The Danish implementation study on response to pregnancy complications, MAMAACT

Differential incidence and severity of pregnancy complications are likely important contributing factors to the increased risk of poor pregnancy outcomes among ethnic minority women in Europe. To address this issue, the MAMAACT trial has been developed based on a thorough mixed methods needs assessment and co-creation process, feasibility tested, now implemented in a nationwide complex intervention. The overall aim of the Danish MAMAACT trial is to reduce ethnic and social disparity in stillbirth and newborns' health by improved management of pregnancy complications. The overall target group is all pregnant women, and the specific target group is women of non-Western origin. The hypothesis of MAMAACT is that improved communication between pregnant women and midwives regarding body symptoms that need prompt reaction will improve perinatal health among these vulnerable groups. The intervention consists of postgraduate training of midwives in intercultural communication and a smart phone application and a leaflet, both in six different languages. The app and leaflet target the women and explain the most serious warning signs of pregnancy complications and how to respond to them.

MAMAACT is implemented and evaluated in a randomized controlled cluster trial and 10 maternity wards consist the intervention groups, while nine maternity wards are the control groups. The evaluation is a mixed method evaluation focusing on understanding the mechanisms of change, how context at both maternity ward level as well as in the everyday life of women affects the implementation, and finally if effects on health literacy of the women and perinatal health of the children can be documented.

“No papers. No doctor”: undocumented immigrant women’s access to maternity care services in Denmark

Background

In Denmark, undocumented immigrants have restricted access to health care including maternity care. Nordic studies describe that undocumented immigrant women face many barriers to access maternity care during pregnancy however, literature in a Danish setting is lacking. This study aims at exploring undocumented immigrant women's experience of and their access to maternity care services in Denmark.

Methods

The study setting was a non-governmental Health Clinic in Denmark, that provides primary health care, including maternity care, to undocumented immigrants. We recruited 21 undocumented immigrant women, conducted semi-structured interviews from 01.2018 to 01.2019. The data was analyzed through systematic text condensation.

Results

Undocumented immigrant women experience several barriers to access maternity care services in Denmark. We identified four themes with subthemes. i) Access to public maternity care services; the experiences with public maternity care providers, fear of deportation and concerns about having to pay for care. ii) Use of private and non-governmental maternity care services; the feeling of being safe at the Health Clinic, reaching care is challenged by logistics and choosing to pay for private health care services. iii) Perception of entitlements to care; wishing for a fair treatment, and uncertainty of what to expect when reaching a public health care facility. iv) Being dependent; dependency on the Health Clinic, social support from network and seeking information from other sources.

Conclusions

Our findings contribute with insights to understand the health behavior of undocumented immigrant women. Accessing public maternity care services is, apart from legal restrictions, dominated by fear of being reported to the immigration authorities, concerns about payment, and the management of rules from the health provider's perspective. Many of them depend on the Health Clinic as well as their personal networks for care and protection.

Key messages

Undocumented immigrant women face many barriers to access maternity care services. Inclusive policies for access to maternity care are needed to safeguard the health of the women and children.

Response of the Salmon Heart Transcriptome to Pancreas Disease: Differences Between High- and Low-Ranking Families for Resistance

Pancreas disease caused by salmonid alphaviruses leads to severe losses in Atlantic salmon aquaculture. The aim of our study was to gain a better understanding of the biological differences between salmon with high and low genomic breeding values (H-gEBV and L-gEBV respectively) for pancreas disease resistance. Fish from H- and L-gEBV families were challenged by intraperitoneal injection of salmonid alphavirus or co-habitation with infected fish. Mortality was higher with co-habitation than injection, and for L- than H-gEBV. Heart for RNA-seq and histopathology was collected before challenge and at four- and ten-weeks post-challenge. Heart damage was less severe in injection-challenged H- than L-gEBV fish at week 4. Viral load was lower in H- than L-gEBV salmon after co-habitant challenge. Gene expression differences between H- and L-gEBV manifested before challenge, peaked at week 4, and moderated by week 10. At week 4, H-gEBV salmon showed lower expression of innate antiviral defence genes, stimulation of B- and T-cell immune function, and weaker stress responses. Retarded resolution of the disease explains the higher expression of immune genes in L-gEBV at week 10. Results suggest earlier mobilization of acquired immunity better protects H-gEBV salmon by accelerating clearance of the virus and resolution of the disease.

What can we learn from the national implementation of The MAMAACT intervention?

Initiatives to improve maternal and child health among non-Western immigrant populations in Western countries are still sparse. So far, interventions within antenatal care have primarily focused on doula support and group-based antenatal care.

A qualitative evaluation of the implementation of the intervention was undertaken to explore midwives and non-Western immigrant women’s attitudes towards and experiences of using the MAMAACT intervention. The evaluation also investigated key contextual factors impacting the interventions utilization. Data consisted of focus group interviews with midwives (n = 9) and in-depth interviews with non-Western immigrant women (n = 15), as well as observations of midwifery visits (n = 42). Data were collected at five intervention sites across Denmark and it was analyzed using systematic text condensation.

Findings show that midwives found the MAMAACT intervention to be a relevant tool, which was easy to implement in antenatal care. Several organizational factors such as task load, interpreter services and lack of cooperation with general practitioners impacted the implementation of the intervention. Non-Western immigrant women found the leaflet and app to be useful tools in distinguishing between normal and abnormal pregnancy symptoms. The degree to which the intervention was used by the women varied between the participants, and women also used other sources of information during their pregnancy. Contextual factors such as lack of social network and material resources as well as language proficiency impacted how women responded to their pregnancy symptoms. Findings show that in addition to targeting the intervention to midwives and non-Western immigrant women’s informational needs, structural factors such as the organization of antenatal care and women’s socioeconomic conditions need to be addressed in order to reduce ethnic disparity in reproductive health.

Using probit regression to disclose the analytical performance of qualitative and semi-quantitative tests

BACKGROUND

The analytical performance of qualitative and semi-quantitative tests is usually studied by calculating the fraction of positive results after replicate testing of a few specimens with known concentrations of the analyte. We propose using probit regression to model the probability of positive results as a function of the analyte concentration, based on testing many specimens once with a qualitative and a quantitative test.

METHODS

We collected laboratory data where urine specimens had been analyzed by both a urine albumin ('protein') dipstick test (Combur-Test strips) and a quantitative test (BN ProSpec System). For each dipstick cut-off level probit regression was used to estimate the probability of positive results as a function of urine albumin concentration. We also used probit regression to estimate the standard deviation of the continuous measurement signal that lies behind the binary test response. Finally, we used probit regression to estimate the probability of reading a specific semi-quantitative dipstick result as a function of urine albumin concentration.

RESULTS

Based on analyses of 3259 specimens, the concentration of urine albumin with a 0.5 (50%) probability of positive result was 57 mg/L at the lowest possible cut-off limit, and 246 and 750 mg/L at the next (higher) levels. The corresponding standard deviations were 29, 83, and 217 mg/L, respectively. Semi-quantitatively, the maximum probability of these three readings occurred at a u-albumin of 117, 420, and 1200 mg/L, respectively.

CONCLUSIONS

Probit regression is a useful tool to study the analytical performance of qualitative and semi-quantitative tests.

Bariatric surgery or lifestyle intervention? An exploratory study of severely obese patients' motivation for two different treatments

BACKGROUND

In the complex field of treating severe obesity, motivation is receiving increased attention. This explorative study aims to highlight what influences the preferences of severely obese patients deciding for either gastric bypass surgery or lifestyle treatment.

METHODS

Patients awaiting laparoscopic gastric bypass were presented with an 18-week inpatient lifestyle programme alternative to gastric bypass. Questionnaires provided qualitative data (reasons for choosing one treatment over another) and quantitative data (mental health assessment using the Hospital Anxiety and Depression Scale). The material was analysed according to a sequential exploratory design involving thematic analysis of patients' arguments, validation using HADS, and statistical computations (hypothesis testing) with one-way ANOVA followed by Dunnett's post hoc test.

RESULTS

159 participants (mean BMI 47.2 kg/m(2)) returned questionnaires of which 32% wanted the lifestyle treatment alternative to surgery. Reasons for choosing the two treatments varied widely as did also the corresponding data on mental health. Two subgroups stood out with particularly high mental symptom scores, namely patients choosing surgery due to reluctance to engage in social interaction in lifestyle treatment, and patients preferring lifestyle treatment due to the fear of dying during general anaesthesia. These two subgroups showed significantly higher symptom scores than other subgroups within their therapy-of-choice group. The number of comorbid diseases was also found to impact upon motivation.

CONCLUSIONS

Patients carry different incentives for choosing the same type of treatment. On a subgroup level, psychopathological symptoms seem to follow motivational patterns. Analysing motivation and mental health may provide measures for identifying subgroups with various prospects for therapy outcome.

Evaluering av inflammatoriske mediatorer i diagnostikk av alvorlige neonatale infeksjoner

 Formål: SAMMENDRAGStudie design: Resultater: IL-6 predikerte uavhengig infeksjon (bidrag til infeksjonsdiagnosen. En kombinert parameter bestående av CRP≥ 10 mg/l og/eller IL-6 > 50 pg/mlga en sensitivitet på 96% (95% CI: 88–100%), en spesifisitet på 74% (95% CI: 65–83%), en negativ prediktivverdi på 99% (95% CI: 96–100%) og en positiv prediktiv verdi på 49% (95% CI: 35–63%).Konklusjon: diagnosis of severe neonatal infections  ObjectiveENGLISH SUMMARY Study design Results: of IL-6 yielded independent contributions to the diagnosis of infection ( mediator made any further contribution to the diagnosis. A combined parameter of CRP≥ 10 mg/l and/or IL-6 >50 pg/ml yielded a sensitivity of 96% (95% CI: 88–100%), a specificity of 74% (95% CI: 65–83%), a negativepredictive value of 99% (95% CI: 96–100%) and a positive predictive value of 49% (95% CI: 35–63%).Conclusion: severe neonatal infections.IL-6 in combination with CRP may constitute a valuable parameter in the early diagnosis ofp

Amylase, pancreatic isoamylase and lipase in serum before and after endoscopic pancreatography

Serum amylase, isoamylase and lipase were determined in 17 patients with pancreatic or biliary diseases before and after endoscopic retrograde pancreatography (ERP). Within 1/2-2 hours after cannulation of the pancreatic duct, serum lipase was increased to approximately 4 times the upper reference level and normalized almost completely at 24 hours. A much smaller increase was found in amylase and isoamylase. The elevation in enzyme activities was less in patients with abnormal than with normal ERP. The results suggest that lipase is a more sensitive indicator of pancreatic injury than amylase and isoamylase.

Effects of gadolinium contrast agents in naïve and nephrectomized rats: relevance to nephrogenic systemic fibrosis

BACKGROUND

Human nephrogenic systemic fibrosis (NSF) is a rare condition reported in patients with severe renal insufficiency exposed to a gadolinium (Gd)-based contrast agent. An animal model of NSF could help to investigate its mechanisms and lead to prevention and treatment.

PURPOSE

To evaluate a possible animal model of NSF using naive and partially nephrectomized rats to induce conditions similar to those in patients at risk of NSF.

MATERIAL AND METHODS

Naive rats received intravenous doses of 5 or 10 mmol/kg Omniscan; 5 mmol/kg Magnevist; 1 mmol/kg caldiamide; 1, 2.5, or 5 mmol/kg gadodiamide; 25 micromol/kg GdCl(3); or 25 micromol/kg Gd citrate. Partially nephrectomized rats received 5 mmol/kg Omniscan; 5 mmol/kg Magnevist; 1 mmol/kg caldiamide; 1 mmol/kg gadodiamide; 25 micromol/kg GdCl(3); or 25 micromol/kg Gd citrate. There were three or four animals per group. Clinical signs were recorded during treatment. At termination, clinical biochemistry, histopathology, and tissue Gd and Zn concentrations were investigated.

RESULTS

Similar responses to treatment were seen in naive and nephrectomized rats. High doses of gadodiamide were toxic, necessitating early termination of the affected animals. Skin lesions appeared in naive and nephrectomized groups treated with gadodiamide or Omniscan, coinciding with the onset of signs of pruritus, i.e., intensive scratching. The histomorphological features of the skin lesions were also consistent with superficial physical trauma. Dermal fibrosis was not a feature of these skin lesions in any of the groups, i.e., no increased collagen density, CD34+ cells, or increased fibroblasts. This was supported by skinfold measurements that demonstrated no increased skin thickness. Treatment with the gadolinium-based contrast agents and Gd salts resulted in increased Gd content of several tissues. The Gd salts were mainly taken up by the liver and spleen, possibly reflecting formation of insoluble particles and macrophage uptake. Zn tissue concentrations were normal or increased. Other major treatment-related changes included increased serum rat C-reactive protein and histamine; mineralization affecting the dermis, stomach, and blood vessels; and renal proximal tubule vacuolation.

CONCLUSION

The visible skin lesions seen in this study appeared to be caused by excessive scratching in response to pruritus. As there was no evidence of dermal fibrosis, the cardinal feature of human NSF, this did not appear to be a model of human NSF.

Severe antibody-mediated agranulocytosis

A 56-year-old female with Crohn's disease was admitted to the hospital with malaise, fever, and a low white blood cell count (0.8 x 10(9)/l) with no granulocytes or myeloid precursor cells in the bone marrow. The leucopenia was initially thought to be the result of an infection and she was treated with antibiotics and granulocyte colony-stimulating factor (G-CSF, filgrastim). However, the bacterial cultures and viral tests were all negative. The patient's condition deteriorated and she became morbidly ill, but recovered after high dose steroid treatment. Six weeks later she relapsed whilst receiving 7.5 mg daily dose of prednisolone. She recovered quickly after being given high dose methylprednisolone in combination with filgrastim. A high maintenance dose of prednisolone was tapered over 5 months. She has not relapsed since and is currently well. Antibodies to the human neutrophil antigen (HNA)-3a were detected, but these antibodies could not easily explain her agranulocytosis as she had a HNA-3a negative phenotype. It seems plausible that her agranulocytosis was immune mediated through autoantibodies directed towards the early myeloid cells.

Gut luminal microdialysis of glycerol as a marker of intestinal ischemic injury and recovery

OBJECTIVE

To evaluate microdialysis as a method to assess different degrees of intestinal damage and recovery during ischemia and reperfusion; to evaluate information obtained from microdialysis catheters in the peritoneum, the gut wall, and the gut lumen.

DESIGN

Randomized, controlled animal experiment.

SETTING

University laboratory animal center.

SUBJECTS

Twenty-seven domestic pigs.

INTERVENTIONS

The superior mesenteric artery was cross-clamped for 60 mins (n = 14) or 120 mins (n = 10) followed by 2 or 4 hrs of reperfusion. Three pigs served as controls.

MEASUREMENTS AND MAIN RESULTS

Intestinal mucosal integrity was assessed by morphometry, adenosine triphosphate in the gut wall, and permeability of C-polyethylene glycol. Lactate, glycerol, pyruvate, and glucose were measured by microdialysis. Changes in adenosine triphosphate, permeability, or lactate did not correlate to different extents of intestinal damage caused by 60 or 120 mins of ischemia. During the reperfusion period, pigs with 60 mins of intestinal ischemia showed a faster recovery of these variables than pigs with 120 mins of intestinal ischemia. Glycerol increased with increasing duration of the ischemic insult. After 60 mins of intestinal ischemia, glycerol in the gut lumen decreased toward baseline but remained high after 120 mins of intestinal ischemia. There was a good correlation between gut luminal glycerol and recovery of mucosal damage throughout the reperfusion period. In the peritoneal cavity, both glycerol and lactate decreased to baseline relatively shortly after onset of reperfusion independent of the duration of intestinal ischemia.

CONCLUSIONS

Microdialysis of glycerol provides information about the extent and severity of intestinal damage after ischemia and about the ensuing recovery. The gut lumen is to be preferred as a site for placement of microdialysis catheters.

Validation of the Modification of Diet in Renal Disease formula for estimating GFR with special emphasis on calibration of the serum creatinine assay

BACKGROUND

The Modification of Diet in Renal Disease (MDRD) formula is recommended by European and American guidelines for estimating glomerular filtration rate (GFR). However, the accuracy of the formula has been questioned in several studies. Our objective is to evaluate the performance of the MDRD formula with special emphasis on the possibility that interlaboratory calibration differences for serum creatinine reduce the accuracy of the formula.

METHODS

The MDRD and 7 other commonly used formulae were evaluated regarding bias, precision, and accuracy. The 215 adults included were patients with chronic kidney disease, potential kidney donors, and patients referred before nephrotoxic chemotherapy. Serum creatinine was measured by means of a kinetic Jaffé method (Hitachi 917, Hitachi, Tokyo, Japan; reagents from Roche Diagnostics, Mannheim, Germany). GFR, measured as plasma clearance of chromium 51-labeled EDTA (Cr-EDTA), ranged from 3 to 162 mL/min/1.73 m2.

RESULTS

The MDRD formula was heavily biased, but it still had significantly better accuracy than the other formulae tested. After recalibrating our serum creatinine values (serum creatinine [mg/dL] = -0.215 + 1.08 * serum creatinine), systematic bias was greatly reduced and better accuracy was achieved: 45.6% of results differed less than 15% from Cr-EDTA, 64.2% differed less than 30%, and 81.4% differed less than 50%. The equation for recalibrating creatinine values was based on data with traceability to reference methods and on sensitivity analysis.

CONCLUSION

The MDRD formula seems to be the best formula available for GFR estimating, but it is based on a serum creatinine method calibrated to give much lower values than most laboratories, leading to underestimation of GFR in mild renal insufficiency.

Intestinal injury after thoracic aortic cross-clamping in the pig

BACKGROUND

The mucosal surface epithelium is an essential part of the functional intestinal barrier, but its structural response to ischemia/reperfusion is only partly characterized. The purpose of this study was to provide a detailed morphological evaluation of intestinal surface epithelium after aortic cross-clamping.

MATERIAL AND METHODS

Pigs were subjected to thoracic aortic cross-clamping for 60 min and subsequent reperfusion for 120 min. Tissue blood flow and high-energy phosphates were measured with microspheres and HPLC, respectively. Urinary excretion of (14)C polyethylene glycol (MW 4000 Da) (PEG-4000), loaded into an intestinal loop, provided an index of intestinal permeability.

RESULTS

Jejunal blood flow was restored at 10 min after aortic declamping. Denudation of the basement membrane of the intestinal villi tips, as a consequence of epithelial shedding, increased markedly during the initial 60 min of reperfusion (P = 0.002). During the following 45 min, the denuded basement membrane was partly covered with low cuboidal and squamous-shaped cells extending lamellipodia over a wavy basement membrane. Restoration of ATP at 60 min after aortic declamping correlated inversely to the extent of denuded basement membrane (r = 0.75, P = 0.032). Permeability of PEG-4000 increased markedly after aortic declamping and was linearly correlated to the area of denuded basement membrane (r = 0.87, P = 0.01).

CONCLUSIONS

Reperfusion for 2 h after aortic cross-clamping is associated with initial aggravation of ischemia-induced injury in the porcine jejunum, but thereafter with restitution of the surface epithelium. Restoration of ATP may be important to avoid intestinal injury after ischemia. Increased permeability of a macromolecule in response to reperfusion is closely correlated to injury of the surface epithelium.

Gut barrier dysfunction as detected by intestinal luminal microdialysis

OBJECTIVE

To evaluate the use of gut luminal microdialysis as a tool for monitoring ischaemic metabolites, particularly glycerol, as markers of intestinal dysfunction during and after intestinal ischaemia.

DESIGN

A randomised, controlled animal experiment.

SETTING

National laboratory animal centre.

INTERVENTIONS

In seven pigs the thoracic aorta was cross-clamped for 60 min followed by 2 h of reperfusion, while five pigs served as controls.

MEASUREMENTS AND RESULTS

Glycerol, lactate and glucose in the intestinal lumen and mucosa were measured by microdialysis. Intestinal tissue blood flow was determined by means of colour-labelled microspheres. To assess intestinal permeability, (14)C-polyethylene glycol 4000 (PEG-4000) was instilled in a jejunal segment and then measured in venous blood. Intestinal blood flow was reduced to 10% of baseline by aortic cross-clamping ( p=0.001) and returned to baseline during reperfusion. Intestinal luminal lactate increased during ischaemia and further increased during reperfusion. The increase was paralleled by augmented intestinal permeability; there was a significant correlation between luminal lactate and venous PEG-4000 ( r=0.89, p<0.01). Aortic cross-clamping caused a marked increase in intestinal mucosal glycerol concentrations, which correlated with luminal glycerol during both ischaemia and reperfusion ( r=0.85, p<0.01).

CONCLUSION

Microdialysis of lactate may be useful for monitoring intestinal ischaemia and reperfusion. Release of lactate into the intestinal lumen appears to be related to increased permeability. Intestinal luminal glycerol closely mirrored glycerol concentrations in the intestinal wall.

Etiology of cecal and hepatic lesions in mice after administration of gas-carrier contrast agents used in ultrasound imaging

The aim of the study was to investigate the etiology of cecal and hepatic lesions in mice and rats after intravenous administration of gas-carrier contrast agents (GCAs). A modified fluorescein flowmetry technique and 24 h necropsy were used in mice (conventional and germ free), rats, and guinea pigs after GCA administration. Different diets and oral nonabsorbable antibiotics were used. Nonfluorescence, edema, congestion, hemorrhage, and mucosal erosion in cecum and colon and nonfluorescent areas in the liver were observed from 16 min after GCA administration in conventional mice on standard diet. Numerous gas bubbles (>50 microm) were observed in the vasculature around the nonfluorescent areas of cecum and colon and in mesenteric vessels draining to the portal vein. Acute inflammation, edema, hemorrhage, and ulceration of the cecum and colon and liver necrosis were seen 24 h after GCA administration in conventional mice on standard diet. When mice were maintained on either a diet with glucose as the only carbohydrate source or on a standard diet supplemented with antibiotics, uniform fluorescence and no organ lesions were observed after GCA administration. Uniform fluorescence and no organ lesions were observed in germ-free mice, rats, and guinea pigs dosed with GCAs and in control animals (mice, rats, and guinea pigs) dosed with sucrose. The results indicate that intravascular growth of GCA microbubbles occurs in the cecal and colonic wall of mice, leading to occlusive ischemia and necrosis in these intestinal segments and secondary gas embolisation in the liver. Transmural gas supersaturation in the cecal wall may explain the intravascular bubble growth in mice.

Intestinal and hepatic lesions in mice, rats, and other laboratory animals after intravenous administration of gas-carrier contrast agents used in ultrasound imaging

Single intravenous administration of three different gas-carrier contrast agents used in ultrasound imaging to mice caused inflammation, necrosis, and ulceration of cecum and proximal colon (cecocolonic area) and focal necrosis in the liver. Similar intestinal lesions were also found in rats after treatment with a single iv administration of a gas-carrier contrast agent. Strain differences in the incidences of these lesions were found in both rats and mice. HsdHan:NMRI mice were among the most sensitive of the strains of mice studied. Even at the lowest dose of Sonazoid technically possible to inject in HsdHan:NMRI mice, lesions were found and a no-effect dose could not be determined. In a time-course experiment in HsdHan:NMRI mice, it was found that the lesions began to develop in the cecum and colon within 15 to 30 min after dosing. Lesions in the liver were first observed 120-240 min after dosing. Diet played a role in the etiology of the lesions, as HsdHan:NMRI mice given a diet with reduced amounts of cellulose and starch had reduced incidences of lesions, and when glucose was the only carbohydrate source, no lesions were observed. No intestinal or hepatic lesions were found in guinea pigs or rabbits after repeated intravenous administrations of Sonazoid. In dogs, minimal to mild granulocytic inflammation of the cecum and/or colon was found after daily repeated intravenous injections for 28 days, but not after daily repeated administration for 14 days nor after a single administration. It is proposed that the intestinal and hepatic lesions in rats and mice after a single intravenous injection of gas-carrier contrast agents are caused by a common mechanism: intravascular growth of gas-carrier agents in tissues with gas supersaturation, as occurs in the cecal wall of rats and mice. In this particular environment the growing gas bubbles cause ischemia and necrosis in the cecal and colonic wall and liver. This proposed mechanism of action is consistent with the absence of clinical reports indicative of intestinal and/or hepatic lesions in humans after administration of gas-carrier contrast agents.

Reference intervals for procalcitonin and C-reactive protein after major abdominal surgery

Procalcitonin (PCT). a new marker proposed as a diagnostic tool for bacterial infections, triggers a systemic-inflammatory reaction in the body (sepsis, septic shock) and has potential use in a wide range of patient settings. To interpret the results from PCT measurements, we depend on reference intervals established from relevant populations. PCT and C-reactive protein (CRP) concentrations were analysed in 47 patients with a normal postoperative course after major abdominal surgery. The mean concentration of PCT declines from the first day and reaches half its initial values on the second day after the operation. whereas the mean concentration of CRP increases in the first 48 h and reaches half its maximum value on the fifth day after the operation. We present a continuous reference interval for plasma PCT and CRP concentrations in the first week following major abdominal surgery. For PCT we also present a graphic display of expected mean and expected upper reference limits predicted from the value measured on the first postoperative day.

Perfusion abnormalities in pulmonary embolism studied with perfusion MRI and ventilation-perfusion scintigraphy: an intra-modality and inter-modality agreement study

PURPOSE

To compare perfusion magnetic resonance imaging (MRI) and ventilation-perfusion scintigraphy (V-P scan) in the study of perfusion abnormalities in pulmonary embolism (PE) and to compare the PE results to the findings previously reported for pneumonia and chronic obstructive pulmonary disease (COPD), in terms of perfusion abnormalities.

MATERIALS AND METHODS

Dynamic contrast-enhanced MR images and V-P scans of 20 patients with PE, 11 patients with acute pneumonia, and 13 patients with exacerbation of COPD were studied. Five categories of perfusion abnormalities within each imaging modality were defined. Intra- and inter-modality agreement (kappa values) in the evaluation of perfusion abnormalities were calculated, based on the two observers of each imaging modality (all blinded to each other and true diagnosis). Finally, three categories of perfusion MRI diagnosis (PE, pneumonia, and COPD) were also defined and the inter-observer agreement (kappa value) was calculated.

RESULTS

For PE, the intra-modality agreement (kappa value) in the evaluation of perfusion abnormalities was 0.77 for MRI and 0.65 for V-P scan. The inter-modality agreement varied from 0.52 to 0.57, respectively, and was observer-dependent. For the pooled group of PE, pneumonia, and COPD, the intra-modality agreement of perfusion abnormalities was 0.76 for MRI and 0.65 for V-P scan, and the inter-modality agreement varied from 0.51 to 0.56. The kappa value for inter-observer agreement for MRI diagnosis was 0.92.

CONCLUSION

Evaluation of perfusion abnormalities in PE, pneumonia, and COPD using perfusion MRI and V-P scan showed a high intra-modality agreement that was higher than the inter-modality agreement. Further studies are now needed in patients presenting with possible PE to evaluate the sensitivity and specificity of the method.

Gene expression patterns of breast carcinomas distinguish tumor subclasses with clinical implications

The purpose of this study was to classify breast carcinomas based on variations in gene expression patterns derived from cDNA microarrays and to correlate tumor characteristics to clinical outcome. A total of 85 cDNA microarray experiments representing 78 cancers, three fibroadenomas, and four normal breast tissues were analyzed by hierarchical clustering. As reported previously, the cancers could be classified into a basal epithelial-like group, an ERBB2-overexpressing group and a normal breast-like group based on variations in gene expression. A novel finding was that the previously characterized luminal epithelial/estrogen receptor-positive group could be divided into at least two subgroups, each with a distinctive expression profile. These subtypes proved to be reasonably robust by clustering using two different gene sets: first, a set of 456 cDNA clones previously selected to reflect intrinsic properties of the tumors and, second, a gene set that highly correlated with patient outcome. Survival analyses on a subcohort of patients with locally advanced breast cancer uniformly treated in a prospective study showed significantly different outcomes for the patients belonging to the various groups, including a poor prognosis for the basal-like subtype and a significant difference in outcome for the two estrogen receptor-positive groups.

Influence of TP53 gene alterations and c-erbB-2 expression on the response to treatment with doxorubicin in locally advanced breast cancer

TP53 status [mutations, immunostaining, and loss of heterozygosity (LOH)], expression of c-erbB-2, bcl-2, and histological grading were correlated to the response to doxorubicin monotherapy (14 mg/m2) administered weekly to 90 patients with locally advanced breast cancer. Mutations in the TP53 gene, in particular those affecting or disrupting the loop domains L2 or L3 of the p53 protein, were associated with lack of response to chemotherapy (P = 0.063 for all mutations and P = 0.008 for mutations affecting L2/L3, respectively). Similarly, expression of c-erbB-2 (P = 0.041), a high histological grade (P = 0.023), and lack of expression of bcl-2 (P = 0.018) all predicted chemoresistance. No statistically significant association between either p53 immunostaining or TP53 LOH and response to therapy was recorded, despite the finding that both were associated with TP53 mutation status (p53 immunostaining, P < 0.001; LOH, P = 0.021). Lack of immunostaining for p53 despite mutation of the TP53 gene was particularly seen in tumors harboring nonsense mutations or deletions/splices (7 of 10 negative for staining compared with 4 of 16 with missense mutations). TP53 mutations (total/affecting L2/L3 domains) were associated with expression of c-erbB-2 (P < 0.001 for both), high histological grade (P = 0.001 and P = 0.025), and bcl-2 negativity (P = 0.003 and P = 0.002). TP53 mutations, histological grade, and expression of bcl-2 (but not LOH or c-erbB-2 expression) all predicted for relapse-free as well as breast cancer-specific survival in univariate analysis (Ps between <0.0001 and 0.0155), but only tumor grade was found to be predictive in multivariate analysis (P = 0.01 and P = 0.0007, respectively). Our data are consistent with the hypothesis that certain TP53 mutations predict for resistance to doxorubicin in breast cancer patients. However, the observation that the majority of patients with TP53 mutations affecting or disrupting the L2/L3 domains with LOH in addition (n = 12) obtained a partial response (n = 4) or stabilization of disease (n = 5) during chemotherapy suggests redundant mechanisms to compensate for loss of p53 function. Our findings are consistent with the hypothesis that other defects may act in concert with loss of p53 function, causing resistance to doxorubicin in breast cancers.

Molecular portraits of human breast tumours

Human breast tumours are diverse in their natural history and in their responsiveness to treatments. Variation in transcriptional programs accounts for much of the biological diversity of human cells and tumours. In each cell, signal transduction and regulatory systems transduce information from the cell's identity to its environmental status, thereby controlling the level of expression of every gene in the genome. Here we have characterized variation in gene expression patterns in a set of 65 surgical specimens of human breast tumours from 42 different individuals, using complementary DNA microarrays representing 8,102 human genes. These patterns provided a distinctive molecular portrait of each tumour. Twenty of the tumours were sampled twice, before and after a 16-week course of doxorubicin chemotherapy, and two tumours were paired with a lymph node metastasis from the same patient. Gene expression patterns in two tumour samples from the same individual were almost always more similar to each other than either was to any other sample. Sets of co-expressed genes were identified for which variation in messenger RNA levels could be related to specific features of physiological variation. The tumours could be classified into subtypes distinguished by pervasive differences in their gene expression patterns.

Constant denaturant gel electrophoresis (CDGE) in BRCA1 mutation screening

Screening for mutations in the breast and ovarian cancer susceptibility gene, BRCA1, is complicated by the wide spectrum of mutations found in this large gene. In the present study a constant denaturant gel electrophoresis (CDGE) mutation screening strategy was established for approximately 80% of the genomic coding sequence (exons 2, 11, 13-16, 20, 24). This strategy was applied to screen genomic DNA from 50 familial breast and/or ovarian cancer patients who had previously been examined for BRCA1 mutations by SSCP. A total of 14 carriers of 12 distinct disease-associated mutations and 7 carriers of 6 distinct rare substitutions leading to amino acid substitutions were identified. The SSCP failed to detect 40% of the different deletions/insertions (4/10) and 75% (6/8) of the different base substitutions leading to terminating codons or rare amino acid changes. SSCP did, however, identify one rare base substitution that could not be detected in the CDGE screening. To evaluate the CDGE mutation screening strategy further, 25 unrelated patients from Norwegian breast and/or ovarian cancer families were examined for BRCA1 mutations using a combined genomic DNA/cDNA approach covering the entire coding sequence of the gene. A total of six mutation carriers were detected, all of whom had cases of ovarian cancer in their families. Three patients from independent families carried an 1135insA mutation in exon 11, two others had a Gly484ter and an 1675delA mutation, respectively, and the sixth carried a splice mutation (5194-2 a-->c) causing deletion of exon 18. CDGE may become an efficient tool in diagnostic and population based screening for BRCA1 mutations.

Impact on survival of high-dose therapy with autologous stem cell support in patients younger than 60 years with newly diagnosed multiple myeloma: a population-based study. Nordic Myeloma Study Group

High-dose therapy has become a common treatment for myeloma. The objectives of this study were to estimate in a prospective, population-based setting the impact on survival of high-dose therapy in newly diagnosed, symptomatic patients less than 60 years old and to compare the results with those of conventionally treated historic controls. The prospective population comprised 348 patients. Of these, 274 were treated according to a specified intensive-therapy protocol (Nordic Myeloma Study Group [NMSG] #5/94) and constituted the intensive-therapy group. The historic population consisted of 313 patients identified from 5 previous population-based Nordic studies. Of these, 274 fulfilled the eligibility criteria for high-dose therapy stated in NMSG #5/94 and constituted the control group. The expected numbers of patients in the prospective population and the historic population were 450 and 410, respectively, estimated from previously established data on the incidence in this population and the population base for each study. Survival was prolonged in the intensive-therapy group compared with the control group (risk ratio for the control group 1.62; 95% confidence interval 1.22-2.15; P =.001). These groups represented more than 60% of the expected number of patients. When survival for all the registered patients in the 2 populations was compared, representing more than 75% of the expected number of patients, the advantage for the prospective population persisted (risk ratio for the historic population 1.46; 95% confidence interval 1.14-1.86; P =. 002). These results indicate that the introduction of high-dose therapy for newly diagnosed myeloma has resulted in prolonged survival for the total patient population aged less than 60 years. (Blood. 2000; 95:7-11)

Multicentre European study comparing selection techniques for the isolation of CD34+ cells

Primitive haemopoietic cells are required for studies in both the clinical and research fields and a number of systems have been developed to facilitate isolation of these haemopoietic cell populations. We have analysed the results from several European centres using positive selection of CD34+ cells from haemopoietic tissues (n = 110). Four selection techniques including immunoaffinity columns (Ceprate LC), immunomagnetic beads (Dynabeads, Baxter Isolex 50) and submicroscopic magnetic beads (MACS) were used and the selected CD34+ cells were assessed for purity, yield and enrichment of colony-forming cells (CFC). The mean purities for all samples ranged from 68.4-78.4% for MACS, 33.9-69.9% for Dynabeads, 46.9-66.8% for Ceprate LC and 43.2-65% for Baxter Isolex 50. Yields were variable with all techniques. On average CFC enrichment using the immunoaffinity columns was greater than that observed for the other systems. Some techniques appear to be problematic and may require further expertise to improve the results. Nevertheless, the study demonstrates that highly purified CD34+ cells can be isolated from various haemopoietic sources, though yield and CFC enrichment varies significantly depending on the technique selected. This extends our previous report indicating that not all selection methods generate similar results and that there are differences in the purity, number and colony-forming ability of the cells recovered.

Gas supersaturation in the cecal wall of mice due to bacterial CO2 production

PCO2 in the lumen and serosa of cecum and jejunum was measured in mice. The anesthetic used was a fentanyl-fluanisone-midazolam mixture. PCO2 was recorded in vivo and postmortem. PCO2 was 409 +/- 32 Torr (55 +/- 4 kPa) in the cecal lumen and 199 +/- 22 Torr (27 +/- 3 kPa) on the serosa in normal mice. Irrigation of the cecum resulted in serosal and luminal PCO2 levels of 65-75 Torr. Cecal PCO2 was significantly lower in germ-free mice (65 +/- 5 Torr). Cecal PCO2 increased significantly after introduction of normal bacterial flora into germ-free mice. Introduction of bacterial monocultures into germ-free mice had no effect. After the deaths of the mice, cecal PCO2 increased rapidly in normal mice. The intestinal bacteria produced the majority of the cecal PCO2, and the use of tonometry in intestinal segments with a high bacterial activity should be interpreted with caution. We propose that serosal PCO2 levels >150-190 Torr (20-25 kPa) in the cecum of mice with a normal circulation may represent a state of gas supersaturation in the cecal wall.

The APC gene I1307K variant is rare in Norwegian patients with familial and sporadic colorectal or breast cancer

Recently, a T-to-A transversion creating an 8-base mononucleotide tract in the APC gene, resulting in substitution of lysine for isoleucine at codon 1307 (I1307K), was found in a subset of Ashkenazi Jews. This sequence variant was most frequent in colorectal cancer patients with a positive family history of colorectal cancer. To determine whether the I1307K variant plays a role in colorectal or breast cancer predisposition in the Norwegian population, we have analyzed blood samples from 210 colorectal cancer patients and 183 breast cancer patients by PCR and direct sequencing. Thirty-seven of the colorectal cancer patients had a positive family history of cancer. Among the breast cancer patients, 24 had a family history of colorectal cancer and 75 a family history of breast and/or ovarian cancer. Only one colorectal cancer patient who belonged to a Jewish family was found to carry the A variant. Our data show that the I1307K variant is rare in the Norwegian population and should not be viewed as a candidate for susceptibility testing for colorectal cancer.

Urinary excretion of catecholamines in hospitalized and non-hospitalized healthy children and adolescents

Non-conjugated catecholamines were measured in morning urine samples from 111 healthy, non-hospitalized subjects aged 8-18 y and in 16 hospitalized, healthy subjects aged 12 16 y. The catecholamines were extracted by cation exchange columns and alumina adsorption and quantitated with HPLC with electrochemical detection. The concentration of catecholamines was related both to the urinary creatinine concentration and to the collecting period and body surface area. Linear regression analysis was used to estimate continuous age-related reference centiles based upon the measurements from the 111 non-hospitalized subjects. The upper limits for the adrenaline/creatinine and noradrenaline/creatinine ratios were lower than in previous studies. The excretion of adrenaline and noradrenaline per hour and m2 body surface area was higher in the 16 hospitalized than in the 74 age-matched non-hospitalized subjects. The excretion of the catecholamines expressed per hour and m2 body surface area and expressed relative to creatinine excretion, decreased with increasing age, and the excretion of adrenaline and noradrenaline per hour and m2 body surface area was higher in boys than in girls. In conclusion, standardization of urine sampling leads to more narrow ranges for urinary adrenaline and noradrenaline excretion in healthy children and adolescents.

Specific P53 mutations are associated with de novo resistance to doxorubicin in breast cancer patients

The mechanisms causing resistance to chemotherapeutic drugs in cancer patients are poorly understood. Recent evidence suggests that different forms of chemotherapy may exert their cytotoxic effects by inducing apoptosis. The tumor suppressor gene P53 has a pivotal role inducing apoptosis in response to cellular damage. In vitro investigations have shown intact p53 to play a critical role executing cell death in response to treatment with cytotoxic drugs like 5-fluorouracil, etoposide and doxorubicin. Recently, mutations in the P53 gene were found to confer resistance to anthracyclines in a mouse sarcoma tumor model, and overexpression of the p53 protein (which, in most cases, is due to a mutated gene) was found to be associated with lack of response to cisplatin-based chemotherapy in non-small cell lung cancer. Previous studies have shown mutations in the P53 gene or overexpression of the p53 protein to predict a poor prognosis, but also a beneficial effect of adjuvant radiotherapy or chemotherapy in breast cancer. In this study we present data linking specific mutations in the P53 gene to primary resistance to doxorubicin therapy and early relapse in breast cancer patients.

Three related brain nuclear receptors, NGFI-B, Nurr1, and NOR-1, as transcriptional activators

Three related orphan nuclear receptors that are expressed in the brain, NGFI-B, Nurr1, and NOR-1, were studied to compare their function as transcriptional activators. NGFI-B was able to activate (in the absence of added hormone) in CV1 cells both an NGFI-B-responsive luciferase reporter gene (containing eight copies of a response element for NGFI-B upstream of a basal prolactin promoter driving the luciferase gene, NBRE(8)-LUC), a similar thyroid hormone-receptor-responsive reporter gene (TRE(3)-LUC), and a reporter gene with an authentic promoter from a Xenopus vitellogenin gene containing two binding sites for the estrogen receptor (vit-LUC). NGFI-B activated NBRE(8)-LUC and TRE(3)-LUC (but not the vitLUC) with an amino-terminal activation domain. Nurr1 was less promiscuous as a transcriptional activator, activating.the NBRE(8)-LUC better than NGFI-B, but less than NGFI-B at the other reporter genes. NOR-1 activated only the NBRE(8)-LUC reporter gene. These results indicate that closely related nuclear receptors may differentiate between response elements or promoters and that different activation mechanisms exist depending on the promoter. This may contribute to regulation of specificity of target gene expression in the brain.

Lymph drainage and the development of post-reconstructive leg oedema is not influenced by the type of inguinal incision. A prospective randomised study in patients undergoing femoropopliteal bypass surgery

OBJECTIVES

To see whether the type of groin incision influenced the degree of postoperative leg oedema and the occurrence of lymphatic damage.

DESIGN

Prospective randomised clinical study.

SETTING

University Department of Surgery.

MATERIALS

Twenty-four patients undergoing femoropopliteal bypass reconstruction with either a lateral groin incision (Group A, n = 12) or a direct incision over the femoral vessels (Group B, (n = 12).

CHIEF OUTCOME MEASURES

The leg volume increase was measured according to the formula of a truncated cone. Deep venous thrombosis was excluded by air plethysmography and colour-coded Duplex scanning. Lymphatic lesions were detected by lymphoscintigraphy using 99mTc labelled human serum albumin.

MAIN RESULTS

One week following vascular reconstruction the median leg volume increase was 24.5% in Group A vs. 23.3% in Group B (NS). Lymphoscintigraphy revealed obstruction of the lymphatics in five patients of Group A vs. three patients of Group B (NS). Neither the occurrence of lymph cysts nor extravasation of lymph differed between the two groups. In seven patients no lymphatic lesion was observed. Patients with interruption of the lymphatics (n = 8) had a higher leg volume increase compared to the remaining patients with no or minor lymphatic lesions, 31.2% vs. 19.6%, respectively (p < 0.05).

CONCLUSIONS

Leg oedema and the occurrence of lymphatic damage following femoropopliteal bypass surgery is not reduced by applying a lateral approach to the femoral artery in the groin. However, the higher leg volume increase in patients with lymphatic obstruction indicates that lymphatic damage could play a part in the leg oedema formation.

Expression of the receptor for urokinase-type plasminogen activator in normal and neoplastic blood cells and hematopoietic tissue

Expression of the receptor for the urokinase type plasminogen activator (uPAR) has been studied by flow cytometry and immunohistology in normal blood and bone marrow cells, in vitro activated lymphoid cells, and tissue samples from reactive lymph nodes (n = 6), thymus (n = 2) and malignant lymphomas (n = 82), or leukemias (n = 32). HL-60 myeloid precursor cells and CD34-positive normal stem cells also were analyzed. In the normal cells, staining was confined to monocytes, macrophages, neutrophils, and myeloid precursors. No labelling was seen of normal or activated lymphoid cells. Purified CD34-positive hematopoietic progenitors were uPAR negative, but expressed uPAR during differentiation in short-term liquid culture stimulated in vitro by recombinant interleukin (IL)-1, IL-3, IL-6, granulocyte-macrophage colony stimulating factor (CSF), granulocyte-CSF, and stem cell factor. Enhanced uPAR expression was also seen in HL-60 cells after induction of differentiation with dimethyl sulfoxide or 1 alpha,25-dihydroxyvitamin D3. In lymphomas and leukemias, the staining pattern was similar to that seen in the normal cells with labelling of monocytic and myeloid that seen in the normal cells with labelling of monocytic and myeloid malignancies, but not of the neoplastic cells in B-cell or T-cell lymphomas or Hodgkin's disease. In conclusion, uPAR is a differentiation marker for myeloid and monocytic cells, and may act to facilitate migration of these cells in normal and pathologic conditions by cell-associated plasminogen activation. Whether expression of uPAR in myeloid and monocytic malignancies relates to their growth and behavior will be an important topic for investigations in the future.

Chlamydia trachomatis serovar L2 induces protein tyrosine phosphorylation during uptake by HeLa cells

Chlamydia trachomatis L2 is an obligate intracellular microorganism with a unique biphasic life cycle. The extracellular form, the elementary body (EB), is infectious but metabolically inactive. Attachment of EBs to host cells is medicated by a heparan sulfate-like glycosaminoglycan. Following attachment, the EB is internalized within a membrane-bound vesicle, and during the first 8 h of infection the vesicles are transported to a perinuclear location where they aggregate and fuse. By use of a monoclonal antibody against phosphotyrosine, we showed that three classes of proteins are tyrosine phosphorylated: a triple band of 68, 66, and 64 kDa, a 97-kDa band, and a 140-kDa band. The phosphorylation could be detected by immunoblotting from 15 min after infection of HeLa cells. We followed the movement of the EBs and the tyrosine phosphorylation of proteins by double-labelling immunofluorescence microscopy with the same monoclonal anti-phosphotyrosine antibody and a polyclonal antibody against the C. trachomatis L2 outer membrane complex. During the first 8 h of infection, the phosphorylation colocalized with EBs. Sixteen hours after infection, EBs have reorganized to the replicating reticulate bodies, forming an inclusion. At this time, phosphorylation was seen as dotted spots in the periphery of the inclusion.

Cytokine levels in amniotic fluid and inflammatory changes in the placenta from normal deliveries at term

Cytokine levels in amniotic fluid have been shown to increase towards term in normal pregnancies, and may play a regulatory role in parturition by stimulating the local production of prostaglandins. The work reported in the present paper was conducted in order to test the hypothesis that the increased cytokine levels may be induced by a subclinical inflammatory reaction in intrauterine tissues. The concentrations of tumor necrosis factor (TNF), interleukin 1 (IL-1), interleukin 2 (IL-2) and interleukin 6 (IL-6) were determined in samples of amniotic fluid from 38 women in delivery at term, after a clinically normal pregnancy. In 33 of the cases, tissue material was available for histological examination. In these, the extent of inflammatory cell infiltration was assessed in the fetal membranes, placenta and umbilical cord. A close interrelation was observed between the levels of the mediators typically released during inflammatory processes (TNF, IL-1, IL-6). Frank chorioamnionitis was not found in any of the histological specimens, although most placentae showed varying degrees of granulocyte infiltration in the fibrin layer under the chorion, sometimes also in the chorionic membrane. The degree of such leukocytic infiltration correlated positively with the levels of TNF, IL-1 and IL-6. These findings lend support to the hypothesis that a low-level inflammatory process may be a normal occurrence in the term placenta, and that this process may induce the production of cytokines, which, in turn, may play a role in the regulation of parturition. Such inflammation could be due to exposure of the fetal membranes to microbial material from the vagina, as the cervix dilates towards term.

Pressure increase following primary laser trabeculoplasty. Effect on the visual field

Possible damaging effects on the visual field of postlaser pressure elevations the first 24 h following primary laser trabeculoplasty were investigated in 61 patients with exfoliative or open-angle glaucoma. The intraocular pressure was monitored the first 24 h after treatment. Treatment with pressure reducing agents was started if the intraocular pressure was > or = 50 mmHg. The visual field was plotted before and 1, 3, and 6 months after laser treatment with the C-30-2 program on a Humphrey visual field analyzer. Peak pressures > or = 50 mmHg occurred with 15 (25%) patients. There was no relationship between visual field changes at 1 month and pressure increase, peak pressure, prelaser pressure, prelaser visual field indices, the use of timolol postlaser, or the pressure decrease or pressure level 1 month after laser treatment. From 1 to 6 months after laser trabeculoplasty the visual field parameters remained stable. Postlaser pressure spikes do not seem to damage the visual field providing they are detected and treated.

Methodological approach to the evaluation of neurotoxicity data and the classification of neurotoxic chemicals

This text is the result of the authors' involvement in a working group on criteria for the identification and classification of neurotoxic chemicals. (The work of the group does not necessarily represent the official stand of the affiliated institutes.) A definition of neurotoxicity and criteria for evaluating studies dealing with neurotoxicology are presented. The evaluation is a stepwise process that ends with assigning the chemicals to groups depending on the available evidence for neurotoxicity (ie, neurotoxic, probably neurotoxic, possibly neurotoxic, probably not neurotoxic, or not classifiable). Finally, the description of the potency of neurotoxic chemicals is briefly discussed. The model has been tested by evaluating selected research papers on the following 10 chemicals: manganese, aluminum, tetrahydrofuran, cyclohexanone, dichlorvos, trichloroethylene, formaldehyde, tri-ortho-cresyl phosphate, n-hexane, and vinyl chloride. There was sufficient evidence for classifying five of the ten chemicals (aluminum, manganese, n-hexane, trichloroethylene, tri-ortho-cresyl phosphate) as definitely neurotoxic to humans, and three were considered to be possibly neurotoxic to humans (dichlorvos, tetrahydrofuran, vinyl chloride). Cyclohexanone and formaldehyde were not classifiable according to the model.