A sub-national real-time epidemiological and vaccination database for the COVID-19 pandemic in Canada

The COVID-19 pandemic has demonstrated the need for real-time, open-access epidemiological information to inform public health decision-making and outbreak control efforts. In Canada, authority for healthcare delivery primarily lies at the provincial and territorial level; however, at the outset of the pandemic no definitive pan-Canadian COVID-19 datasets were available. The COVID-19 Canada Open Data Working Group was created to fill this crucial data gap. As a team of volunteer contributors, we collect daily COVID-19 data from a variety of governmental and non-governmental sources and curate a line-list of cases and mortality for all provinces and territories of Canada, including information on location, age, sex, travel history, and exposure, where available. We also curate time series of COVID-19 recoveries, testing, and vaccine doses administered and distributed. Data are recorded systematically at a fine sub-national scale, which can be used to support robust understanding of COVID-19 hotspots. We continue to maintain this dataset, and an accompanying online dashboard, to provide a reliable pan-Canadian COVID-19 resource to researchers, journalists, and the general public.

Trends and determinants of newborn mortality in Kyrgyzstan: a Countdown country case study

BACKGROUND

Kyrgyzstan has made considerable progress in reducing child mortality compared with other countries in the region, despite a comparatively low economic standing. However, maternal mortality is still high. Given the availability of an established birth registration system, we aimed to comprehensively assess the trends and determinants of reproductive, maternal, newborn, and child health in Kyrgyzstan.

METHODS

For this Countdown to 2030 country case study, we used publicly available data repositories and the national birth registry of Kyrgyzstan to examine trends and inequalities of reproductive, maternal, and newborn health and mortality between 1990 and 2018, at a national and subnational level. Coverage of newborn and maternal health interventions was assessed and disaggregated by equity dimensions. We did Oaxaca-Blinder decomposition to determine the contextual factors associated with the observed decline in newborn mortality rates. We also undertook a comprehensive review of national policies and programmes, as well as a prospective Lives Saved Tool analysis, to highlight interventions that have the potential to avert the most maternal, neonatal, and child deaths.

FINDINGS

Over the past two decades, Kyrgyzstan reduced newborn mortality rates by 46% and mortality rates of children younger than 5 years by 69%, whereas maternal mortality rates were reduced by 7% and stillbirth rates by 29%. The leading causes of neonatal deaths were prematurity and asphyxia or hypoxia, and preterm small-for-gestational-age infants were more than 80 times more likely to die in their first month of life compared with those born appropriate-for-gestational age at term. Except for contraceptive use, coverage of essential interventions has increased and is generally high, with limited sociodemographic inequities. With scale-up of a few essential neonatal and maternal interventions, 39% of neonatal deaths, 11% of stillbirths, and 19% of maternal deaths could be prevented by 2030.

INTERPRETATION

Kyrgyzstan has reduced newborn mortality rates considerably, with the potential for further reduction. To achieve and exceed the Sustainable Development Goal 3 targets for newborn survival and reducing stillbirths, Kyrgyzstan needs to scale up packages of interventions for the care of small and sick babies, assure quality of care in all health-care facilities with regionalised perinatal care, and create a linked national registry for mothers and neonates with rapid feedback and accountability.

FUNDING

US Fund for UNICEF under the Countdown to 2015, UNICEF Kyrgyzstan Office.

Social Equity and COVID-19: The Case of African Americans

Emerging statistics demonstrate that COVID-19 disproportionately affects African Americans. The effects of COVID-19 for this population are inextricably linked to areas of systemic oppression and disenfranchisement, which are exacerbated by COVID-19: (1) health care inequality; (2) segregation, overall health, and food insecurity; (3) underrepresentation in government and the medical profession; and (4) inequalities in participatory democracy and public engagement. Following a discussion of these issues, this essay shares early and preliminary lessons and strategies on how public administration scholars and practitioners can lead in crafting equitable responses to this global pandemic to uplift the African American community.

The impact of community-wide, mass drug administration on aggregation of soil-transmitted helminth infection in human host populations

Background

Soil-transmitted helminths (STH) are intestinal parasites estimated to infect over 1.5 billion people. Current treatment programmes are aimed at morbidity control through school-based deworming programmes (targeting school-aged children, SAC) and treating women of reproductive age (WRA), as these two groups are believed to record the highest morbidity. More recently, however, the potential for interrupting transmission by treating entire communities has been receiving greater emphasis and the feasibility of such programmes are now under investigation in randomised clinical trials through the Bill & Melinda Gates Foundation funded DeWorm3 studies. Helminth parasites are known to be highly aggregated within human populations, with a small minority of individuals harbouring most worms. Empirical evidence from the TUMIKIA project in Kenya suggests that aggregation may increase significantly after anthelminthic treatment.

Methods

A stochastic, age-structured, individual-based simulation model of parasite transmission is employed to better understand the factors that might induce this pattern. A simple probabilistic model based on compounded negative binomial distributions caused by age-dependencies in both treatment coverage and exposure to infection is also employed to further this understanding.

Results

Both approaches confirm helminth aggregation is likely to increase post-mass drug administration as measured by a decrease in the value of the negative binomial aggregation parameter, k. Simple analytical models of distribution compounding describe the observed patterns well.

Conclusions

The helminth aggregation that was observed in the field was replicated with our stochastic individual-based model. Further work is required to generalise the probabilistic model to take account of the respective sensitivities of different diagnostics on the presence or absence of infection.

A Half Century of Oral Rehydration Therapy in Childhood Gastroenteritis: Toward Increasing Uptake and Improving Coverage

Termed by the Lancet, as "potentially the most important medical advance of the twentieth century," therapy with oral rehydration solutions (ORSs) has been essential to reducing mortality in children less than 5 years (under five) with infectious gastroenteritis and diarrhea. The target of the diarrhea-control programs in the 1990s was to achieve ORS use in 80% of diarrhea cases by the year 2000. Nevertheless, nearly 20 years later, global uptake remains limited to only a third of the cases. Our analysis shows that from 1990 to 2017, mean ORS coverage in Countdown countries [the 81 Countdown-to-2030 priority countries, which together account for 95% of maternal deaths and 90% of under-five deaths] increased from ~ 30% to nearly 40%. Flawed government policies, inadequate supplies, and lack of awareness among health workers and communities all contributed to this shortfall in coverage. Moreover, imperfect measurement methodology is implicated in questionable coverage data. A multipronged approach focusing on the manufacture, supply, training, and behavioral change is essential to ensure that ORS is used in all epidemic diarrhea cases globally, especially in the under-five population.

Contemporary Management of Bulbar Urethral Strictures

Urethral stricture disease (USD) is a progressive scar-forming disease commonly encountered by urologists and is challenging to manage. USD most frequently occurs in the bulbar urethra. Patients typically present with chronic obstructive voiding symptoms but may develop recurrent urinary tract infections, detrusor failure, or renal disease. The authors review the pathophysiology, diagnostic workup, and evidence-based management of bulbar urethral strictures (BUS). There are multiple surgical options to treat BUS. Endoscopic techniques (eg, dilation and urethrotomy) are suitable for the initial management of short strictures but new evidence-based guidelines recommend against repeated endoscopic treatment. Urethroplasty is the gold standard treatment for BUS of all lengths, with anastomotic techniques appropriate for strictures <2 cm and tissue substitution performed for longer strictures. New techniques, such as non-transecting urethroplasty, lack long-term data but may represent a paradigm shift in the field. Future treatments may utilize tissue-engineered grafts and agents that inhibit inflammation and scar formation.

Defining stopping criteria for ending randomized clinical trials that investigate the interruption of transmission of soil-transmitted helminths employing mass drug administration

The current World Health Organization strategy to address soil-transmitted helminth (STH) infections in children is based on morbidity control through routine deworming of school and pre-school aged children. However, given that transmission continues to occur as a result of persistent reservoirs of infection in untreated individuals (including adults) and in the environment, in many settings such a strategy will need to be continued for very extended periods of time, or until social, economic and environmental conditions result in interruption of transmission. As a result, there is currently much discussion surrounding the possibility of accelerating the interruption of transmission using alternative strategies of mass drug administration (MDA). However, the feasibility of achieving transmission interruption using MDA remains uncertain due to challenges in sustaining high MDA coverage levels across entire communities. The DeWorm3 trial, designed to test the feasibility of interrupting STH transmission, is currently ongoing. In DeWorm3, three years of high treatment coverage-indicated by mathematical models as necessary for breaking transmission-will be followed by two years of surveillance. Given the fast reinfection (bounce-back) rates of STH, a two year no treatment period is regarded as adequate to assess whether bounce-back or transmission interruption have occurred in a given location. In this study, we investigate if criteria to determine whether transmission interruption is unlikely can be defined at earlier timepoints. A stochastic, individual-based simulation model is employed to simulate core aspects of the DeWorm3 community-based cluster-randomized trial. This trial compares a control arm (annual treatment of children alone with MDA) with an intervention arm (community-wide biannual treatment with MDA). Simulations were run for each scenario for both Ascaris lumbricoides and hookworm (Necator americanus). A range of threshold prevalences measured at six months after the last round of MDA and the impact of MDA coverage levels were evaluated to see if the likelihood of bounce-back or elimination could reliably be assessed at that point, rather than after two years of subsequent surveillance. The analyses suggest that all clusters should be assessed for transmission interruption after two years of surveillance, unless transmission interruption can be effectively ruled out through evidence of low treatment coverage. Models suggest a tight range of homogenous prevalence estimates following high coverage MDA across clusters which do not allow for discrimination between bounce back or transmission interruption within 24 months following cessation of MDA.

Current epidemiological evidence for predisposition to high or low intensity human helminth infection: a systematic review

BACKGROUND

The human helminth infections include ascariasis, trichuriasis, hookworm infections, schistosomiasis, lymphatic filariasis (LF) and onchocerciasis. It is estimated that almost 2 billion people worldwide are infected with helminths. Whilst the WHO treatment guidelines for helminth infections are mostly aimed at controlling morbidity, there has been a recent shift with some countries moving towards goals of disease elimination through mass drug administration, especially for LF and onchocerciasis. However, as prevalence is driven lower, treating entire populations may no longer be the most efficient or cost-effective strategy. Instead, it may be beneficial to identify individuals or demographic groups who are persistently infected, often termed as being "predisposed" to infection, and target treatment at them.

METHODS

The authors searched Embase, MEDLINE, Global Health, and Web of Science for all English language, human-based papers investigating predisposition to helminth infections published up to October 31st, 2017. The varying definitions used to describe predisposition, and the statistical tests used to determine its presence, are summarised. Evidence for predisposition is presented, stratified by helminth species, and risk factors for predisposition to infection are identified and discussed.

RESULTS

In total, 43 papers were identified, summarising results from 34 different studies in 23 countries. Consistent evidence of predisposition to infection with certain species of human helminth was identified. Children were regularly found to experience greater predisposition to Ascaris lumbricoides, Schistosoma mansoni and S. haematobium than adults. Females were found to be more predisposed to A. lumbricoides infection than were males. Household clustering of infection was identified for A. lumbricoides, T. trichiura and S. japonicum. Ascaris lumbricoides and T. trichiura also showed evidence of familial predisposition. Whilst strong evidence for predisposition to hookworm infection was identified, findings with regards to which groups were affected were considerably more varied than for other helminth species.

CONCLUSION

This review has found consistent evidence of predisposition to heavy (and light) infection for certain human helminth species. However, further research is needed to identify reasons for the reported differences between demographic groups. Molecular epidemiological methods associated with whole genome sequencing to determine 'who infects whom' may shed more light on the factors generating predisposition.

Testing for soil-transmitted helminth transmission elimination: Analysing the impact of the sensitivity of different diagnostic tools

In recent years, an increased focus has been placed upon the possibility of the elimination of soil-transmitted helminth (STH) transmission using various interventions including mass drug administration. The primary diagnostic tool recommended by the WHO is the detection of STH eggs in stool using the Kato-Katz (KK) method. However, detecting infected individuals using this method becomes increasingly difficult as the intensity of infection decreases. Newer techniques, such as qPCR, have been shown to have greater sensitivity than KK, especially at low prevalence. However, the impact of using qPCR on elimination thresholds is yet to be investigated. In this paper, we aim to quantify how the sensitivity of these two diagnostic tools affects the optimal prevalence threshold at which to declare the interruption of transmission with a defined level of confidence. A stochastic, individual-based STH transmission model was used in this study to simulate the transmission dynamics of Ascaris and hookworm. Data from a Kenyan deworming study were used to parameterize the diagnostic model which was based on egg detection probabilities. The positive and negative predictive values (PPV and NPV) were calculated to assess the quality of any given threshold, with the optimal threshold value taken to be that at which both were maximised. The threshold prevalence of infection values for declaring elimination of Ascaris transmission were 6% and 12% for KK and qPCR respectively. For hookworm, these threshold values are lower at 0.5% and 2% respectively. Diagnostic tests with greater sensitivity are becoming increasingly important as we approach the elimination of STH transmission in some regions of the world. For declaring the elimination of transmission, using qPCR to diagnose STH infection results in the definition of a higher prevalence, than when KK is used.

Soil-transmitted helminths are categorised as a neglected tropical disease and comprise four dominant species (two hookworms, Trichuris trichuria & Ascaris lumbricoides) that affect the poorest people in the world. The World Health Organisation (WHO) has made great strides in reducing the morbidity induced by STH infections in pre-school aged and school-aged children through mass drug administration. Many countries are now considering moving from morbidity reduction in school-aged children to community-wide treatment with the aim of transmission elimination. These helminths reproduce sexually within a human host and therefore both male and female worms must be present to produce fertilized eggs. The density of female and male worms below which mating success is too low to sustain parasite populations is defined as the ‘breakpoint’ in transmission. Both the prevalence and intensity of infection are very low as this breakpoint is approached when worm numbers are highly aggregated in their distribution within the human host population. Consequently, it becomes increasingly challenging to identify infected individuals using standard microscopic diagnostic tools (such as Kato-Katz). New and more sensitive molecular diagnostics tools, such as qPCR, are a necessity in settings where communities are moving towards the interruption of transmission. This paper demonstrates that the threshold to declare interruption of transmission is 50% lower when microscopic techniques are applied compared with molecular techniques.

Identifying optimal threshold statistics for elimination of hookworm using a stochastic simulation model

BACKGROUND

There is an increased focus on whether mass drug administration (MDA) programmes alone can interrupt the transmission of soil-transmitted helminths (STH). Mathematical models can be used to model these interventions and are increasingly being implemented to inform investigators about expected trial outcome and the choice of optimum study design. One key factor is the choice of threshold for detecting elimination. However, there are currently no thresholds defined for STH regarding breaking transmission.

METHODS

We develop a simulation of an elimination study, based on the DeWorm3 project, using an individual-based stochastic disease transmission model in conjunction with models of MDA, sampling, diagnostics and the construction of study clusters. The simulation is then used to analyse the relationship between the study end-point elimination threshold and whether elimination is achieved in the long term within the model. We analyse the quality of a range of statistics in terms of the positive predictive values (PPV) and how they depend on a range of covariates, including threshold values, baseline prevalence, measurement time point and how clusters are constructed.

RESULTS

End-point infection prevalence performs well in discriminating between villages that achieve interruption of transmission and those that do not, although the quality of the threshold is sensitive to baseline prevalence and threshold value. Optimal post-treatment prevalence threshold value for determining elimination is in the range 2% or less when the baseline prevalence range is broad. For multiple clusters of communities, both the probability of elimination and the ability of thresholds to detect it are strongly dependent on the size of the cluster and the size distribution of the constituent communities. Number of communities in a cluster is a key indicator of probability of elimination and PPV. Extending the time, post-study endpoint, at which the threshold statistic is measured improves PPV value in discriminating between eliminating clusters and those that bounce back.

CONCLUSIONS

The probability of elimination and PPV are very sensitive to baseline prevalence for individual communities. However, most studies and programmes are constructed on the basis of clusters. Since elimination occurs within smaller population sub-units, the construction of clusters introduces new sensitivities for elimination threshold values to cluster size and the underlying population structure. Study simulation offers an opportunity to investigate key sources of sensitivity for elimination studies and programme designs in advance and to tailor interventions to prevailing local or national conditions.

The past matters: estimating intrinsic hookworm transmission intensity in areas with past mass drug administration to control lymphatic filariasis

Background

Current WHO guidelines for soil-transmitted helminth (STH) control focus on mass drug administration (MDA) targeting preschool-aged (pre-SAC) and school-aged children (SAC), with the goal of eliminating STH as a public health problem amongst children. Recently, attention and funding has turned towards the question whether MDA alone can result in the interruption of transmission for STH. The lymphatic filariasis (LF) elimination programme, have been successful in reaching whole communities. There is the possibility of building upon the infrastructure created for these LF-programmes to enhance the control of STH. Using hookworm as an example, we explore what further MDA coverage might be required to induce interruption of transmission for hookworm in the wake of a successful LF programme.

Results

Analyses based on the model of STH transmission and MDA impact predict the effects of previous LF control by MDA over five years, on a defined baseline prevalence of STH in an area with a defined transmission intensity (the basic reproductive number R₀). If the LF MDA programme achieved a high coverage (70, 70 and 60% for pre-SAC, SAC and adults, respectively) we expect that in communities with a hookworm prevalence of 15%, after 5 years of LF control, the intrinsic R₀ value in that setting is 2.47. By contrast, if lower LF coverages were achieved (40, 40 and 30% for pre-SAC, SAC and adults, respectively), with the same prevalence of 15% at baseline (after 5 years of LF MDA), the intrinsic hookworm R₀ value is predicted to be 1.67. The intrinsic R₀ value has a large effect on the expected successes of follow-up STH programmes post LF MDA. Consequently, the outcomes of identical programmes may differ between these communities.

Conclusion

To design the optimal MDA intervention to eliminate STH infections, it is vital to have information on historical MDA programmes and baseline prevalence to estimate the intrinsic transmission intensity for the defined setting (R₀). The baseline prevalence alone is not sufficient to inform policy for the control of STH, post cessation of LF MDA, since this will be highly dependent on the intensity and effectiveness of past programmes and the intrinsic transmission intensity of the dominant STH species in any given setting.

Research Needs for Effective Transition in Lifelong Care of Congenital Genitourinary Conditions: A Workshop Sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases

Over the last 5 decades, health-care advances have yielded quantum improvements in the life expectancy of individuals with congenital genitourinary conditions (CGCs), leading to a crisis of care. Many individuals with CGC enter adulthood unprepared to manage their condition. Pediatric CGC specialists lack training to manage adulthood-related health-care issues, whereas adult genitourinary specialists lack training within the context of CGCs. To address these challenges, the National Institutes of Diabetes and Digestive and Kidney Diseases convened individuals with CGCs and experts from a variety of fields to identify research needs to improve transitional urology care. This paper outlines identified research needs.

Effects of magnitude of food reinforcement on free-operant response rates

In Experiment 1 rats were trained to press a lever on a variable-ratio schedule of food presentation and were then exposed to progressively increasing magnitudes of food reinforcement. Response running rates (rates exclusive of the postreinforcement pause) were found to increase as a function of increasing reinforcement magnitudes. The effect of reinforcement magnitude on response rates inclusive of the postreinforcement pause, however, was less pronounced. Increases in the magnitude of reinforcement were also found to increase the length of the postreinforcement pause. Rats in Experiment 2 were trained to respond on a chained differential-reinforcement-of-low-rate variable-ratio schedule, and were exposed to increasing magnitudes of reinforcement as in Experiment 1. Response running rates increased in the variable-ratio component but decreased in the other component of the schedule. The results are discussed with reference to incentive accounts of reinforcement and the action of reinforcement on the response units generated by the operative contingencies.

Does fever or myalgia indicate reduced physical performance capacity in viral infections?

To study prospectively the effects of a brief febrile viral infection on parameters of muscle and circulatory function, seven volunteers were inoculated with sandfly fever virus and two control subjects with sterile saline. During but not after fever, decreased isometric and dynamic strength and endurance were recorded in various muscles. Impairment could not be explained by altered activities of relevant muscle enzymes in serum or muscle tissue or by altered muscle ultrastructure, but correlated with the severity of perceived symptoms, including myalgia, as rated by each subject. Compared to baseline, cardiac stroke volume was lower during and after fever. During fever, an increased heart rate maintained cardiac output at pre-inoculation values, whereas cardiac output fell in early convalescence. This decrease in cardiac output correlated significantly with the severity of fever. Thus, in brief viral infections a transient impairment of muscle performance capacity is correlated to subjective symptoms such as myalgia, rather than to fever, whereas a decreased cardiac output following such infections seems to be associated with the fever reaction.

Wound Infection: Experience with 12,000 Sutured Surgical Wounds in a General Hospital over a Period of 11 years

Wound infection rates in a general hospital over an 11-year period have been studied, the review embracing over 12,000 sutured surgical wounds. There is a remarkably constant downward trend in the wound infection rate. This is considered real, as there has been no change in the method of recording. Changes in operating theatre technique have not individually influenced the rates or the trend. In particular, the use or non-use of surgical masks made no difference to the incidence of wound infection. Changes in scrub-up-technique and the introduction of air-conditioning in the operating rooms had no appreciable effect. There is a difference between wound infection rates of acute operations and elective operations, of "clean" operations and "dirty" operations. The possible sources of surgical wound infection are discussed. The classification into "inherent" and "sporadic" groups is offered, and in "sporadic" infections the role of the patient as a source of infection is considered.

Comparison of mechanical behavior among the extrapulmonary arteries from rats

Results of comparative tests on pulmonary arteries from untreated Long-Evans rats are presented from three sections of the artery: the trunk, and the right and left main extrapulmonary arteries. Analyses were conducted looking for mechanical differences between the flow (longitudinal) and circumferential directions, between the right and left main arteries, and between each of the mains and the trunk. The mechanical properties of rat pulmonary arteries were obtained with a bubble inflation technique. A flat disk of rat pulmonary artery was constrained at the periphery and inflated, and the geometry of the resulting bubble of material recorded from six different angles. To analyze the data, the area under the stress-strain curve was calculated for each test and orientation. This area, related to the strain-energy density, was calculated at stress equal to 200kPa, for the purpose of statistical comparison. The mean values for the area show that the trunk is less compliant than the main arteries; this difference is supported by histological evidence. When comparing the circumferential and longitudinal properties of the arteries, differences are found for the trunk and left main arteries, but with opposite orientations being more compliant. The mean values for the two orientations for the right main artery are statistically identical. There was indication of significant difference in mechanical properties between the trunk and the main arteries. The left main artery in the circumferential orientation is highly compliant and appears to strongly influence the likelihood that significant differences will exist when included in a statistical population. These data show that each section of the extrapulmonary arterial system should not be expected to behave identically, and they provide the baseline mechanical behavior of the pulmonary artery from normotensive rats.

Bubble-test method for synthetic and bovine vascular material

A measurement system has been designed and constructed at NIST for the study of the mechanical properties of synthetic and bovine vascular materials. The measurement technique was validated on latex, where good agreement was found with the Neo-Hookean model. Measurements were also made on expanded polytetrafluoroethylene, which is commonly used for vascular grafts. The measurements of this material were carried out over a pressure range greater than would be seen in vivo. However, the strains were still small enough to effectively apply the Neo-Hookean model to these data.

Comparison of the effects on glucose and lipid metabolism of equipotent doses of insulin detemir and NPH insulin with a 16-h euglycaemic clamp

AIMS/HYPOTHESIS

The association of insulin detemir with non-esterified fatty acid binding sites on albumin may limit its transfer from the circulation into the extravascular extracellular space in adipose tissue and muscle, due to the capillary endothelial cell barrier. In the liver, the open sinusoids may expose hepatocytes to insulin detemir, enabling it to have a greater effect in the liver than in peripheral tissues.

METHODS

We investigated the effects of equipotent doses of insulin detemir and NPH insulin on hepatic glucose rate of appearance (Ra), peripheral glucose rate of disposal (Rd) and glycerol Ra (a measure of lipolysis) using stable isotope techniques. We also investigated the effects of these insulins on NEFA concentrations in seven healthy volunteers during a 16-h euglycaemic clamp. A higher dose of insulin detemir was also studied.

RESULTS

There was no difference in the glucose infusion profile between insulin detemir and NPH. Insulin detemir had a greater effect on mean suppression of glucose Ra (mean difference 0.24 mg kg(-1) min(-1); CI 0.09-0.39; p<0.01), and minimum glucose Ra, with minimum low dose detemir -0.10+/-0.15 mg.kg(-1).min(-1) and minimum NPH 0.17+/-0.10 mg.kg(-1).min(-1) (p<0.02). However, it had a lesser effect on mean suppression of NEFA concentrations (mean difference -0.10 mmol/l; CI -0.03 to -0.17; ANOVA, p<0.02) than NPH. The effect of insulin detemir on glucose Rd and glycerol Ra was not different from NPH. Following high-dose detemir, total glucose infused and maximum glucose Rd were higher (p<0.02, p<0.03) and plasma NEFA concentrations lower (p<0.01) than with low-dose determir.

CONCLUSIONS/INTERPRETATION

This study suggests that insulin detemir, when compared to NPH insulin, has a greater effect on the liver than on peripheral tissues and thus has the potential to restore the physiological insulin gradient.

Noladin ether, a putative endocannabinoid, attenuates sensory neurotransmission in the rat isolated mesenteric arterial bed via a non-CB1/CB2 G(i/o) linked receptor

1 Noladin ether has recently been reported to be an endocannabinoid, with selectivity for the cannabinoid (CB) CB1 receptor. In the present study, we investigated the effects of noladin ether in the rat isolated mesenteric arterial bed, cultured dorsal root ganglia (DRG) cells and human vanilloid (TRPV1)-receptor-expressing HEK293 cells (TRPV1-HEK293 cells). 2 Electrical field stimulation of the mesenteric bed evoked frequency-dependent vasorelaxation due to the action of calcitonin gene-related peptide (CGRP) released from sensory nerves. Noladin ether (0.1-3 microm) attenuated sensory neurogenic relaxation in a concentration-dependent manner. Noladin ether (1 microm) reduced vasorelaxation at a submaximal frequency (8 Hz), from 57.3+/-6.8 to 23.3+/-3.8% (P<0.05, n=4). 3 The inhibitory effects of noladin ether were unaffected by the CB1 antagonists SR141716A and LY320135, and the CB2 antagonist SR144528 (1 microm). 4 Noladin ether had no effect on vasorelaxation elicited by exogenous CGRP or capsaicin. These data suggest that noladin ether is acting at a prejunctional site and no interaction with TRPV1 is involved. 5 In mesenteric beds from pertussis toxin (PTX)-pretreated rats, the inhibitory actions of noladin ether on sensory neurotransmission were abolished, indicating the involvement of G(i/o) protein-coupled receptors. 6 Noladin ether evoked a concentration-dependent increase in intracellular Ca2+ concentration in TRPV1-HEK293 cells at 10 microm (36.5+/-3.2% of maximal capsaicin-induced response), but it was a less potent agonist than both capsaicin and anandamide and at 1 microm it was essentially inactive. Noladin ether (1 microm) had no effect on capsaicin-evoked Ca2+ responses in DRG cells, and produced no response alone, indicating it neither modulates nor acts directly on TRPV1 receptors. 7 These data demonstrate that noladin ether attenuates sensory neurotransmission in rat mesenteric arteries via a non-CB1 non-CB2 PTX-sensitive prejunctional site, independently of TRPV1 receptors.

Comparison of strength properties of normotensive and hypertensive rat pulmonary arteries

A series of tests were conducted to quantify the difference in the mechanical properties of normo- and hypertensive pulmonary arteries. A bubble-test design was employed to measure the biaxial properties of a segment of artery. The test results compare the properties at multiple orientations of the trunk, right, and left pulmonary arteries from normal (Control) and monocrotaline-treated male Long-Evans wild rats that ranged in age from 8 to 17 weeks old, along with some preliminary results from hypoxic Long-Evans knock-out rats. Data show little difference between the stress-strain relationship of the control pulmonary arteries and that of the monocrotaline-treated pulmonary arteries. However, the preliminary results from the hypoxic pulmonary arteries show that the arterial material strains less before the onset of strain-stiffening behavior. The longitudinal orientation exhibits strain stiffening at lower strains than does the circumferential orientation. The differences between the left and right main arteries are minor. The trunk consistently demonstrates less stiffening in the region of larger strains for all conditions.

Clinical features associated with survival of patients with lymphoma of the ocular adnexa

PURPOSE

Although systemic or eyelid involvement by ocular adnexal lymphoma carries a worse prognosis, there have been few reports of the outcome in relation to clinical presentation. The outcome of malignant ocular adnexal lymphoma was, therefore, related to presenting clinical symptoms and signs.

DESIGN AND METHODS

A retrospective, noncomparative case-note review of 326 patients treated in the Orbital Clinic at Moorfields Eye Hospital. The associations between presenting symptoms or signs and three outcome measures (v.i.) were assessed by univariate and multiple variable regression together with Kaplan-Meier analysis.

MAIN OUTCOME MEASURES

(i) Presence of extra-orbital disease at the time of presentation; (ii) development of systemic lymphoma after new presentation with solely ocular adnexal disease; and (iii) death attributable to widespread lymphoma.

RESULTS

Presentation with disseminated disease was rarer with over 1 year's ophthalmic symptoms (odds ratio (OR) 0.7; 95% CI 0.5-0.9) and much more frequent with bilateral adnexal disease (OR 5.8; 95% CI 3.0-11.2). With solely adnexal disease at presentation, subsequent extra-orbital lymphoma was more frequent and earlier with lacrimal gland disease (as compared to those without; hazard ratio (HR) 1.9; 95% CI 1.2-4.5) or with eyelid disease (compared to those without; HR 2.4; 95% CI 1.2-4.5), or with bilateral disease (compared to unilateral disease; HR 2.6; 95% CI 1.4-5.2). Prior or concurrent systemic disease was the most significant predictive factor for lymphoma-related death (HR 6.8; 95% CI 4.3-10.9), but tumour-related death was also commoner and earlier with bilateral disease (HR 2.4; 95% CI 1.4-4.0) or where a relative afferent papillary defect was present (HR 2.8; 95% CI 1.6-4.9). Similarly, the rate of tumour-related death was slightly less where symptoms had been present for more than a year (HR 0.8; 95% CI 0.7-1.0) and slightly greater in the elderly (HR 1.03; 95% CI 1.01-1.05). Conjunctival lymphoma had the lowest rate of extra-orbital spread and lymphoma-related death, the rate of these two events being sequentially greater for patients with predominantly deep orbital lymphoma, lacrimal gland lymphoma, or eyelid lymphoma.

CONCLUSION

These data suggest that presenting symptoms and signs of patients with ocular adnexal lymphoma are significantly associated with the risk of systemic disease at orbital presentation, the rate of subsequent spread, and the rate of lymphoma-related death.

TRPV3 is a temperature-sensitive vanilloid receptor-like protein

Vanilloid receptor-1 (VR1, also known as TRPV1) is a thermosensitive, nonselective cation channel that is expressed by capsaicin-sensitive sensory afferents and is activated by noxious heat, acidic pH and the alkaloid irritant capsaicin. Although VR1 gene disruption results in a loss of capsaicin responses, it has minimal effects on thermal nociception. This and other experiments--such as those showing the existence of capsaicin-insensitive heat sensors in sensory neurons--suggest the existence of thermosensitive receptors distinct from VR1. Here we identify a member of the vanilloid receptor/TRP gene family, vanilloid receptor-like protein 3 (VRL3, also known as TRPV3), which is heat-sensitive but capsaicin-insensitive. VRL3 is coded for by a 2,370-base-pair open reading frame, transcribed from a gene adjacent to VR1, and is structurally homologous to VR1. VRL3 responds to noxious heat with a threshold of about 39 degrees C and is co-expressed in dorsal root ganglion neurons with VR1. Furthermore, when heterologously expressed, VRL3 is able to associate with VR1 and may modulate its responses. Hence, not only is VRL3 a thermosensitive ion channel but it may represent an additional vanilloid receptor subunit involved in the formation of heteromeric vanilloid receptor channels.

Jack Smyth: a major contribution to surgery

This personal comment records the contributions of the late Dr John Smyth and Royal Newcastle Hospital to surgical audit and surgical training. Smyth introduced surgical audit to this country against considerable professional opposition. The first publication on the subject appeared in The Medical Journal of Australia in 1959.

Histological features of ocular adnexal lymphoma (REAL classification) and their association with patient morbidity and survival

BACKGROUND

The histological characteristics of ocular adnexal lymphomas have previously provided only a limited guide to clinical outcome for affected patients. This clinicopathological relation was re-examined using the Revised European American Lymphoma (REAL) system to classify the tumours in a large cohort of patients.

METHODS

The biopsies and clinical follow up data for 192 patients with ocular adnexal lymphoma were reviewed, the biopsies being regraded in accordance with the REAL classification. For each of five histological groups, logistic regression analysis was used to determine the odds ratios (OR) for the presence of systemic disease at the time of orbital diagnosis and Cox regression analysis was used to assess the hazard ratios (HR) for disseminated disease and lymphoma related death. For 108 patients in whom extraorbital spread occurred, the histological category of lymphoma was compared with the sites of dissemination.

RESULTS

At presentation, the frequency of previous or concurrent extraorbital disease increased from marginal zone lymphoma (OR 1.0), diffuse lymphoplasmacytic/lymphoplasmacytoid lymphoma (OR 2.3), follicle centre lymphoma (OR 3.8), diffuse large B cell lymphoma (OR 4.0) to other histological lymphoma variants (OR 26.8). For all histological types, the estimated risk of extraorbital disease and lymphoma related death continued for many years and the proportion of patients with at least one extraorbital recurrence after 5 years was 47% for MZL, 48% for LPL, 64% for FCL, 81% for DLCL, and 95% for other lymphoma variants. The corresponding estimated rates for 5 year lymphoma related mortality were 12%, 19%, 22%, 48%, and 53% respectively.

CONCLUSIONS

Patients with ocular adnexal lymphoma can be classified by REAL into five distinct groups, which show a progressive increase in the risks of extraorbital disease at diagnosis, of disease dissemination with time, and of tumour related death.

Indole alkaloids from a culture of the fungus Aporpium caryae

In a screening for antifungal metabolites, two indole compounds of mixed biogenesis, 1H-indole-3-carboxylic acid, 1-(1,1-dimethyl-2-propenyl) methyl ester and 1H-indole-3-carboxylic acid, 1-(2,3-dihydroxy-1,1-dimethylpropyl) methyl ester were isolated from a culture of the basidiomycete Aporpiums caryae. The structural elucidation of these compounds was accomplished by spectroscopic methods.

Efficient utilization of the reduced folate carrier in CCRF-CEM human leukemic lymphoblasts by the potent antifolate N(alpha)-(4-amino-4-deoxypteroyl)-N(delta)-hemiphthaloyl-L- ornithine (PT523) and its B-ring analogues

The potent nonpolyglutamatable dihydrofolate reductase inhibitor N(alpha)-(4-amino-4-deoxypteroyl)-N(delta)-hemiphthaloyl-L-o rnithine (PT523) and six of its B-ring (5-deaza, 8-deaza, and 5,8-dideaza) analogues were compared in terms of their ability to: (a) inhibit the growth of CCRF-CEM human leukemic lymphoblasts, and (b) utilize the reduced folate carrier (RFC) in these cells as measured in a competition assay of [(3)H]methotrexate ([(3)H]MTX) influx. The IC(50) values of the hemiphthaloylornithine derivatives against CCRF-CEM cells after 72 hr of drug exposure varied from 0.64 to 1.3 nM as compared with 14 nM for MTX and 4.4 nM for aminopterin (AMT). The K(i) values of these compounds in the [(3)H]MTX influx assay were in the 0.3 to 0.7 microM range as compared with a K(i) of 5.4 microM for AMT and a K(t) of 7.1 microM for MTX. As a group, the affinities of these compounds for the RFC were approximately 10-fold greater than those of their respective glutamate analogues. These results indicate that, in addition to their previously reported tight binding to dihydrofolate reductase, a property contributing to the high potency of PT523 and its B-ring analogs as inhibitors of tumor cell growth is their strong affinity for the RFC.

Analogues of the potent nonpolyglutamatable antifolate N(alpha)-(4-amino-4-deoxypteroyl)-N(delta)-hemiphthaloyl-L-ornithine (PT523) with modifications in the side chain, p-aminobenzoyl moiety, or 9,10-bridge: synthesis and in vitro antitumor activity

Seven N(alpha)-(4-amino-4-deoxypteroyl)-N(delta)-hemiphthaloyl-L-o rnithine (2, PT523) analogues were synthesized by modifications of the literature synthesis of the corresponding AMT (1) analogues and were tested as inhibitors of tumor cell growth. In growth assays against cultured CCRF-CEM human leukemic cells exposed to drug for 72 h, the IC(50) values of analogues in which N(10) was replaced by CH(2) and CHMe were found to be 0.55 +/- 0.07 and 0.63 +/- 0.08 nM, and thus these analogues are more potent than 1 (IC(50) = 4.4 +/- 1.0 nM) or 2 (IC(50) = 1.5 +/- 0.39 nM). The 10-ethyl-10-deaza analogue of 2 (IC(50) = 1.2 +/- 0.25 nM) was not statistically different from 2 but was more potent than edatrexate, the 10-ethyl-10-deaza analogue of 1, which had an IC(50) of 3.3 +/- 0.36 nM. In contrast, the analogue of 2 with both an ethyl and a CO(2)Me group at the 10-position had an IC(50) of 54 +/- 4.9 nM, showing this modification to be unfavorable. The 4-amino-1-naphthoic acid analogue of 2 had an IC(50) of 1.2 +/- 0.22 nM, indicating that replacement of the p-aminobenzoic acid (pABA) moiety does not diminish cytotoxicity. The analogues in which the (CH(2))(3) side chain was replaced by slightly longer CH(2)SCH(2) and (CH(2))(2)SCH(2) groups gave IC(50) values of 4.4 +/- 1.1 and 5.0 +/- 0.56 nM and thus were somewhat less potent than the parent molecule. However the analogues in which the aromatic COOH group was at the meta and para positions of the phthaloyl ring had IC(50) values of 7.5 +/- 0.47 and 55 +/- 0.07 nM, confirming the low potency we had previously observed with these compounds against other cell lines. Overall, the results in this study support the conclusion that, while the position of the phthaloyl COOH group and the length of the amino acid side chain in 2 are important determinants of cytotoxic potency, changes in the pABA region and 9, 10-bridge are well-tolerated and can even increase potency.

The effect of side-chain, para-aminobenzoyl region, and B-ring modifications on dihydrofolate reductase binding, influx via the reduced folate carrier, and cytotoxicity of the potent nonpolyglutamatable antifolate N(alpha)-(4-amino-4-deoxypteroyl)-N(delta)-hemiphthaloyl-L- ornithine

N(alpha)-(4-Amino-4-deoxypteroyl)-N(delta)-hemiphthaloyl-L-o rnithine (PT523) is an unusually tight-binding dihydrofolate reductase (DHFR) inhibitor and is efficiently taken up into cells via the reduced folate carrier (RFC). Unlike classical DHFR inhibitors with a glutamate side chain, such as methotrexate and aminopterin, PT523 cannot form polyglutamates. Thus, it resembles lipophilic antifolates such as trimetrexate in not requiring metabolic activation by folylpolyglutamate synthetase in order to produce its antifolate effect. However, in contrast to trimetrexate, PT523 retains growth inhibitory activity in cells with the multidrug resistance phenotype. As part of the preclinical development of this drug, we have performed systematic modification of several regions of the PT523 molecule, with the aim of defining the optimal structural features for DHFR binding, influx into cells via the RFC, and the ability to inhibit cell growth. The following structure-activity correlations have emerged from this ongoing investigation, and are discussed: (1) the hemiphthaloylornithine side chain has the optimal length; (2) the preferred location of the aromatic carboxyl group is the ortho position; and (3) replacement of the phenyl ring of the para-aminobenzoic acid moiety by naphthalene, of nitrogen at the 10-position of the bridge by carbon, and of nitrogen at the 5- and/or 8-position of the B-ring by carbon are all well tolerated. Several of the second generation analogs of PT523 are more potent DHFR inhibitors and better RFC substrates than PT523 itself, and are more potent inhibitors of tumor cell growth in culture.

Non-traumatic orbital haemorrhage

PURPOSE

To establish the incidence of underlying orbital vascular anomalies, the presence of systemic associations and predisposing factors, the natural history and appropriate management of patients with non-traumatic orbital haemorrhage presenting in an orbital clinic.

METHODS

The records of 115 patients with a diagnosis of non-traumatic orbital haemorrhage were reviewed with regard to clinical findings, investigations, management and outcome.

RESULTS

Associated orbital vascular malformations were present in 104 patients (90%). Thirteen (11%) had additional or other predisposing factors (childbirth, prolonged headstands, hypertension or coagulopathies). Six patients (5%) had no predisposing factor. Acute onset painful proptosis, associated with lid swelling or a mass, was the most common presentation. Visual acuity was reduced in 37 patients (32%) at presentation. Excluding eight patients (7%) who underwent surgery for optic nerve compression, spontaneous resolution of the haemorrhage was complete in 62%, partial in 27%, while 4% had no resolution. Final visual acuity was reduced in 23 patients (20%).

CONCLUSION

The majority of bleeds are associated with some form of orbital vascular anomaly. Where no such anomaly can be demonstrated a search for an underlying systemic cause should be performed. Haemorrhages in the young were usually localized whereas those in older patients were diffuse. Orbital imaging, with a combination of computed tomography and magnetic resonance imaging, was helpful in the assessment of these lesions. Most bleeds are venous and self-limiting. Surgical intervention was rarely necessary and should be confined to those with optic nerve compromise or a localized lesion which persists.

Human neutralizing monoclonal antibodies of the IgG1 subtype protect against mucosal simian-human immunodeficiency virus infection

Although maternal human immunodeficiency virus type 1 (HIV-1) transmission occurs during gestation, intrapartum and postpartum (by breast-feeding), 50-70% of all infected children seem to acquire HIV-1 shortly before or during delivery. Epidemiological evidence indicates that mucosal exposure is an important aspect of intrapartum HIV transmission. A simian immunodeficiency virus (SIV) macaque model has been developed that mimics the mucosal exposure that can occur during intrapartum HIV-1 transmission. To develop immunoprophylaxis against intrapartum HIV-1 transmission, we used SHIV-vpu+ (refs. 5,6), a chimeric simian-human virus that encodes the env gene of HIV-IIIB. Several combinations of human monoclonal antibodies against HIV-1 have been identified that neutralize SHIV-vpu+ completely in vitro through synergistic interaction. Here, we treated four pregnant macaques with a triple combination of the human IgG1 monoclonal antibodies F105, 2G12 and 2F5. All four macaques were protected against intravenous SHIV-vpu+ challenge after delivery. The infants received monoclonal antibodies after birth and were challenged orally with SHIV-vpu+ shortly thereafter. We found no evidence of infection in any infant during 6 months of follow-up. This demonstrates that IgG1 monoclonal antibodies protect against mucosal lentivirus challenge in neonates. We conclude that epitopes recognized by the three monoclonal antibodies are important determinants for achieving substantial protection, thus providing a rational basis for AIDS vaccine development.

Whipple's disease presenting as sarcoidosis and valvular heart disease

Whipple's disease is a rare systemic disorder that can present in a variety of ways and is often difficult to diagnose. It can involve almost any organ system and can mimic other diseases both in its symptoms and pathologic appearance. We present a case initially diagnosed as sarcoidosis that was found to be Whipple's disease after pathologic examination of the patient's mitral and aortic valves.

Synthesis and potent antifolate activity and cytotoxicity of B-ring deaza analogues of the nonpolyglutamatable dihydrofolate reductase inhibitor Nalpha-(4-amino-4-deoxypteroyl)-Ndelta-hemiphthaloyl- L-ornithine (PT523)

Six new B-ring analogues of the nonpolyglutamatable antifolate Nalpha-(4-amino-4-deoxypteroyl)-Ndelta-hemiphthaloy l-L-ornithine (PT523, 3) were synthesized with a view to determining the effect of modifications at the 5- and/or 8-position on dihydrofolate reductase (DHFR) binding and tumor cell growth inhibition. The 5- and 8-deaza analogues were prepared from methyl 2-L-amino-5-phthalimidopentanoate and 4-amino-4-deoxy-N10-formyl-5-deaza- and -8-deazapteroic acid, respectively. The 5,8-dideaza analogues were prepared from methyl 2-L-[(4-aminobenzoyl)amino]-5-phthalimidopentanoate and 2, 4-diaminoquinazoline-6-carbonitriles. The Ki for inhibition of human DHFR by the 5-deaza and 5-methyl-5-deaza analogues was about the same as that of 3 (0.35 pM), 11-fold lower than that of aminopterin (AMT, 1), and 15-fold lower than that of methotrexate (MTX, 2). However the Ki of the 8-deaza analogue was 27-fold lower than that of 1, and that of the 5,8-dideaza, 5-methyl-5,8-dideaza, and 5-chloro-5,8-dideaza analogues was approximately 50-fold lower. This trend was consistent with the published literature on the corresponding DHFR inhibitors with a glutamate side chain. In colony formation assays against the human head and neck squamous carcinoma cell line SCC25 after 72 h of treatment, the 5- and 8-deaza analogues were approximately as potent as 3, whereas the 5,8-dideaza analogue was 3 times more potent. 5-Methyl and 5-chloro substitution was also favorable, with the 5-methyl-5-deaza analogue being 2. 5-fold more potent than the 5-deaza analogue. However the effect of 5-methyl substitution was less pronounced in the 5,8-dideaza analogues than in the 5-deaza analogues. The 5-chloro-5,8-dideaza analogue of 3 was the most active member of the series, with an IC50 = 0.33 nM versus 1.8 nM for 3 and 15 nM for MTX. The 5-methyl-5-deaza analogue of 3 was also tested at the National Cancer Institute against a panel of 50 human tumor cell lines in culture and was consistently more potent than 3, with IC50 values in the low-nanomolar to subnanomolar range against most of the tumors. Leukemia and colorectal carcinoma cell lines were generally most sensitive, though good activity was also observed against CNS tumors and carcinomas of the breast and prostate. The results of this study demonstrate that B-ring analogues of 3 inhibit DHFR activity and tumor cell colony formation as well as, or better than, the parent compound. In view of the fact that 3 and its B-ring analogues cannot form polyglutamates, their high cytotoxicity relative to the corresponding B-ring analogues of AMT is noteworthy.

Cutaneous findings associated with cardiac myxomas

The clinical diagnosis of cardiac myxomas remains a challenge despite the advent of echocardiographic technology. These tumors may produce a variety of clinical and laboratory findings that can mimic systemic disease and obscure the proper diagnosis. Although histologically benign, cardiac myxomas may cause significant morbidity and mortality via intracardiac obstruction and arterial embolism. Possible long-term sequelae may be avoided by early recognition and prompt surgical excision. We briefly review the various findings associated with cardiac myxomas (nonfamilial and familial) with emphasis on cutaneous presentations. An illustrative case of left atrial myxoma with cutaneous findings contributing to the diagnosis is discussed. Certain skin lesions and multifocal clinical findings should alert the clinician to consider cardiac myxoma in the differential diagnosis.

Pharmacokinetics, antifolate activity and tissue distribution of PT523 in SCC VII tumor-bearing mice

PURPOSE

To monitor the pharmacokinetics of PT523 and methotrexate in C3H mice with transplanted SCC VII tumors; to compare the impact of PT523 and methotrexate on tumor and normal host 5,10-methylenetetrahydrofolate levels; and to synthesize [14C]PT523 and determine its time-dependent tissue distribution in tumor and host tissues.

METHODS

C3H mice bearing SCC VII tumors were given i.p. PT523 or methotrexate. Plasma drug levels and tumor, gut and marrow 5,10-methylenetetrahydrofolate were assayed. [14C]PT523 was synthesized and administered i.v. to tumor-bearing mice for tissue distribution analysis.

RESULTS

Areas under the curve, mean residence times, whole body clearances, apparent distribution volumes, and plasma protein binding of PT523 vs methotrexate were, respectively, 4311 vs 6472 microM x min(-1); 20 vs 16 min; 0.56 vs 0.36 ml min(-1); 532 vs 325 ml x kg(-1); and 70% vs 30%. Both PT523 and methotrexate caused time-dependent declines in 5,10-methylenetetrahydrofolate in tumor and marrow, but not in gut mucosa [corrected]. Gut levels began to recover within 4 h in the PT523-treated group only. [14C]PT523 distributed mainly into the liver, duodenum, kidneys, lungs, tumor, pancreas and muscle; less into the spleen, blood cells, heart, brain and testicles; and very little into gut [corrected. Only 35% of the dose was excreted, and 2.9-fold more in feces than urine.

CONCLUSIONS

Despite its more rapid clearance, accumulation of PT523 in extravascular tissues was greater than that of methotrexate. Consequently, less PT523 was recovered in feces and urine and its apparent volume of distribution was greater. PT523 selectively depleted 5,10-methylenetetrahydrofolate pools in tumor and, less persistently, in marrow, but spared the gut mucosa [corrected]. [14C]PT523 tissue distribution correlated with organ mass and blood supply.

An evaluation of quality of life in patients with continent urinary diversions after cystectomy

OBJECTIVE

To determine the long-term results and assess the quality of life in patients with continent urinary diversions after cystectomy.

PATIENTS AND METHODS

Eighty-six consecutive patients who received a continent urinary diversion from 1988 to 1994 at the Vancouver Hospital and Health Sciences Center were evaluated. The evaluation comprised a review of their hospital charts and clinic visits at 3 months and then yearly. Quality of life issues were assessed using a postal questionnaire pertaining to the patient's urinary symptoms. activity level and overall well-being while living with a continent urinary diversion. Two separate questionnaires were sent, addressing heterotopic or orthotopic diversions.

RESULTS

There was an acceptable rate of complications, with stone formation and urinary tract infection as the most common morbidities. Continence was rated as good in most patients, with no patient reporting complete incontinence. Undesirable urinary symptoms occurred less often than 20% of the time in most patients. Although there was a significant effect on sex life, the overall quality of life appeared to be very good, as 70% of the patients had no limitations to their activities.

CONCLUSIONS

The techniques currently evolved for urinary diversion produce good long-term results and quality of life. These diversions should be considered in a well selected patient population.

Orbital rhabdomyosarcoma--the radiological characteristics

We reviewed computed tomography (CT) studies in 30 patients with histologically confirmed orbital rhabdomyosarcoma. There were 17 male and 13 female patients, mean age 8.8 years (median age 7 years, age range 1 month to 51 years). The tumour occupied the intra and extraconal compartments in 14 (47%) cases; it was solely extraconal in 11 (37%) and intraconal in five (16%). Within the orbit the upper inner quadrant was the most common site, 20 (67%) of the tumours lying in this region. More than one quadrant was involved in 16 (53%) cases. The epicentre of the tumour was in the eyelids of three (10%) patients. At presentation the mean size of the mass was 25 x 17 mm in long and short axis diameters, respectively. The tumours were of soft tissue density with moderately well defined margins and an irregular shape. They showed mild to moderate contrast enhancement. Calcification was seen in one case. Changes in the adjacent bone were seen in at least 12 (40%) patients. Intracranial extension was present in one (3%) patient and invasion of the paranasal sinuses was also seen in one (3%) patient. The intraorbital structures were displaced or encased by the tumour mass. The globe was displaced and distorted but not invaded by the tumour. Magnetic resonance imaging (MRI) studies were also reviewed in five patients. On T1-weighted images the tumour gave a similar signal to muscle but on T2-weighted images it gave a higher signal.

Transurethral electrovaporization of the prostate versus transurethral prostatic resection: a comparison of postoperative hemorrhage

OBJECTIVES

To determine the acute and delayed hemorrhage rate of transurethral electrovaporization of the prostate (TEVP) versus standard transurethral resection of the prostate (TURP).

METHODS

A retrospective review of 524 consecutive patients who underwent TURP and 302 consecutive patients who underwent TEVP was conducted. The indications for both procedures were identical and based on history, physical examination, American Urological Association symptom score, and uroflowmetry. Parameters of evaluation included the incidence of both initial and delayed hemorrhages, the time until a delayed bleed occurred, blood transfusion rates, and the average length of stay in hospital after a bleed.

RESULTS

The overall hemorrhage rate for TURP and TEVP was 4.8% and 4.0%, respectively. In the TURP group, there was a 1.1% incidence of acute bleeds and 3.6% incidence of delayed bleeds. For the TEVP group, 0.3% had an acute hemorrhage, and 3.6% were readmitted for clot retention. The average length of time from original discharge to readmission was 12.9 days for the TURP group with a mean repeat stay of 5.7 days. For the TEVP group, the average interval to readmission was 15.4 days with a stay of 3.1 days.

CONCLUSIONS

The overall rate of hemorrhage for the TEVP group was slightly lower than for the TURP group due to fewer acute bleeds. However, the incidence of delayed bleeds and clot retention between the two was identical at 3.6%. Because of improved hemostasis intraoperatively with similar functional results in the long term as shown by other investigators, we foresee TEVP continuing as a viable alternative to TURP.

Accuracy of patient care staff in estimating and documenting meal intake of nursing home residents

OBJECTIVES

To determine the accuracy of patient care staff estimates and documentation of food intake of residents in nursing homes.

DESIGN

Prospective, observed, unblinded cohort study.

SETTING

Three urban nursing home facilities.

SUBJECTS

Staff estimation and documentation of 27 nursing home residents' meal intake.

MEASUREMENTS

Actual amount consumed by 27 nursing home residents was ascertained by weighing food and caloric fluids on resident trays before and after one lunch time meal. Staff estimates and documentation of percent of meal consumed was compared with actual intake.

RESULTS

Patient care staff estimates differed from actual intake by approximately 20%, and in most instances intake was overestimated. Almost one-third of the residents at risk for nutritional problems were not identified correctly by staff. Chart documentation of meal intake frequently did not reflect either actual amount of meal consumed or the staff's estimation of what was eaten.

CONCLUSION

Study findings indicate that the present system used to document nursing home residents' intake is inadequate and that a more accurate mechanism or an entirely different process for identifying residents at risk for nutritional problems should be developed and implemented.

Re-do cardiac surgery in patients over 70 years old

OBJECTIVE

This study was conducted in order to determine the outcome of cardiac re-operations in patients over the age of 70.

METHODS

All patients who underwent 're-do' cardiac surgery at our institution, between January 1987 and October 1995 were identified. The case notes of patients over the age of 70 were reviewed retrospectively and follow-up was by telephone.

RESULTS

A total of 687 re-do operations were performed during this 8 years and 9 months period. Operations, 110 (16%) were on patients aged 70 years and over (CABG 54, MVR 32, AVR 9, AVR + MVR 5, MVR + CABG 4, AVR + CABG 3, repair of paraprosthetic leak 2 and closure of VSD 1). Operations, 63 (57%) were elective and 42 (38%) were urgent. The median age was 73 years (range 70-82) and 64 patients (58%) were male. Pre-operatively, 78 patients (72%) were NYHA functional class III/IV and 55 (50%) had angiographically impaired left ventricular function (ejection fraction < 50%). The overall operative mortality was 7% (8/110). Median ITU stay was one night (range 1-21) and hospital stay was 7 days (range 5-35). Major in-hospital complications included resternotomy in five patients (5%), permanent stroke in three (3%), renal failure requiring haemodialysis in two (2%) and heart block requiring permanent pacing in two (2%). At a median follow-up of 34 months (range 2-101), 69 of the 77 patients alive at follow-up (90%) were NYHA functional class I/II.

CONCLUSIONS

'Re-do' cardiac surgery in patients over the age of 70 carries an acceptable operative morbidity and mortality with a good functional improvement at medium term follow-up.

Multidisciplinary management of refractory orbital rhabdomyosarcoma

PURPOSE

Combined chemotherapy and radiation therapy have improved the survival of children with primary orbital rhabdomyosarcoma, but recurrence or persistence of the local orbital tumor still occurs. There are no established guidelines for dealing with these uncommon patients, and the authors present a review of the combined method treatment and outcome of children with refractory primary orbital rhabdomyosarcoma.

METHODS

From clinical databases, 67 children with orbital rhabdomyosarcoma were identified. Seven (10%) of the 67 children had tumors refractory to combined chemotherapy and radiation therapy and underwent exenteration or eye-sparing tumor excision. Their clinical course and outcome were reviewed retrospectively.

RESULTS

No patient was lost to follow-up, which ranged from 3.2 to 11 years. Five (71%) of the seven children with refractory tumor are still alive at more than 3 years after surgery (3.2-11 years; mean, 6.9). In one of the two children who died, tumor extended beyond the operative margins at exenteration, and the other child died with regional metastasis within a month of exenteration.

CONCLUSIONS

Although more than 90% of children with orbital rhabdomyosarcoma respond to combined therapy by pediatric oncologists and radiotherapists, local orbital (salvage) surgery by ophthalmologists may be of value in the minority of children with refractory tumors. All of the five surviving children appear to be disease free.

Orbital venous anomalies

PURPOSE

The purpose of the study is to establish the natural history, probable nature, and optimal treatment of lesions within the orbit described previously as lymphangiomas or orbital varices.

METHODS

The clinical and radiologic records of 158 patients with these lesions were reviewed. Of these, 91 had surgery, and histologic specimens from 57 were re-examined.

RESULTS

Most patients were infants or children with a dark blue swelling in the superomedial part of the orbit, orbital hemorrhage, or proptosis. Computed tomography showed smooth, contoured lesions denser than brain extending posteriorly. Half enlarged with the Valsalva maneuver, 31% contained phleboliths. Surgery was performed in 91 patients, mainly for cosmesis. Excised tissue included endothelium-lined channels containing blood in the orbit and clear fluid in many superficial specimens.

CONCLUSIONS

The behavior of these lesions and their prevalence in infancy and childhood favor a hamartoma. The authors observed a seamless range of clinical features that they could not subdivide, particularly in relation to any connection with the orbital veins. Many bleed and enlarge permanently and need excision, but surgery is difficult and management should be as conservative as possible. The origin of these lesions cannot be determined by histopathologic analysis, although the authors have evidence of venous features in the orbit and lymphatic features more superficially. The authors' clinical findings support a venous origin. Two-thirds have either a free venous connection or phleboliths. Their distribution corresponds with that of the normal orbital veins, and at surgery they derive from or replace those veins. "Orbital venous anomaly" is the most accurate term for their description.

NMR solution structure of the antitumor compound PT523 and NADPH in the ternary complex with human dihydrofolate reductase

The antitumor compound PT523 [N(alpha)-(4-amino-4-deoxypteroyl)-N(delta)-hemiphthaloyl-L- ornithine] was found to have an inhibition constant (K(i)) of 0.35 +/- 0.10 pM against human dihydrofolate reductase (hDHFR), 15-fold lower than that of the classical antifolate drug methotrexate (MTX). The structure of PT523 bound to hDHFR and hDHFR-NADPH was investigated using multinuclear NMR techniques. NMR data indicate that the binary complex has two distinct conformations in solution which are in slow exchange and that the addition of NADPH stabilizes the ternary complex in a single bound state. Comparison of resonance assignments in the PT523 and MTX ternary complexes revealed that substantial protein chemical shift differences are limited to small regions of hDHFR tertiary structure. A restrained molecular dynamics and energy minimization protocol was performed for the hDHFR-PT523-NADPH complex, using 185 NOE restraints (33 intermolecular) to define the ligand-binding region. The positions of the pteridine and pABA rings of PT523 and the nicotinamide and ribose rings of NADPH are well defined in the solution structures (RMSD = 0.59 A) and are consistent with previously determined structures of DHFR complexes. The N(delta)-hemiphthaloyl-L-ornithine group of PT523 is less well defined, and the calculated model structures suggest the hemiphthaloyl ring may adopt more than one conformation in solution. Contacts between the hemiphthaloyl ring and hDHFR, which are not possible in the hDHFR-MTX-NADPH complex, may explain the greater inhibition potency of PT523.

Outcome of orbital myositis. Clinical features associated with recurrence

PURPOSE

Although orbital myositis usually responds to prompt systemic therapy, recurrent or persistent episodes often require prolonged therapy. This study presents the clinical and radiologic features of 26 patients with orbital myositis and suggests a treatment regimen with special emphasis on recurrent or persistent orbital myositis.

METHODS

Retrospective analysis and comparison of clinical and radiologic parameters with clinical outcome in 26 patients with strictly defined orbital myositis was performed. A consultant radiologist reviewed computed tomography studies without knowledge of the clinical data or outcome. The frequency of certain clinical and radiologic parameters among two outcome groups was analyzed using Fisher's exact test.

RESULTS

Comparison of clinical and radiologic features of 20 patients with a single acute episode and 6 patients with recurrent episodes disclosed several characteristics associated with recurrence. Male gender, lack of proptosis, eyelid retraction, horizontal extraocular muscle (EOM) involvement, multiple or bilateral EOM involvement (P = 0.05), muscle tendon sparing, and lack of response to systemic corticosteroids (P = 0.01), or nonsteroidal anti-inflammatory agents (P = 0.01) were associated with recurrent orbital myositis.

CONCLUSIONS

A treatment algorithm is suggested for patients with orbital myositis. Those patients whose clinical or radiologic features are associated with recurrence may benefit from early systemic steroid therapy.

Analogues of N alpha-(4-amino-4-deoxypteroyl)-N delta-hemiphthaloyl-L-ornithine (PT523) modified in the side chain: synthesis and biological evaluation

Four heretofore undescribed side chain analogues of N alpha-(4-amino-4-deoxypteroyl)-N delta-hemiphthaloyl-L-ornithine (PT523, 4) were synthesized via straightforward methods of antifolate chemistry, and their properties were compared with those of PT523 and two related compounds with the aim of defining the contribution of the hemiphthaloyl-L-ornithine moiety to the exceptional in vitro antitumor activity of this novel non-polyglutamatable aminopterin analogue. The IC50 values of N alpha-(4-amino-4-deoxypteroyl)-N beta-hemiphthaloyl-L-2,3-diaminopropanoic acid (10) and N alpha-(4-amino-4-deoxypteroyl)-N gamma-hemiphthaloyl-L-2,4- diaminobutanoic acid (9) against A549 human non-small-cell lung carcinoma cells in culture were 23 and 22 nM, whereas those of PT523 and N alpha-(4-amino-4-deoxypteroyl)-N epsilon-hemiphthaloyl-L-lysine (8) were 1.3 and 5.2 nM. A decrease in the in vitro activities of 8 and 9 relative to PT523 was also observed against the panel of cell lines used by the National Cancer Institute to screen new drugs. However the potency of 8 and 9 remained several times greater than that of the historical control methotrexate against many of the cell lines in the screening panel. In an in vivo tumor model, SCC-VII murine squamous cell carcinoma, 9 and methotrexate were well tolerated as 5-day continuous infusions at doses of 0.52 and 0.75 mg/kg/day, whereas the highest tolerated dose of PT523 on this schedule was 0.19 mg/kg/day, in agreement with its lower IC50 in culture. To assess the importance of the hemiphthaloyl group in PT523, N alpha-(4-amino-4-deoxypteroyl)-N delta-isophthaloyl-L-ornithine (11), N alpha-(4-amino-4-deoxypteroyl)-N delta-terephthaloyl-L-ornithine (12), and N alpha-(4-amino-4-deoxypteroyl)-N delta-(4,5-dichlorohemiphthaloyl)-L-ornithine (13) were also synthesized. The IC50 values of 11 and 12 against A549 cells were 45 and 3300 nM, as compared with 1.3 nM for PT523 and 23 nM for methotrexate. In a clonogenic assay against SCC25 human squamous cell carcinoma cells, the IC50 values of 11 and 12 were 2.9 and 72 nM, as compared with 0.3 nM for PT523 and 27 nM for methotrexate. Thus, activity was decreased by moving the aromatic carboxyl group in PT523 to the meta position and was further diminished by moving it to the para position. The IC50 of the halogenated analogue 13 against SCC25 human head and neck squamous carcinoma cells was 18 nM, suggesting lack of tolerance for this 4,5-disubstitution in the phthaloyl moiety. Our results suggest that the combination of a hemiphthaloyl group and three CH2 groups in the side chain are critical determinants of the potent in vitro activity of PT523.

Primary localised amyloidosis of the orbit

AIMS/BACKGROUND

Primary localised amyloidosis is rarely encountered in the orbit. The typical clinical and radiological appearances have not been clearly established, in particular the single site deposition of amyloid has never been proved.

METHODS

Six cases were reviewed in detail and their clinical and radiological characteristics are described here. Four patients had scintigraphy with 123I serum amyloid P component and one patient had typing of the amyloid fibrils.

RESULTS

All the patients had a firm mass in the upper orbit with a predilection for the region of the lacrimal gland. Computed tomography showed a homogeneous mass with thickening and irregularity of the adjacent bone and/or calcification within the mass. None was associated with systemic disease. Scintigraphy with 123I serum amyloid P component demonstrated that the amyloid was confined to the orbit. In one patient the amyloid fibrils were derived from an IgG4 heavy chain constant domain. The lesions were partially excised with subsequent clinical stability over 6 months to 18 years in all but one patient who had continued enlargement of the lesion.

CONCLUSION

There is a characteristic clinical and radiological pattern for primary localised amyloidosis of the orbit. The disease process is truly local and not part of a systemic process. A majority respond to simple debulking with subsequent observation.

Psychological and behavioural effects of endogenous testosterone and anabolic-androgenic steroids. An update

Endogenous testosterone levels have been linked to aggressive behaviour in both animals and humans. Studies administering moderate doses of exogenous testosterone for contraceptive and clinical purposes reveal essentially no adverse effects on male sexual and aggressive behaviour. However, investigations and case reports of athletes, usually involving higher doses, demonstrate an association between anabolic-androgenic steroid use and affective and psychotic syndromes and psychological dependence. Efforts to study the psychological and behavioural effects of anabolic-androgenic steroids are complicated by a variety of methodological limitations. Only 3 prospective, blinded studies demonstrating aggression or adverse overt behaviour resulting from anabolic-androgenic steroid use have been reported. With estimates of over 1 million past or current users in the US, an extremely small percentage of individuals using anabolic-androgenic steroids appear to experience mental disturbances severe enough to result in clinical treatment and medical case reports. Even among those so affected, the roles of previous psychiatric history, genetic susceptibility to addictions or mental disorders, environmental and peer influences, and individual expectations remain unclear.