2 strains, but clear separation from other epidemic MRSA strains. There was no obvious correlation between PFGE profile and either antibiotic resistance pattern or toxin gene possession. All but three Irish-1 isolates possessed only the staphylococcal enterotoxin A (sea) gene, whereas almost all Irish-2 isolates were negative for all 12 enterotoxin genes. Sixty-nine percent of Irish-2 isolates were resistant to ciprofloxacin, erythromycin, kanamycin, neomycin and streptomycin, while 90% of Irish-1 isolates were resistant to all these plus gentamicin and mupirocin. All isolates were sensitive to quinupristin/dalfopristin, teicoplanin and vancomycin. Urease production was negative in both strains. The results suggest that Irish-1 and Irish-2 are distinct epidemic strains, identifiable by phage typing, DNA profiles, antibiotic resistance and toxin gene carriage.

Observer variation in the sonographic measurement of optic nerve sheath diameter in normal adults

AIM

To quantify the observer variation in the sonographic measurement of optic nerve sheath diameter (ONSD) in normal adults.

MATERIALS AND METHODS

Sixty-seven normal adult volunteers underwent ultrasound examination of each eye by three independent observers using a 7 MHz sector probe. Three measurements were made of each eye by each observer and a mean value calculated for each eye. Median and 5th-95th centile values for both intra- and inter-observer variation were calculated for the three observers.

RESULTS

The median intra-observer variation was +/-0.1 mm, with 5th-95th centile values of +/-0-0.4 mm. The median inter-observer variation was +/-0.2-0.3 mm, with 5th-95th centile values of +/-0-0.7 mm. Careful review of examination technique by the three observers after the first 17 examinations was shown to reduce both intra- and inter-observer variation.

CONCLUSION

The sonographic measurement of ONSD is a readily learned, reproducible technique with low intra- and inter-observer variation. The average inter-observer variation (+/-0.2 mm) is comparable to the inherent variability of the ultrasound machine. The importance of standardisation of examination technique is stressed.

The occurrence of Corynosoma strumosum in the grey seal, Halichoerus grypus, caught off the Atlantic coast of Ireland

The occurrence, location and sex ratio of Corynosoma strumosum (Acanthoceophala: Polymorphidae) from 26 juvenile grey seals, Halichoerus grypus, by-caught from around the Inishkea Islands, Co. Mayo, from March to June 1997 were recorded. The location of C. strumosum within the seal did not vary, with all worms being found in the small intestine. The prevalence of infection was 100%, with no other acanthocephalan species being recorded. The mean abundance was 416 (range 80-846) C. strumosum per seal. There was no significant change in abundance by month. The sex ratio of mature female to mature male parasites was 1.2:1. The lengths of female and male worms did not differ significantly.

Obstetric and neonatal outcomes associated with maternal naltrexone exposure

Poor maternal and neonatal outcomes are associated with the pregnant heroin user. These include increased antepartum haemorrhage, decreased neonatal birthweight and increased neonatal mortality Medically supervised withdrawal from heroin during pregnancy has, however, been discouraged due to possible risk to the fetus and because of the high incidence of return to regular illicit heroin use by the mother. In recent years, however, a number of withdrawal procedures using anaesthesia, oral sedation, or intravenous sedation, precipitated by naloxone and/or naltrexone have been developed and carried out successfully on pregnant heroin users. We have now collated information on 18 cases (19 detoxifications) from three countries (Portugal, Australia and the United Kingdom). These case study data, although limited, indicate that detoxification of the pregnant heroin user is possible without significant risk to the neonate or mother, with many women not returning to dependent heroin use following detoxification. Naltrexone maintenance has also been used in the non-pregnant heroin user to discourage illicit heroin use. Similarly to methadone, stabilisation on naltrexone may be associated with conception and pregnancy Over the past three years, 26 women have conceived while on the Western Australia naltrexone program. Due to the unknown teratogenic effects, most have ceased naltrexone intake at approximately seven or eight weeks gestation. In a number of instances, however, naltrexone maintenance has been recommenced following return to a dependent pattern of heroin use. As a consequence, neonates have had different periods of naltrexone exposure, building from the initial seven or eight weeks. We now report on seven women who have delivered and three who are well into their third trimester. Neonatal and obstetric features were unremarkable with good Apgar scores, birthweight and head circumference observed. In the three cases still in third-term gestation, normal fetal development has been observed at recent ultrasound examinations. These case data indicate that naltrexone maintenance may have a role in the management of the pregnant heroin user.

Methadone and the pregnant user: a matter for careful clinical consideration

The practice of placing all pregnant heroin users on methadone as the treatment of choice needs to be questioned. While it may be suitable for those who stabilise their illicit heroin use at or shortly after conception, its suitability for those who show little movement away from regular heroin use and its associated lifestyle is more circumspect. Neonates of women who continue heroin use throughout pregnancy are likely to be below birthweight and/or premature. As a consequence, they are in a less than optimal condition to cope with the additional assault caused by prescribed methadone such as neonatal withdrawal. This may help explain why the relative risk of neonatal mortality in women who continue illicit heroin use during pregnancy and are prescribed methadone, is greater than for those who continue to use heroin but are not prescribed methadone. Clinicians must take the time of maternal presentation and the likelihood of continued maternal heroin use into consideration when determining who is suitable for methadone and whether a reduced level of methadone will suffice. A number of different clinical scenarios are identified and possible management strategies discussed. The need to develop innovative services appropriate for pregnant women who continue regular heroin use, and for well-designed studies that define best practice for the management of these women is evident.

Frequent loss of estrogen receptor-beta expression in prostate cancer

The role of estrogen and its receptors in the etiology and progression of prostate cancer (PC) is poorly understood. In normal and malignant human prostate, estrogen receptor-alpha is expressed only in the stroma, whereas estrogen receptor-beta (ERbeta) is present in both normal stroma and epithelium. Because loss of ERbeta expression is associated with prostate hyperplasia in ERbeta-null mice, this study determined patterns of ERbeta expression in normal, hyperplastic, and malignant human prostate and associations with clinical outcome. Five normal prostates from organ donors and 159 radical prostatectomy specimens from patients with clinically localized PC were assessed for ERbeta expression using immunohistochemistry. ERbeta-positivity was defined as > or =5% of cells demonstrating nuclear immunoreactivity. All of the five normal prostates showed strong ERbeta-nuclear staining in >95% of the epithelium and 35% of the stromal cells. The number of ERbeta-positive cases declined to 24.2% (38/157) in hyperplasia adjacent to carcinoma and 11.3% (18/159) in PCs. ERbeta-positivity was related to decreased relapse-free survival (log-rank P = 0.04). Thus, loss of ERbeta expression is associated with progression from normal prostate epithelium to PC, whereas those cancers that retained ERbeta expression were associated with a higher rate of recurrence. These data identify the need to further investigate the potential role of ERbeta in the regulation of prostate epithelial cell proliferation and the functional consequences of decreased ERbeta expression in the evolution of PC.

Sheep and goats: natural and experimental TSEs and factors influencing incidence of disease

The major factor influencing incidence of disease following challenge with transmissible spongiform encephalopathies (TSEs) in sheep is the allotype at amino acid numbers 136, 154 and 171 of the PrP protein. There are at least two groups of TSEs, one which targets the amino acid encoded at position 136 and the other which is more influenced by the amino acid at codon 171. Within these groups of TSE types, there may additionally be sub-types, as resistance to some, but not all, "136-type" TSEs can also be affected by the amino acid at codon 154. In goats, there are also PrP polymorphisms which apparently influence incubation period of TSE disease, however, this has not found to be true for cattle and BSE incidence. Sheep PrP amino acid codons 136, 154 and 171 do not explain everything about, for example, natural scrapie occurrence in sheep flocks, and attention is now turning to the flanking regions of the PrP gene looking for sequence differences in gene expression control motifs which may also have an influence on disease development. The sheep PrP gene produces two mRNAs in peripheral tissues, the result of alternative polyadenylation in the 3' untranslated region of the gene. Results from transfection assays of murine neuroblastoma cells with constructs expressing different regions of ovine PrP mRNA have revealed the presence of sequences in the 3' untranslated region that modulate protein synthesis and have therefore the potential to affect disease progression.

Dual AV nodal pathway physiology after injury with radiofrequency energy in a patient without a history of reentrant tachycardia

Radiofrequency (RF) atrioventricular (AV) nodal modification has been reported to occasionally produce a proarrhythmic effect. Dual AV nodal pathway physiology in patients without reentrant tachychardia has also been reported. This case describes AV nodal modification with RF energy in an anatomically intermediate area resulting in the appearance of discontinuous antegrade conduction curves and reentry in a patient in which these were previously not present. This suggests that AV nodal injury may be a mechanism for acquired AV nodal reentry.

Systematic errors in bone conduction audiometry

Air and bone conduction audiometry was carried out on two separate groups of 12 normal hearing volunteers. One group was tested at St Mary's hospital, the other at Charing Cross hospital. The results from both centres showed evidence of a systematic error in bone conduction resulting in a pattern of 'notching' at 2 kHz. We argue that the effect is likely to be more apparent in conductive deafness and that a significant distortion of the audiogram occurs in about 17% of such cases. Since the problem appears not to be restricted to the centres involved in the study, we strongly recommend that the issue be addressed by the appropriate professional bodies.

Segregation of micrometer-dimension biosensor elements on a variety of substrate surfaces

With the rapid development of micro total analysis systems and sensitive biosensing technologies, it is often desirable to immobilize biomolecules to small areas of surfaces other than silicon. To this end, photolithographic techniques were used to derivatize micrometer-sized, spatially segregated biosensing elements on several different substrate surfaces. Both an interference pattern and a dynamic confocal patterning apparatus were used to control the dimensions and positions of immobilized regions. In both of these methods, a UV laser was used to initiate attachment of a photoactive biotin molecule to the substrate surfaces. Once biotin was attached to a substrate, biotin/avidin/biotin chemistry was used to attach fluorescently labeled or nonlabeled avidin and biotinylated sensing elements such as biotinylated antibodies. Dimensions of 2-10 microm were achievable with these methods. A wide variety of materials, including glassy carbon, quartz, acrylic, polystyrene, acetonitrile-butadiene-styrene, polycarbonate, and poly(dimethylsiloxane), were used as substrates. Nitrene- and carbene-generating photolinkers were investigated to achieve the most homogeneous films. These techniques were applied to create a prototype microfluidic sensor device that was used to separate fluorescently labeled secondary antibodies.

Fluorescent amplified-fragment length polymorphism analysis of the MRSA epidemic

Genotypes and putative genetic relationships were characterised for epidemic methicillin-resistant Staphylococcus aureus (EMRSA) strains and isolates from England and Wales, using a high resolution DNA fingerprinting technique, fluorescent amplified-fragment length polymorphism (FAFLP). Each of the phage types of EMRSA had a distinct FAFLP profile. The technique revealed clusters of strains and isolates, and could distinguish isolates belonging to the same phage type. FAFLP provides a new approach to the epidemiological study and control of MRSA.

Adult neuronal ceroid lipofuscinosis (Kufs' disease) in two siblings of an Irish family

The clinico-pathologic features of two siblings with biopsy-proven adult onset neuronal ceroid lipofuscinosis (Kufs' disease) are described. A 38-year-old woman had intractable seizures, delusions and hallucinations followed by ataxia, declining cognitive function and death. At autopsy there was widespread cerebral neuronal accumulation of autofluorescent pigment, in which fingerprint profiles were demonstrated. Systemic involvement was not demonstrated. A 43-year-old brother developed slowly progressive cerebellar ataxia and was found to have similar neuronal autofluorescent pigment on brain biopsy. Nine years later there is gradual cognitive decline and profound ataxia. The salient features of Kufs' disease including cases published since 1988 are reviewed.

The detection of enterotoxins and toxic shock syndrome toxin genes in Staphylococcus aureus by polymerase chain reaction

A simple polymerase chain reaction (PCR)-based procedure was developed for the detection of fragments of staphylococcal enterotoxins (SEs) SEA, SEB, SEC, SED, SEE, SEG, SEH, and SEI together with the toxic shock syndrome toxin (TSST-1) genes of Staphylococcus aureus. One hundred and twenty-nine cultures of S. aureus were selected, 39 of which were recovered from 38 suspected staphylococcal food-poisoning incidents. The method was reproducible, and 32 different toxin genotypes were recognized. The presence of SE genes was associated with S. aureus strains reacting with phages in group III, and the TSST-1 gene with phages in group I. There was a 96% agreement between the PCR results for detection of SEA-D and TSST-1 as compared with a commercial reverse passive latex agglutination assay for the detection of SEs from cultures grown in vitro. Enterotoxin gene fragments were detected in S. aureus cultures recovered from 32 of the 38 suspected staphylococcal food poisoning incidents, and of these, 17 were associated with SEE, SEG, SEH, and SEI in the absence of SEA-D. Simple PCR procedures were also developed for the detection of SE directly in spiked food samples, and this was most successfully achieved in mushroom soup and ham. Detection was less successful in three types of cheese and in cream. SEA or SEB were detected by enzyme-linked immunosorbent assay in three food samples (two of which were associated with food poisoning incidents) naturally heavily contaminated with S. aureus: the appropriate SEA or SEB gene fragments were detected directly in these three foods by PCR.

Novel mutations in the gene encoding ATP-binding cassette 1 in four tangier disease kindreds

Tangier disease (TD) is an autosomal co-dominant disorder in which homozygotes have a marked deficiency of high density lipoprotein (HDL) cholesterol and, in some cases, peripheral neuropathy and premature coronary heart disease (CHD). Homozygotes are further characterized by cholesteryl ester deposition in various tissues throughout the body, most notably in those of the reticuloendothelial system. Several studies have demonstrated that the excess lipid deposition in TD is due to defective apolipoprotein-mediated efflux of cellular cholesterol and phospholipids. Although much progress has been made in our understanding of the metabolic basis of TD, the precise molecular defect had remained elusive until very recently. By positional cloning methods, we: 1) confirm the assignment of TD to chromosome 9q31, 2) provide evidence that human ATP-binding cassette-1 (hABC-1) maps to a 250 kb region on 9q31, and 3) describe novel deletion, insertion, and missense mutations in the gene encoding hABC-1 in four unrelated TD kindreds. These results establish a causal role for mutations in hABC-1 in TD and indicate that this transporter has a critical function in the regulation of intracellular lipid trafficking that dramatically affects plasma HDL cholesterol levels.

Synthesis of the nanomolar photoaffinity GABA(B) receptor ligand CGP 71872 reveals diversity in the tissue distribution of GABA(B) receptor forms

A radioiodinated probe, [125I]-CGP 71872, containing an azido group that can be photoactivated, was synthesized and used to characterize GABA(B) receptors. Photoaffinity labeling experiments using crude membranes prepared from rat brain revealed two predominant ligand binding species at approximately 130 and approximately 100 kDa believed to represent the long (GABA(B)R1a) and short (GABA(B)R1b) forms of the receptor. Indeed, these ligand binding proteins were immunoprecipitated using a GABA(B) receptor-specific antibody confirming the receptor specificity of the photoaffinity probe. Most convincingly, [125I]-CGP 71872 binding was competitively inhibited in a dose-dependent manner by cold CGP 71872, GABA, saclofen, (-)-baclofen, (+)-baclofen and (L)-glutamic acid with a rank order and stereospecificity characteristic of the GABA(B) receptor. Photoaffinity labeling experiments revealed that the recombinant GABA(B)R2 receptor does not bind [125I]-CGP 71872, providing surprising and direct evidence that CGP 71872 is a GABA(B)R1 selective antagonist. Photoaffinity labeling experiments using rat tissues showed that both GABA(B)R1a and GABA(B)R1b are co-expressed in the brain, spinal cord, stomach and testis, but only the short GABA(B)R1b receptor form was detected in kidney and liver whereas the long GABA(B)R1a form was selectively expressed in the adrenal gland, pituitary, spleen and prostate. We report herein the synthesis and biochemical characterization of the nanomolar affinity [125I]-CGP 71872 and CGP 71872 GABA(B)R1 ligands, and differential tissue expression of the long GABA(B)R1a and short GABA(B)R1b receptor forms in rat and dog.

Genotyping of epidemic methicillin-resistant Staphylococcus aureus phage type 15 isolates by fluorescent amplified-fragment length polymorphism analysis

Fluorescent amplified-fragment length polymorphism (FAFLP) analysis was investigated for its ability to identify and subtype isolates of an epidemic methicillin-resistant phage type of Staphylococcus aureus, EMRSA-15. These isolates were also characterized by PCR-restriction fragment length polymorphism (PCR-RFLP) of the coagulase gene and pulsed-field gel electrophoresis (PFGE). For FAFLP, DNA was double digested with restriction enzymes ApaI plus TaqI or EcoRI plus MseI. Site-specific adaptors were ligated to one or the other set of restriction fragments, and PCR amplification was carried out with adaptor-specific primers. Amplified fragments separated on an ABI 377 automated sequencer and analyzed with Genescan version 2.1 software generated FAFLP profiles for all the isolates. The presence or absence of fragments was scored, similarity coefficients were calculated, and UPGMA (unweighted pair group method using arithmatic averages) cluster analysis was performed. Either enzyme-primer combination readily differentiated EMRSA-15 from other methicillin-resistant S. aureus (MRSA) isolates and also revealed heterogeneity within the phage type. The discriminatory power of FAFLP was high. By combining both enzyme-primer data sets, 24 isolates were divided into 11 profiles. PCR-RFLP did not discriminate among these EMRSA-15 isolates. PFGE could discriminate well between isolates but was not as reproducible as FAFLP. All S. aureus and MRSA isolates in this study were typeable by FAFLP, which was easy to perform, robust, and reproducible, with evident potential to subtype MRSA for purposes of hospital infection control.

Receptor for motilin identified in the human gastrointestinal system

Motilin is a 22-amino acid peptide hormone expressed throughout the gastrointestinal (GI) tract of humans and other species. It affects gastric motility by stimulating interdigestive antrum and duodenal contractions. A heterotrimeric guanosine triphosphate-binding protein (G protein)-coupled receptor for motilin was isolated from human stomach, and its amino acid sequence was found to be 52 percent identical to the human receptor for growth hormone secretagogues. The macrolide antibiotic erythromycin also interacted with the cloned motilin receptor, providing a molecular basis for its effects on the human GI tract. The motilin receptor is expressed in enteric neurons of the human duodenum and colon. Development of motilin receptor agonists and antagonists may be useful in the treatment of multiple disorders of GI motility.

The laryngeal mask airway in tonsillectomy: the surgeon's perspective

The laryngeal mask airway presents certain advantages in the management of the airway during general anaesthesia. However, from the surgeon's perspective, there have been reports of problems occurring when the laryngeal mask airway is used in tonsillectomy. This study of 90 patients undergoing tonsillectomy suggests that surgical access is inferior with a laryngeal mask airway and the weight of tonsillar tissue excised is less. In addition the laryngeal mask airway needs to be changed to an endotracheal tube during the procedure in 11.4% of patients.

Confirmation of linkage of type 1 hereditary sensory neuropathy to human chromosome 9q22

OBJECTIVES

1) To confirm linkage of hereditary sensory neuropathy type 1 (HSN-I) to human chromosome 9q22 in a large American family of German origin. 2) To construct a yeast artificial chromosome (YAC) contig spanning the HSN-I candidate interval. 3) To investigate the HSN-I contig for potential candidate genes.

BACKGROUND

HSN-I is a rare peripheral neuropathy characterized by loss of temperature sensation, ulceration and osteomyelitis of the digits, and subtle distal weakness. A gene for HSN-I has previously been mapped to human chromosome 9q22.1-q22.3 between markers D9S318 and D9S176 in an 8-cM interval in four Australian families.

METHODS

In a large German-American family with HSN-I, genome-wide linkage analysis was performed on 68 family members extending over five generations and including 17 affected members. Genotyping was performed with PCR, and the resulting genotypes were analyzed with two-point linkage analysis with Fastlink. A YAC contig was constructed based on the Whitehead Institute YAC contig WC9.3.

RESULTS

Two-point linkage analysis resulted in a maximum lod score of 8.2 at theta = 0 for marker D9S1815. Haplotype analysis locates the HSN-I gene between markers D9S1797 and D9S197. Using YAC clones from the Centre d'Etude du Polymorphism Humain YAC Library, we constructed a YAC contig spanning these markers. Based on the radiation hybrid map of the human genome, we estimate that the size of this interval is less than 2,500 kb.

CONCLUSIONS

Our study confirms linkage of a putative HSN-I gene to chromosome 9q22, considerably narrows the HSN-I locus, and provides a basis for identification of the HSN-I gene.

Refined mapping and characterization of the recessive familial amyotrophic lateral sclerosis locus (ALS2) on chromosome 2q33

Amyotrophic lateral sclerosis (ALS) is a progressive degenerative neuromuscular disease that shows familial, autosomal dominant inheritance in 10%-15% of cases. Previous genetic analysis of one large family linked a recessive form of familial ALS (FALS-AR type 3) to the chromosome 2q33-35 region. Using additional polymorphic markers, we have narrowed the size of the linked region to approximately 1.7 cM by linkage and haplotype analysis. We have also established a yeast artificial chromosome contig across the locus that covers an approximate physical distance of 3 million bases. Based on this contig, genes and expressed sequences that map near the 2q33 region have been examined to determine whether they are located within this ALS2 candidate locus. Five identified genes and 34 expressed sequence tags map within the region defined by crossover analysis and merit further consideration as candidate genes for this disease.

DNA oxidation by potassium bromate; a direct mechanism or linked to lipid peroxidation?

Following incubation of calf thymus DNA with potassium bromate (KBrO3) and glutathione (GSH), a statistically significant increase in the concentration of 8-oxodeoxyguanosine (8-oxodG) relative to deoxyguanosine was measured. This was GSH-dependent and was associated with loss of GSH during incubation. In contrast, 8-oxodG was not found to be elevated significantly in either total tissue DNA or mitochondrial DNA isolated from Sprague-Dawley rat kidney perfused in situ with KBrO3 (5 mM) for 15 min or 1 h. There was also no associated increase in the level of renal lipid peroxidation or reduced or oxidised GSH. Following intraperitoneal administration of KBrO3 to Sprague-Dawley rats, a dose of 100 mg/kg (maximum tolerated) gave evidence for oxidative stress in the kidney at 24 h as indicated by a significant increase in lipid peroxidation (P < 0.05) and oxidised GSH (P < 0.05). This was associated with a greater than 2-fold, significant (P < 0.01) increase in the level of 8-oxodG in kidney total DNA and a 57% (not statistically significant) increase in kidney mitochondrial 8-oxodG. Pretreatment of rats with diethylmaleate (DEM) to deplete GSH, elevated the toxicity of 100 mg/kg KBrO3. However, at a dose of 20 mg/kg, no change in any of the parameters indicative of kidney oxidative stress (including indicators of oxidative DNA damage; 8-oxodG or etheno-DNA adducts, which can be produced by lipid peroxides) was seen either with or without DEM pretreatment with the exception of a small but statistically significant (P < 0.05) increase in mitochondrial 8-oxodG when KBrO3 was given following DEM pretreatment. DNA oxidation in the kidney is therefore not inhibited by GSH depletion (contrasting with in vitro findings) and requires a sustained exposure at a near-toxic concentration of KBrO3 which is associated with lipid peroxidation and GSH oxidation. The results do not support a role, in rat kidney, of a direct, GSH-mediated mechanism for KBrO3-induced DNA oxidation as seen in vitro.

Characterization of nasal airflow

Nasal airflow and trans-nasal pressure difference was measured by active anterior rhinomanometry in 24 subjects. An analysis was undertaken to determine the 'goodness of fit' of two models used to characterize nasal airflow, one model by Broms and the other by O'Neill and Tolley. A judicious approach to choice of fit criterion led to the conclusion that the latter model provided a more accurate characterization of nasal airflow. Additionally this model may be useful to quantify alar valve stiffness. A portable computerized system incorporating the use of the model has been developed and is currently in use.

Cytosolic phospholipase A2, cyclo-oxygenases and arachidonate in human stomach tumours

Human stomach tumours usually form more prostaglandins (PGs) than their associated normal mucosa/submucosa, but the mechanisms are not fully understood. The key enzymes are cytosolic phospholipase A2 (cPLA2, Mr 85,000) and the cyclo-oxygenases (COXs) which exist in constitutive (COX-1) and inducible forms (COX-2). In human stomach tumours and associated macroscopically normal tissues, we determined the fatty acid composition by gas chromatography, amounts of cPLA2, COX-1 and COX-2 by immunoblotting with specific antibodies and cPLA2 enzyme activity using a tritiated substrate. Although compared to normal mucosa there was less arachidonate in tumours (P < 0.05), the arachidonate/total fatty acid ratio was higher. Mean amounts of cPLA2 and COX-1 and cPLA2 activity were similar in tumours and normal mucosa. However, substantial amounts of COX-2 were found in the tumours but not in the mucosa, which may explain why many gastric tumours form increased amounts of PGs.