Personalised nutrition for older adults: design challenges, SME barriers, and options and competencies for innovation

Personalised nutrition (PN) products and services have the potential to enhance the health and quality of life of older adults. However, PN innovation is challenging and requires specific competencies and supportive collaborations. This paper reports findings from a Collective Intelligence Scenario-Based Design session conducted with PN experts as part of the Horizon 2020 project INCluSilver, which aims to support the development of products, services, and systems that improve the health and quality of life of older adults through innovation in PN. Experts identified challenges to the design of PN products and services and barriers that small and medium enterprises (SMEs) face when innovating PN products and services for older adults. Options to address these barriers were generated and specific SME competencies supporting PN innovation were identified. This study provides a useful framework for understanding the challenges, opportunities, and key competencies needed to innovate PN products and services for older adults.

The effectiveness of psychological interventions for fatigue in cancer survivors: systematic review of randomised controlled trials

BACKGROUND

Fatigue is a common symptom in cancer patients that can persist beyond the curative treatment phase. This systematic review evaluated the effectiveness of psychological interventions for cancer-related fatigue in post-treatment cancer survivors.

METHODS

We searched relevant online databases and sources of grey literature. Randomised controlled trials (RCTs) evaluating psychological interventions in adult cancer patients after the completion of treatment, with fatigue as an outcome measure, were included. Two review authors extracted data independently from the selected studies and assessed the methodological quality using the Cochrane Collaboration Risk of Bias Tool.

RESULTS

Thirty-three psychological interventions were identified. The sample size of the included studies varied between 28 and 409, with 4525 participants overall. Twenty-three of the included studies reported a significant effect of the interventions on reducing fatigue in cancer survivors. Most interventions focused on psychoeducation, mindfulness, cognitive or behaviour therapy-oriented strategies. However, studies differed widely in terms of measurement tools used to assess fatigue, mode, duration and frequency of the intervention delivery.

CONCLUSIONS

This review showed some tentative support for psychological interventions for fatigue after cancer treatment. However, as the RCTs were heterogeneous in nature and the number of high-quality studies was limited, definitive conclusions are not yet possible. With the growing need for stage-specific research in cancer, this review sought to inform current practice and to summarise the existing evidence base of randomised controlled trials in the area.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42014015219.

Reliability of histologic assessment in patients with eosinophilic oesophagitis

BACKGROUND

The validity of the eosinophilic oesophagitis (EoE) histologic scoring system (EoEHSS) has been demonstrated, but only preliminary reliability data exist.

AIM

Formally assess the reliability of the EoEHSS and additional histologic features.

METHODS

Four expert gastrointestinal pathologists independently reviewed slides from adult patients with EoE (N = 45) twice, in random order, using standardised training materials and scoring conventions for the EoEHSS and additional histologic features agreed upon during a modified Delphi process. Intra- and inter-rater reliability for scoring the EoEHSS, a visual analogue scale (VAS) of overall histopathologic disease severity, and additional histologic features were assessed using intra-class correlation coefficients (ICCs).

RESULTS

Almost perfect intra-rater reliability was observed for the composite EoEHSS scores and the VAS. Inter-rater reliability was also almost perfect for the composite EoEHSS scores and substantial for the VAS. Of the EoEHSS items, eosinophilic inflammation was associated with the highest ICC estimates and consistent with almost perfect intra- and inter-rater reliability. With the exception of dyskeratotic epithelial cells and surface epithelial alteration, ICC estimates for the remaining EoEHSS items were above the benchmarks for substantial intra-rater, and moderate inter-rater reliability. Estimation of peak eosinophil count and number of lamina propria eosinophils were associated with the highest ICC estimates among the exploratory items.

CONCLUSION

The composite EoEHSS and most component items are associated with substantial reliability when assessed by central pathologists. Future studies should assess responsiveness of the score to change after a therapeutic intervention to facilitate its use in clinical trials.

Investigating the Perceived Benefits, Barriers and Beliefs towards Physical Activity in Pregnancy among Women with Gestational Diabetes Mellitus

Gestational Diabetes Mellitus (GDM) is a growing concern and poses serious health risks to both mother and child1. The current study explores the psychological determinants of exercise behaviour in a sample of pregnant women with GDM. A cross-sectional survey design was employed to examine exercise behaviour, illness perceptions, perceived barriers and benefits, exercise beliefs, and exercise self-efficacy using validated questionnaires. A sample of 46 pregnant women was recruited from University College Hospital Galway, Letterkenny General Hospital, Cork University Hospital and Mayo General Hospital in Castlebar. Participant's varied; age (22-44 years), body mass index (19-41). High mean scores for Personal Control (24.5) and Treatment Control (30.2) subscales indicated strongly held positive beliefs in relation to controllability of the illness. Total MET-min/week score was not related to any psychological variables. Analysis of the IPQ-R data revealed 'diet' (n=37, 80.4%) as the most referred to cause of diabetes. Exercise belief data identified "managing weight gain" (n= 21, 45.7%), and "losing baby weight" (n= 31, 67.4%) as the most frequent beliefs for engaging in physical activity during pregnancy and post pregnancy. Further research on the psychological determinants of physical activity behaviour among this population group is needed in order to create successful intervention strategies.

Developing a genetic manipulation system for the Antarctic archaeon, Halorubrum lacusprofundi: investigating acetamidase gene function

No systems have been reported for genetic manipulation of cold-adapted Archaea. Halorubrum lacusprofundi is an important member of Deep Lake, Antarctica (~10% of the population), and is amendable to laboratory cultivation. Here we report the development of a shuttle-vector and targeted gene-knockout system for this species. To investigate the function of acetamidase/formamidase genes, a class of genes not experimentally studied in Archaea, the acetamidase gene, amd3, was disrupted. The wild-type grew on acetamide as a sole source of carbon and nitrogen, but the mutant did not. Acetamidase/formamidase genes were found to form three distinct clades within a broad distribution of Archaea and Bacteria. Genes were present within lineages characterized by aerobic growth in low nutrient environments (e.g. haloarchaea, Starkeya) but absent from lineages containing anaerobes or facultative anaerobes (e.g. methanogens, Epsilonproteobacteria) or parasites of animals and plants (e.g. Chlamydiae). While acetamide is not a well characterized natural substrate, the build-up of plastic pollutants in the environment provides a potential source of introduced acetamide. In view of the extent and pattern of distribution of acetamidase/formamidase sequences within Archaea and Bacteria, we speculate that acetamide from plastics may promote the selection of amd/fmd genes in an increasing number of environmental microorganisms.

Gitelman's syndrome: a rare presentation mimicking cauda equina syndrome

We describe a case of bilateral weakness of the lower limbs, sensory disturbance and intermittent urinary incontinence, secondary to untreated Gitelman's syndrome, in a 42-year-old female who was referred with presumed cauda equina syndrome. On examination, the power of both legs was uniformly reduced, and the perianal and lower-limb sensation was altered. However, MRI of the lumbar spine was normal. Measurements of serum and urinary potassium were low and blood gas analysis revealed metabolic alkalosis. Her symptoms resolved following potassium replacement. We emphasise the importance of measurement of the plasma and urinary levels of electrolytes in the investigation of patients with paralysis of the lower limbs and suggest that they, together with blood gas analysis, allow the exclusion of unusual causes of muscle weakness resulting from metabolic disorders such as metabolic alkalosis.

Alveolar rhabdomyosarcoma originating between the fourth and fifth metatarsal--case report and literature review

We report a case of alveolar rhabdomyosarcoma arising between the fourth and fifth metatarsal. A 13-year-old boy presented to outpatients with a history of pain and swelling in the lateral aspect of his left forefoot. Plain radiographs and MRI showed a soft tissue mass displacing the fourth metatarsal. Percutaneous biopsy revealed an alveolar rhabdomyosarcoma. Staging scans showed advanced metastatic disease. The patient was treated with chemotherapy. This highly malignant lesion remains challenging to diagnose, and difficult to treat successfully.

Natural history of flexed knee gait in diplegic cerebral palsy evaluated by gait analysis in children who have not had surgery

Eighteen children with diplegic cerebral palsy and no history of orthopaedic surgery had two gait analyses a mean of 6.3 years apart to analyse the effects of time on their gait. The mean age of the children at first analysis was 7.7 years (range 4.4-13.3 years). The data was analysed as a whole group (18 children) and as two sub-groups of nine children: those with a shorter follow-up (mean 5.0 years) and those with a longer follow-up (mean 7.5 years) between analyses. The following significant bilateral changes were seen in the whole group and longer follow-up sub-group: deterioration in the range of knee flexion, mid-stance knee flexion, peak knee extension in stance and hamstring length and an improvement in mean and maximum hip rotation. Temporal data showed no significant changes once normalised. There were no bilateral significant changes in data from children evaluated at a mean of 5 years follow-up. GMFCS scores generally improved over time despite the significant increase in flexed knee gait. There was no significant change in gait deviation index in any group over time. There was an increase in body mass index in 16 children but there was no correlation between this and the degree of mid-stance knee flexion. These findings may have implications for longer term follow-up of children with cerebral palsy into adulthood.

Dissociation and implantation of Exeter femoral instrumentation during total hip arthroplasty

Proprietary femoral plug introducers are routinely used to insert intramedullary plugs during total hip arthroplasty. The cement restrictor pin from an Exeter intramedullary plug introducer may become detached during insertion of the cement restrictor plug, or during sponge packing of the femur. We suggest some precautions that should be taken to prevent this from occurring and advise that the patient is unlikely to experience any long-term adverse reactions to the presence of the restrictor pin in the intramedullary canal.;

Paraganglioma of the cauda equina: A case report and literature review

A 26-year-old man presented with left leg pain and progressive paraparesis. Imaging revealed a large intradural tumour compressing the cauda equina. The lesion was radically resected and histological analysis revealed it to be a paraganglioma. The clinical features of this rare tumour are described with a review of the literature.

The effect of information and behavioural training on endoscopy patients' clinical outcomes

This study was designed to examine the effects of preparatory information and behavioural training on patients about to undergo an endoscopy procedure. Forty-five first-time endoscopy patients (aged 20-70 years), were randomly assigned to one of three groups (cognitive, cognitive/behavioural and control group). The cognitive group received a 12 min preparation with sensory and procedural information relating to the sensations and sequence of events associated with the endoscopy procedure. The cognitive/behavioural group received, in addition, instruction in deep breathing exercises, tongue depressor task and swallowing technique. Results indicated that patients in the two experimental conditions experienced significantly fewer signs of behavioural distress during endoscopy. The cognitive group required a significantly shorter time to induce the scope. There were no statistical differences between the groups however, for mood, physiological and anxiety measures, although a positive trend was evident for the two intervention groups.

An assessment of current HIV treatment adherence services in the UK

The aim of this study was to examine current approaches to supporting adherence to antiretroviral therapy in UK HIV clinics. One hundred HIV/AIDS/GUM physicians were interviewed: 97% were personally involved in discussing adherence, spending 22% of consultation time on this issue and assessing adherence most commonly by patient self-report (88%). Other personnel involved included nurses (74%), other doctors (56%), health advisers (54%) and pharmacists (48%). Among criteria for achieving treatment success, adherence support ranked fourth after 'treatment fitting well into patient's lifestyle', regular viral load monitoring and the 'experience of the clinician/healthcare team'. A variety of tools were used to support adherence including dosette boxes (53%), written information (44%) and verbal communication (42%). Only 20% of physicians followed adherence protocols or formal guidelines. Three-quarters of physicians had received no training on adherence issues. The most common ways physicians kept informed about adherence matters were by attending conferences (87%), reading literature (71%) and learning from colleagues (51%). Eighty-seven per cent of physicians believed national adherence guidelines would be valuable. In conclusion, there is a need for training and direction within current adherence support services. National guidelines could provide a valuable framework for health care professionals.

Reasons for non-adherence to antiretroviral therapy: patients' perspectives provide evidence of multiple causes

The objective of the study was to define common reasons for non-adherence (NA) to highly active antiretroviral therapy (HAART) and the number of reasons reported by non-adherent individuals. A confidential questionnaire was administered to HIV-seropositive patients taking proteinase inhibitor based HAART. Median self-reported adherence was 95% (n = 178, range = 60-100%). The most frequent reasons for at least 'sometimes' missing a dose were eating a meal at the wrong time (38.2%), oversleeping (36.3%), forgetting (35.0%) and being in a social situation (30.5%). The mean number of reasons occurring at least 'sometimes' was 3.2; 20% of patients gave six or more reasons; those reporting the lowest adherence reported a significantly greater numbers of reasons (rho = - 0.59; p < 0.001). Three factors were derived from the data by principal component analysis reflecting 'negative experiences of HAART', 'having a low priority for taking medication' and 'unintentionally missing doses', accounting for 53.8% of the variance. On multivariate analysis only the latter two factors were significantly related to NA (odds ratios 0.845 and 0.849, respectively). There was a wide spectrum of reasons for NA in our population. The number of reasons in an individual increased as adherence became less. A variety of modalities individualized for each patient are required to support patients with the lowest adherence.

The tricarbonylchromium template for stereocontrol in radical reactions of arenes

Chromium tricarbonyl complexed aryl aldeyhydes and ketones underwent Sm(II)-promoted radical lactone formation in the presence of alpha,beta-unsaturated esters to produce diastereomerically pure lactones in good yields. The completely diastereoselective lactone formation involves capture of the benzylic ketyl radical by the ester anti to the chromium tricarbonyl moiety. The relative stereochemistry of the lactone and chromium tricarbonyl moieties was proven by X-ray crystallography and supports the proposed mechanism. Enantiopure chromium tricarbonyl complexed arenes afforded single enantiomers when subjected to Sm(II)-promoted radical lactone formation condiditions. The enantio- and diastereomerically pure chromium tricarbonyl complexed lactones were subsequently treated with BF3.OEt2 to generate a mixture of diastereomers via Lewis acid promoted chromium tricabonyl directed cationic rearrangement. The diastereomers were separated and individually decomplexed with I2 to afford both of the corresponding chromium-free enantiomerically pure lactones starting from a single enantiomerically pure chromium tricarbonyl complex.

Adherence in clinical trials and in clinical practice

The degree of patient adherence is increasingly recognized to be a key factor in the success of highly active antiretroviral therapy (HAART). HAART regimens are also among the most complex ever prescribed and low adherence is directly related to treatment complexity. Physicians prescribing HAART need to make adherence a priority both in clinical practice and in the design and interpretation of clinical trials if HAART really is to succeed in the long term.

PU.1 regulates both cytokine-dependent proliferation and differentiation of granulocyte/macrophage progenitors

PU.1 is a unique regulatory protein required for the generation of both the innate and the adaptive immune system. It functions exclusively in a cell-intrinsic manner to control the development of granulocytes, macrophages, and B and T lymphocytes. We demonstrate that mutation of the PU.1 gene causes a severe reduction in myeloid (granulocyte/macrophage) progenitors. PU.1 -/- myeloid progenitors can proliferate in vitro in response to the multilineage cytokines interleukin-3 (IL-3), IL-6 and stem cell factor but are unresponsive to the myeloid-specific cytokines granulocyte-macrophage colony-stimulating factor (GM-CSF), G-CSF and M-CSF. The failure of PU.1 -/- progenitors to respond to G-CSF is bypassed by transient signaling with IL-3. In the presence of IL-3 and G-CSF, PU.1 -/- progenitors can differentiate into granulocytic precursors containing myeloperoxidase-positive granules. Thus PU.1 is not essential for specification of granulocytic precursors, but is required for their further differentiation. The failure of PU.1 -/- progenitors to respond to M-CSF is due to lack of c-fms gene transcription. Transduction of c-fms into PU.1 -/- myeloid progenitors bypasses the block to M-CSF-dependent proliferation but does not induce detectable macrophage differentiation. Therefore, PU. 1 appears to be essential for specification of monocytic precursors. Importantly, retroviral transduction of PU.1 into mutant progenitors restores responsiveness to myeloid-specific cytokines and development of mature granulocytes and macrophages. Thus PU.1 controls myelopoiesis by regulating both proliferation and differentiation pathways.

Increasing survival in AIDS patients with cytomegalovirus retinitis treated with combination antiretroviral therapy including HIV protease inhibitors

OBJECTIVE

To assess the effect of combination antiretroviral therapy including HIV protease inhibitors on the survival of patients with cytomegalovirus retinitis (CMVR).

DESIGN AND PARTICIPANTS

A longitudinal study of patients with CMVR diagnosed between October 1992 and May 1996 and followed to May 1997.

SETTING

UK National Health Service specialist HIV medicine department.

OUTCOME MEASURE

Time to death from first diagnosis of CMVR. Data were censored on 31 May 1997.

RESULTS

Data were available on 147 patients with CMVR. Median survival of CMVR patients before December 1995 was 256 days [95% confidence interval (CI), 197-315]. Following the introduction of protease inhibitors in December 1995 this rose to 555 days (95% CI, 351-759). By 31 May 1996 median survival for the entire group of patients alive with CMVR had risen to 720 days (95% CI, 551-889). The mean survival after CMVR diagnosis was 224 days (n=89; 95% CI, 186-261; 1-year survival, 16%) in those who took no further antiretroviral therapy, 353 days in those who took nucleoside reverse transcriptase inhibitors but no protease inhibitors (n=34; 95% CI, 289-418; 1 -year survival, 50%), and 914 days in those who took a protease inhibitor (n=24; 95% CI, 768-1059; 1-year survival, 83%; P < 0.0001). Multivariate analysis showed that the strongest independent predictor of improved survival was having ever received a protease inhibitor after CMVR (relative risk of death, 0.063; 95% CI, 0.027-0.149; P < 0.0001).

CONCLUSIONS

The use of HIV protease inhibitors in combination antiretroviral therapy has been associated with a marked increase in the survival of patients with CMVR.

Human papillomavirus E6 and E7 oncoproteins alter cell cycle progression but not radiosensitivity of carcinoma cells treated with low-dose-rate radiation

PURPOSE

Low-dose-rate radiation therapy has been widely used in the treatment of urogenital malignancies. When continuously exposed to low-dose-rate ionizing radiation, target cancer cells typically exhibit abnormalities in replicative cell-cycle progression. Cancer cells that arrest in the G2 phase of the cell cycle when irradiated may become exquisitely sensitive to killing by further low-dose-rate radiation treatment. Oncogenic human papillomaviruses (HPVs), which play a major role in the pathogenesis of uterine cervix cancers and other urogenital cancers, encode E6 and E7 transforming proteins known to abrogate a p53-dependent G1 cell-cycle checkpoint activated by conventional acute-dose radiation exposure. This study examined whether expression of HPV E6 and E7 oncoproteins by cancer cells alters the cell-cycle redistribution patterns accompanying low-dose-rate radiation treatment, and whether such alterations in cell-cycle redistribution affect cancer cell killing.

METHODS AND MATERIALS

RKO carcinoma cells, which contain wild-type P53 alleles, and RKO cell sublines genetically engineered to express HPV E6 and E7 oncoproteins, were treated with low-dose-rate (0.25-Gy/h) radiation and then assessed for p53 and p21WAF1/CIP1 polypeptide induction by immunoblot analysis, for cell-cycle redistribution by flow cytometry, and for cytotoxicity by clonogenic survival assay.

RESULTS

Low-dose-rate radiation of RKO carcinoma cells triggered p53 polypeptide elevations, p21WAF1/CIP1 induction, and arrest in the G1 and G2 phases of the cell cycle. In contrast, RKO cells expressing E6 and E7 transforming proteins from high-risk oncogenic HPVs (HPV 16) arrested in G2, but failed to arrest in G1, when treated with low-dose-rate ionizing radiation. Abrogation of the G1 cell-cycle checkpoint activated by low-dose-rate radiation exposure appeared to be a characteristic feature of transforming proteins from high-risk oncogenic HPVs: RKO cells expressing E6 from a low-risk nononcogenic HPV (HPV 11) exposed to low-dose-rate radiation arrested in both G1 and G2. Surprisingly, despite differences in cell-cycle redistribution accompanying low-dose-rate radiation treatment associated with high-risk HPV transforming protein expression, no consistent differences in clonogenic survival following low-dose-rate radiation treatment were found for RKO cell sublines expressing high-risk HPV oncoproteins and arresting only in G2 during low-dose-rate radiation exposure vs. RKO cell sublines exhibiting both G1 and G2 cell-cycle arrest when irradiated.

CONCLUSION

The results of this study demonstrate that neither HPV oncoprotein expression nor loss of the radiation-activated G1 cell-cycle checkpoint alter the sensitivity of RKO carcinoma cell lines to low-dose-rate radiation exposure in vitro. Perhaps for urogenital malignancies associated with oncogenic HPVs in vivo, HPV oncoprotein-mediated abrogation of the G1 cell-cycle checkpoint may not limit the potential efficacy of low-dose-rate radiation therapy.

Androgen ablation-induced programmed death of prostatic glandular cells does not involve recruitment into a defective cell cycle or p53 induction

Proliferating cells characteristically undergo programmed (i.e. apoptotic) death if their progression through the cell cycle is sufficiently perturbed. To determine whether androgen ablation-induced programmed death of prostatic glandular cells involves apoptosis triggered by recruitment of nonproliferating cells into a perturbed cell cycle, rat ventral prostates were assessed temporally after castration for several stereotypical molecular stigmata of entry into the proliferative cell cycle. Northern blot analysis was used to assess levels of transcripts from genes characteristically activated 1) during the transition from quiescence (G(0)) into G1 of the proliferative cell cycle (cyclin-D1 and cyclin-C), 2) during the transition from G1 to S (cyclin-E, cdk2, thymidine kinase, and H4-histone), and 3) during progression through S (cyclin-A). Although levels of each of these transcripts increased as expected in prostatic glandular epithelial cells stimulated to proliferate by the administration of exogenous androgen to previously castrated rats, levels of the same transcripts decreased in prostatic glandular cells induced to undergo apoptosis after androgen withdrawal. Northern and Western blot analyses also demonstrated that there was no increase in prostatic p53 messenger RNA or protein content per cell after androgen ablation. Likewise, after castration, there was no enhanced prostatic expression of the WAF1/CIP1 gene, a gene whose expression is known to be induced in both a p53-dependent and -independent manner during recruitment from G0 into G1. In addition, androgen ablation-induced apoptosis of prostatic glandular cells was not accompanied by retinoblastoma protein phosphorylation, which is characteristic of progression into late G1. Nuclear run-on assays demonstrated that there was no increase in the prostatic rate of transcription of the c-myc and c-fos genes after castration. These results demonstrate that prostatic glandular cells undergo programmed death in G(0) without recruitment into the G1 phase of a defective cell cycle, and that an increase in p53 protein or its function is not involved in this death process.

Molecular characterization of defective antigen processing in human prostate cancer

BACKGROUND

Gene-modified tumor cell vaccines have shown efficacy in animal models of malignancy, including prostate cancer. Class I major histocompatibility complex (MHC) assembly and function in the cellular targets of such therapies is pivotal in determining the efficacy of specific cytokine-secreting tumor vaccines.

PURPOSE

To help guide development of genetically engineered vaccine therapy for human prostate cancer, potential immune resistance pathways were evaluated by analysis of class I MHC assembly in prostate cancer cells.

METHOD

Class I MHC assembly in metastasis-derived human prostate cancer cell lines (LNCaP, PPC-1, DU-145, PC-3, and TSU) and a normal prostate-derived cell line (TP-2) were characterized by phenotypic, molecular, and functional assays. Assembled class I MHC and antigen was measured by flow cytometry; mRNA levels of assembly components (class I MHC heavy chain, beta 2-microglobulin, and the antigen transporter gene product TAP-2) were determined; and antigen processing was measured with a chimeric reconstituted system using vaccinia vectors. Restoration of antigen processing was attempted by interferon gamma stimulation and by transfection with mouse class I MHC heavy-chain cDNA.

RESULTS

Assembled class I MHC was underexpressed in two (LNCaP and PPC-1) of five prostate cancer cell lines compared with normal prostate-derived controls. PPC-1 cells underexpressed TAP-2 mRNA despite abundant class I MHC and beta 2-microglobulin message. Induction of TAP-2 by interferon gamma indicated that coding sequences for TAP-2 message were present in PPC-1. Resistance to cytotoxic T lymphocytes (CTL) lysis showed a functional defect in antigen transport by PPC-1 cells; reversal of the molecular defect with interferon gamma led to restoration of functional antigen processing. In contrast, LNCaP cells had competent antigen transport but deficient class I MHC heavy-chain function despite abundant class I MHC RNA; though refractory to stimulation by interferon gamma, this defect responded to transfection of class I MHC heavy-chain cDNA.

CONCLUSIONS

Metastatic prostate cancer cells can escape T-cell recognition via divergent mechanisms of defective class I MHC assembly. The specific underexpression of TAP-2 gene product in PPC-1 cells contrasts with prior studies of TAP gene underexpression in lung cancer (which concurrently underexpressed class I MHC heavy chain) and provides evidence for a regulatory pathway controlling TAP-2 gene expression in human cancers that may not affect class I MHC heavy-chain expression.

IMPLICATIONS

In clinical application of gene therapy for prostate cancer, these findings provide a rationale for focusing on strategies that can circumvent sole reliance on class I MHC-mediated tumor cell recognition by CTL.

Femoral venous reflux abolished by greater saphenous vein stripping

Preoperative venous duplex scanning has revealed unexpected deep venous incompetence in patients with apparently only varicose veins. Acting on the hypothesis that the deep vein reflux was secondary to deep vein dilation caused by reflux volume, the following was done. Between July 1990 and April 1993, 29 limbs in 21 patients (16 females) were examined by color-flow duplex imaging to determine valve closure by the method of van Bemmelen. Instrumentation included high-resolution ATL-9 venous interrogation using a pneumatic cuff deflation stimulus of reflux in the standing, nonweight-bearing limb. All limbs showed greater saphenous vein reflux. Twenty-nine showed superficial femoral vein reflux and of these three showed popliteal vein reflux. Duplex testing was performed by a certified vascular technologist whose interpretation was blinded as to the results of clinical examination and grading of the severity of venous insufficiency. Surgery was performed on an outpatient basis under general anesthesia using groin-to-knee removal of the greater saphenous vein by the vein inversion technique of Van Der Strict. Stab avulsion of varicose tributary veins was accomplished during the same period of anesthesia. In 27 of 29 limbs with preoperative femoral reflux, that reflux was abolished by greater saphenous stripping. In patients with popliteal reflux both femoral and popliteal reflux was abolished. Improvement of deep venous hemodynamics by ablation of superficial reflux supports the reflux circuit theory of venous overload. Furthermore, preoperative evaluation of venous hemodynamics by duplex scanning appears to provide useful pre- and postoperative information regarding venous insufficiency in individual patients.

Risk factors associated with pulmonary embolism despite routine prophylaxis: implications for improved protection

Despite prophylaxis, pulmonary embolism (PE) remains a major cause of posttraumatic morbidity and mortality in high-risk patients. We studied injury-related risk factors associated with the occurrence of PE despite routine prophylaxis. A review of 9721 trauma patients discharged from January 1, 1985 through December 31, 1992, identified 36 patients (0.4%) who suffered clinically evident PE despite a policy of routine prophylaxis against deep venous thrombosis that included use of prophylactic inferior vena caval filters. (Twenty-nine patients had an inferior vena caval filter placed for prophylaxis against PE.) A detailed analysis of injury-related risk factors was performed. Four high-risk patterns of injury were identified, representing common combinations of significant risk factors. These patient groups have an absolute risk of PE despite prophylaxis ranging from 1.5% to 3.8%. The relative risk is approximately ten times that of control patients. Identification of appropriate high-risk groups is necessary to allow optimization of prophylactic measures, including placement of inferior vena caval filter.

The economic status of trauma centers on the eve of health care reform

An in-depth understanding of the economic problems confronting trauma centers is essential for their continued development and to address impending changes of health care reform. A comprehensive financial and demographic survey was sent to 839 hospitals identified as potential trauma centers. A total of 313 surveys from 48 states were returned. Extensive information was collected in several areas including financial status (58% reported serious financial problems and 36% reported minor financial problems; 68% reported a financial loss), cost containment and management strategies, marketing, "halo" effect (53% reported positive effect), operational impacts, physician support (47% reported problems), malpractice (92% reported no special problem), role of auto insurance reimbursement, and access to rehabilitation. Detailed financial data of actual costs and reimbursements (95 respondents) were analyzed with the costing method used by the Health Care Financing Administration (HCFA). These data will allow us to develop better strategies to deal with the problems of uncompensated and underfunded trauma care and improve trauma center viability.

The effects of aortic crossclamping and resuscitation on intracranial pressure, cerebral blood flow, and cerebral water content in a model of focal brain injury and hemorrhagic shock

Aortic crossclamping (AOXC) is performed frequently in hypotensive trauma patients who may have had a head injury. The effect of AOXC on the injured brain is unknown. We studied the effect of AOXC on mean arterial pressure (MAP), intracranial pressure (ICP), cerebral blood flow (CBF), cerebral perfusion pressure (CPP), and cerebral water content in a porcine model of focal cryogenic brain injury. Four groups of animals were studied: Group I--brain injury only; Group II--brain injury and AOXC; Group III--brain injury with hemorrhage and AOXC; and Group IV--AOXC only. Focal cryogenic grain injury increased the ICP in Groups I-III. Aortic crossclamping increased MAP, CBF, ICP, and CPP after hemorrhage in Group III. Following declamping and resuscitation there were no differences between the groups in any studied variable. Cerebral water content at the site of the focal brain injury was greater than in nonlesioned cortex but there was no significant difference between groups despite a greater positive fluid balance in hemorrhaged animals. AOXC improved perfusion to the injured brain without a significant increase in ICP. Increased MAP induced by AOXC and large fluid resuscitation appeared to have no detrimental effect on ICP, CBF, cerebral water content, or CPP in this model of brain injury.

Lack of late toxicity in patients treated with cisplatin-containing combination chemotherapy for metastatic testicular cancer

To date, the prevalence and nature of the late toxicity of cisplatin-based combination chemotherapy for advanced testicular cancer has been poorly documented. Thirty men with a median age of 35 years (range, 23 to 63), who had undergone such treatment were assessed with detailed investigation to determine the type and frequency of chronic toxicity. The median follow-up from the time of commencement of chemotherapy was 75 months (range, 48 to 126). The most common late toxic effects were high tone hearing loss in 23 men (77%) and electrophysiological evidence of peripheral nerve damage in 15 (50%). Both the hearing and nerve abnormalities were predominantly asymptomatic. In addition, elevation of serum cholesterol, noted in 20 patients (67%), was significant (P = .014) when compared with a control population. Hyperuricemia was present in nine patients (30%). Only one patient, with other risk factors (smoking, family history), had evidence of ischaemic heart disease while 20% (all with a smoking history) had a diminished single breath diffusing capacity for carbon monoxide (DLCO). Cisplatin-based chemotherapy is relatively free of major long-term side effects and should not be withheld for fear of late toxicity.

Hygromycin A, an antitreponemal substance. II. Therapeutic effect for swine dysentery

This study was conducted to evaluate hygromycin A fed to growing swine at 1, 5, 10 or 20 g/ton feed for the control of Treponema hyodysenteriae-caused dysentery. Pigs provided carbadox at 50 g/ton feed served as an infected treatment control group. All pigs were orally, via stomach intubation, administered 100 ml of a T. hyodysenteriae broth culture. During the in vivo test, rectal swabs were taken for T. hyodysenteriae isolation, body weights of all pigs and the feed consumption was determined. All pigs were euthanized and necropsied at study end; the large intestine was cultured for T. hyodysenteriae and gross intestinal lesions were noted. T. hyodysenteriae-caused swine dysentery was successfully controlled by feeding hygromycin A at 5 g/ton. Hygromycin A medicated pigs performed as well as or better than carbadox-medicated pigs.

Hygromycin A, an antitreponemal substance. I. Screening method and therapeutic effect for Treponema hyodysenteriae-caused infection in CF-1 mice

In vitro and in vivo screening methods were established for the discovery of new active substances against Treponema hyodysenteriae. During the screening methods, hygromycin A produced by Streptomyces hygroscopicus KA-355 was found to be active against T. hyodysenteriae. Hygromycin A did not show high antitreponemal activity in in vitro test using the paper disc method on the agar plate inoculated with T. hyodysenteriae. However, the antibiotic exhibited highly therapeutic effect in CF-1 mice, compared with of lincomycin, tiamulin, lankacidin C or olaquindox drinking water. The effective dose (ED50) of hygromycin A was 1.1 micrograms/ml.

Surgical management of subclavian artery injury

During a 10 year period, we have had operative experience with 13 injuries to the subclavian artery. The factors that led to the successful management in 10 consecutive patients were analyzed. Nonspecific signs, such as pain and swelling, were present in all of the patients. Some aspect of vascular injury was present in each patient and included change in the quality of the distal pulse, hematoma, active hemorrhage, and bruit. Roentgenologic signs such as lung opacification, fractured clavicle, fracture of the first or second rib, and pulmonary opacification were present in each patient. Arteriograms were obtained from all stable patients in whom this injury was suspected. There were no false-positive or false-negative findings. The operative approach for the right subclavian vessels was midline sternotomy, whereas for exposure of proximal left subclavian injuries, anterolateral thoracotomy was utilized. Claviculectomy permitted excellent exposure for distal subclavian artery injuries. This exposure was associated with minimal blood loss and permitted direct repair of complex injuries of the arteries and veins. All patients who reached the emergency room with measurable vital signs survived, and all those who underwent subclavian vascular repair had circulation restored. Principal morbidity was due to associated brachial plexus and lung injuries. A high index of suspicion, rapid transportation, aggressive resuscitation, and proper surgical exposure and repair are essential for the successful management of these rare vascular injuries.

Variability on serial testing of pattern reversal visual evoked potential latencies from full-field, half-field and foveal stimulation in control subjects

The change in pattern reversal visual evoked potential (PRVEP) latency over time (test-retest variability, TRV) was assessed in 30 (16 males, 14 females) adult control subjects using full-field (FF), half-field (HF) and foveal (central-field, CF) stimulation. The mean test-retest interval (TRI) was 20.5 months with a range of 18-21.5 months. There were no significant test-retest latency differences in either sex and furthermore there were no significant inter-sex differences in any of the test-retest parameters. Because of the latter finding the test-retest upper limit of normal for each parameter as defined by the mean value + 2.5 S.D. was taken as the largest value obtained in either sex. Thus the test-retest upper limits of normal for absolute latency from FF, right HF, left HF and CF stimulation were 6, 7, 9 and 7 msec, respectively; for interocular latency differences (ILD) from FF and CF stimulation were 4 and 5 msec respectively; and for right HF to left HF intraocular latency difference (IOLD) was 7 msec. It is concluded that the TRV was sufficiently small in our control group with each of the stimulus techniques to make all of them potentially useful in serial PRVEP studies. Furthermore the extra information provided by CF and HF stimulation may increase the sensitivity and accuracy with which change can be monitored.

Estrogen enhancement of androgen-induced renal growth in the male rat

17 beta-estradiol enhances dihydrotestosterone-induced growth of the castrate male rat kidney by increasing cell number, cell size and tissue water retention. No estrogen enhancement was observed in sex accessory tissues or other organs. This estrogen enhancement of androgen-induced growth is discussed in relation to species and organ specificity.

Acute optic neuritis: a prospective study of risk factors for multiple sclerosis

Eighty two patients with isolated optic neuritis were studied prospectively to determine the frequency with which multiple sclerosis developed and the factors which increased its risk. Patients were followed for 6 to 264 months (mean, 57 months). Twenty six patients (32%) developed clinically definite or probable multiple sclerosis during the period of follow-up. Actuarial analysis predicted that 42% would develop multiple sclerosis by 7 years. Of those patients who developed multiple sclerosis, 92% had symptoms within 4 years of the first attack of optic neuritis. The highest incidence of multiple sclerosis occurred in the 21-40 year age group. There was an increased risk of MS in patients with HLA-DR2 and HLA-B7 tissue types. The frequency of HLA-DR4 was increased in patients with optic neuritis alone compared to controls and to patients with multiple sclerosis, but further studies are required to confirm this finding.

Visual evoked responses and ophthalmological examination in optic neuritis. A follow-up study

Ophthalmological examination and visual evoked responses (VERs) were repeated at 6-120 (mean 46) months after the first attack of acute optic neuritis in 80 patients who had abnormal VERs in 98 symptomatic eyes at the initial examination. The wide field VER returned to within the normal range in 19/98 (19%) symptomatic eyes. Fifteen percent of patients had completely normal VERs at follow-up. The yield of VER abnormalities was increased by the use of central field in addition to wide field stimulation. One or more components of the ophthalmological examination were abnormal in 91% of symptomatic eyes at final review. Although the ophthalmological examination was a more sensitive index than the VER of past optic neuritis in symptomatic eyes, the reverse was the case in asymptomatic eyes.

Visual evoked responses in chronic alcoholics

Visual evoked responses (VERs) were recorded on 52 chronic alcoholics patients without Wernicke-Korsakoff syndrome, 22 of whom had cerebellar ataxia, and eight chronic alcoholics with Wernicke-Korsakoff syndrome. Abnormal VERs were found in 23% of patients without and 37% of patients with Wernicke-Korsakoff syndrome. The main VER abnormalities of all the alcoholic groups were prolonged latency and reduced amplitude of the P100 component. Improvement followed a six month period of abstinence. VERs may be useful in the early detection of alcohol induced brain damage, and in following the progress of patients with the condition.

The application of prolonged electroencephalographic monitoring and video recording to the diagnosis of epilepsy

This study reports the results of the application of intensive monitoring by electroencephalogram (EEG) combined with video recording as an aid to the diagnosis of epilepsy. A group of 622 patients was investigated; useful information was obtained in approximately 50% of these patients. Ten per cent of the patients with suspected epilepsy had a seizure during the period of recording. The combined analysis of the video recording and the EEG provided valuable evidence in the analysis of complex partial seizures and highlights the high prevalence of pseudoseizures in patients who are suspected of having epilepsy.

Chronic polyneuropathy of undetermined cause

The case histories of 519 patients with peripheral neuropathy on whom sural nerve biopsy had been performed were reviewed. In 67 patients (50 males, 17 females) (13%) who had symptoms of a symmetrical polyneuropathy for more than one year, the cause remained undiagnosed in spite of intensive investigation. Patients with inflammatory neuropathy were not included, but represented 17% of the whole series. The mean age of onset of symptoms was 50.6 years, and the median time from onset of symptoms to initial investigation was 2 years. Males were affected more commonly than females in a ratio of 3:1. The clinical features in 43 patients were those of a mixed motor and sensory neuropathy, in 17 patients a predominantly sensory neuropathy and in 7 patients a predominantly motor neuropathy. The mean CSF protein was 0.73 g/l and in only six patients was it greater than 1 g/l. Nerve conduction studies most commonly demonstrated mild slowing of motor conduction and impairment of sensory conduction. The usual pathological changes on sural nerve biopsy were those of chronic axonal degeneration. Forty seven patients (70%) were re-examined at intervals of time which ranged from 4 months to 12 years after their initial presentation and nerve biopsy (median, 3 years). As a group, they were only mildly disabled, the condition had a very slowly progressive course and there had been little change in their disability. A possible aetiological factor was found in 17 of the 47 patients (36%) and included malignancy, alcoholism, and benign paraproteinaemia. It is concluded that with intensive investigation the cause of chronic polyneuropathy of duration greater than one year remains undetermined in only about 13% of patients and that continued follow-up is worthwhile since a diagnosis may be established on re-examination.

Abnormalities of proximal conduction in acute idiopathic polyneuritis: comparison of short latency evoked potentials and F-waves

Motor and sensory conduction studies, F-wave latency, and the latency of evoked potentials from the brachial plexus and cervical spine in response to median nerve stimulation were examined in 17 patients with acute idiopathic polyneuropathy. Short latency evoked potentials provided a higher yield of evidence of abnormalities of proximal conduction than did the F-wave latency. Both methods of studying conduction in the proximal segments of a peripheral nerve may be normal, however, in a small number of patients who have significant pathological lesions.

Visual evoked potentials in the detection of subclinical optic toxic effects secondary to ethambutol

In 14 patients with tuberculosis treated with ethambutol hydrochloride, pattern-reversal visual evoked potentials (VEPs) were recorded to monocular, whole-field stimulation before the commencement of treatment and one month and three months subsequently. In six subjects, the VEPs showed changes in the latency and amplitude of the P100 component at the one- or three-month interval. In three cases, the VEP changes reversed after cessation of treatment. In five of the six cases, changes were not associated with a change in visual function, as measured by clinical neuro-ophthalmologic examination. Our findings confirm the usefulness of VEPs in the detection of subclinical optic nerve disease and suggest their use in routine monitoring of ocular function in patients treated with ethambutol.