Diagnostic Delay in HPV-Related Oropharyngeal Squamous Cell Carcinoma

Introduction  Human papillomavirus-related (HPV + ) oropharyngeal squamous cell carcinoma (OPSCC) is increasing in incidence and presents diagnostic challenges given its unique clinical presentation. Objective  The purpose of the present study is to characterize the impact of the unique clinical presentation of HPV-related OPSCC on delays in diagnosis. Methods  Retrospective review of presenting symptoms and clinical characteristics of 284 patients with OPSCC treated from 2002-2014. Delay in diagnosis was defined as the presence of any of the following: multiple non-diagnostic fine needle aspirate (FNA) biopsies; two or more courses of antibiotic therapy; surgery with incorrect preoperative diagnosis; evaluation by an otolaryngologist without further workup; or surgery without definitive postoperative diagnosis. Results  p16+ tumors demonstrated a distinct clinical presentation that more commonly involved a neck mass (85.1% versus 57.3% of p16-; p  < 0.001) and less frequently included odynophagia (24.6% versus 51.7% of p16-; p  < 0.001). Patients who experienced diagnostic delay were more likely to have p16+ tumors (77.7% delayed versus 62.8% not delayed; p  = 0.006). p16+ primary tumors were more likely to be undetectable by physical examination of the head and neck including flexible laryngoscopy (19.0% versus 6.7% of p16-; p  = 0.007) and more frequently associated with nondiagnostic FNA biopsies of a cervical nodal mass (11.8% versus 3.4% of p16-, p  = 0.03). Conclusions  Compared with non-HPV related OPSCC, the unique clinical presentation and characteristics of HPV+ OPSCC are associated with an increased incidence of diagnostic delay. Targeted education of appropriate care providers may improve time to diagnosis and treatment.

Gender Affirmation Surgery of the Face for the Transfeminine Patient

This article discusses the aspects of facial feminine affirmation surgery including forehead reconstruction, midface feminization, and lower face/neck feminization. We will present a brief history of gender affirmation. We discuss the anatomical differences between born XY males and XX females and discuss the subsequent procedures that aim at feminizing the face. The effects of silicone injections are also discussed as this was a trend in the past to feminize the face. Understandably so we discuss the anatomical differences as being a fluid expression and differences based on ethnic background.

Preparing for Facial Feminization Surgery

Preparing for facial feminization surgery (FFS) or gender-affirming facial surgery is a daunting task. Patients do extensive research online to see what FFS means. Oftentimes it is the patients who are educating their physicians when discussing medical clearance or the esteemed "therapy letter." The therapy letter is a letter that details the support for surgery in a stable patient and reaffirms the need to have FFS in a person diagnosed with gender dysphoria. This typically follows the World Professional Association for Transgender Health standards-of-care guidelines. Besides having the therapy letter, patients must be counseled on concurrent mental health illnesses.

A mixed-methods analysis of patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care in England and Wales

Introduction

There is a paucity of knowledge and understanding of medical error in opioid substitution treatment programmes.

Objectives

To characterise patient safety incidents involving opioid-substitution treatment with methadone or buprenorphine in community-based care to identify the sources and nature of harm, describe and interpret themes and use this qualitative analysis to identify priorities to focus future improvement work.

Methods

We undertook a mixed-methods study examining incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care submitted between 2005 and 2015 from the National Reporting and Learning System, a repository of incident reports from England and Wales. We analysed each report using four frameworks to identify incident type, contributory factors, incident outcome and severity of harm. Analysis involved detailed data coding and iterative generation of data summaries using descriptive statistical and thematic analysis.

Results

2,284 reports were identified. We found that most risks of harm came from failure in one of four processes of care delivery: prescribing opiate-substitution (n=151); supervised dispensing errors (n=248); non-supervised dispensing errors (n=318); and monitoring and communication activities (n=1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n=91/127, 72%). Staff- (e.g. mistakes, not following protocols) and organisation-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were present for over half of incidents.

Conclusions

We have identified four processes of care delivery and associated contributory factors, which represent potential target areas for healthcare systems worldwide to develop interventions to improve the safe delivery of opioid substitution treatment.

AB0064 CHANGES IN THE VASCULAR ENDOTHELIAL GROWTH FACTOR A (VEGFA) SPLICING AXIS IN HUMAN SYNOVIUM ARE RELATED TO INFLAMMATION IN ARTHRITIS

Background:

VEGF-A is a key regulator of rheumatoid (RA) and osteoarthritis (OA). During articular inflammation in OA and RA there is increased synovial angiogenesis and upregulation of angiogenic growth factors such as VEGF-A. VEGF-A comprises two splice variant families, VEGF-Axxxa and VEGF-Axxxb (xxx represents the number of amino acids, from 121 to 206), resulting from alternative splice site selection in exon 8. This site selection is controlled by Serine/Arginine Rich Splicing Factor Kinase 1 (SRPK1), which phophorylates Serine/Arginine Rich Splicing Factor 1 (SRSF1), inducing it to translocate to the nucleus. In most normal tissues, VEGF-Axxxb isoforms predominate, with anti-nociceptive and anti-angiogenic functions. I contrast, in pathological conditions such as inflammation and solid tumours, VEGF-Axxxa isoforms predominate, with pro-nociceptive and pro-angiogenic functions. VEGF-A has been proposed as a therapeutic target in RA and OA. To date, there are no published data on the functionally distinct VEGF-A splice variants in either RA or OA.

Objectives:

To determine the patterns of, and relationships between, VEGF-A, SRPK1, and SRSF1 expression and activation and synovial inflammation in human RA and OA.

Methods:

The study was approved by the Nottingham Research Ethics Committee 1 (05/Q2403/24) and Derby Research Ethics Committee 1 (11/H0405/2). Tissues were selected from age- and sex-matched cases in the University of Nottingham joint tissue repository. Post-mortem (PM) samples of healthy knee synovium (n=14, no history of arthritis or knee pain in the 12 months prior to death, no significant articular or synovial pathology) and arthroplasty-derived synovium samples from OA (n=35) or RA (n=14) patients were compared. OA samples were selected to represent the variety of inflammation levels, from low to high grade (0-3, Haywood et al., 2003). 8um thick sections were stained for SRSF1, SRPK1, total VEGF-A and VEGFxxxb via immunohistochemistry. Expression was estimated as fractional area, relative staining intensity (VEGF-Axxxb), and SRSF1 activation quantified by the degree of nuclear localisation. Statistical analyses were performed using Kruskal-Wallis followed by Dunn’s tests and Spearman’s rank correlations.

Results:

SRPK1 expression was similar across all conditions. SRSF1 showed significantly higher expression in the OA tissue compared to PM (H(2)= 11.29, p=0.002; OA median=0.2, IQR(0.15, 0.28); PM median=0.09, IQR(0.07, 0.16)), and significantly higher nuclear localisation (indicating activation) in RA vs. OA, and in both RA and OA vs PM (H(2)=37.65, p<0.0001 RA cf. PM; p=0,007 OA cf. PM; RA median=89, IQR(83, 93); OA median=36.1, IQR(29, 42); PM median=19.8, IQR(14,21)). Nuclear SRSF1 was significantly correlated with inflammation score (r= 0.52, p<0.05). Total VEGF-A expression was significantly increased in RA compared to PM and OA (H(2)=23.3, p<0.001 RA cf. PM; RA median=0.4, IQR(0.37,0.59); PM median=0.18, IQR(0.15,0.2)) and was also correlated with the severity of inflammation (r=0.47 p<0.05). VEGF-Axxxb showed no changed in expression in OA or RA, although VEGF-Axxxb staining intensity was significant higher in RA samples, compared to controls (H(2)=7.2 p=0.02; RA median=2.3(1, 4); PM median=0.9 (0.7, 1.4)).

Conclusion:

Increased levels of SRSF1 activation, and the association of total VEGF-A expression with inflammation score, support the hypothesis that there is activation of alternative splicing in inflamed synovium in RA and OA. Targeting this pathway could be a novel therapeutic strategy in OA & RA.

References:

[1]HAYWOOD L., MCWILLIAMS D. F., PEARSON C. I., GILL S. E., GANESAN A., WILSON D. & WALSH D. A. 2003. Inflammation and angiogenesis in osteoarthritis.Arthritis Rheum,48, 2173-7.

Disclosure of Interests:

Dimitrios Amanitis: None declared, Seyed Shahtaheri: None declared, Daniel Daniel McWilliams: None declared, Nicholas Beazley-Long: None declared, David Walsh Grant/research support from: 2016: Investigator-led grant from Pfizer Ltd (ICRP) on Pain Phenotypes in RA; non-personal financial disclosure (payment to University)., Consultant of: DAW has undertaken paid consultancy to Pfizer Ltd, Eli Lilly and Company and GSK Consumer Healthcare., Paid instructor for: 2019: Consultancy to Love Productions; consultancy on programme design, contribution to programme content on self-management of chronic pain (payments to University)

2019: Consultancy to AbbVie Ltd; 13.06.19; presentation on RA pain at EULAR, Madrid, and webinar (payments to University).

2019: Consultancy to Eli Lilly and Company Ltd. 06.06.19 Centre for Collaborative Neuroscience, Windlesham, Surrey, UK (payment to University).

2019: Consultancy to Pfizer (payment to University).

2018: Consultancy to Pfizer. 07.12.18. USA. 1 day. Tanezumab (payment to University).

2018: Consultancy to Pfizer. 23.11.18. Manchester UK. 1 day. Tanezumab (payment to University).

2018: Consultancy to Pfizer. 1.11.18. Skype. 4h. Tanezumab (payment to University).

2018: Consultancy to GlaxoSmithKline Plc. 1 day. Pain in RA and anti-GM-CSF (payment to University).

2018: Consultancy to Pfizer Ltd; Presentation at OARSI; non-personal financial disclosure (payment to University)

2018: Consultancy to Pfizer Ltd; Patient preference study; non-personal financial disclosure (payment to University)

2017: Consultancy to Pfizer Ltd; personal financial disclosure

2017: Consultancy to Pfizer Ltd through Nottingham University; non-personal financial disclosure (payment to University).

2015: Consultancy to GSK Consumer Healthcare; personal financial disclosure., Speakers bureau: 2019: Irish Society of Rheumatology: speaker fees (personal pecuniary), Lucy Donaldson Shareholder of: LFD is a co-inventor on patents protecting alternative RNA splicing control and VEGF-A splice variants for therapeutic application in a number of different conditions. LFD is also a founder equity holder in, and consultant to, Exonate Ltd, and Emenda Therapeutics Ltd. Both companies have with a focus on development of alternative RNA splicing control for therapeutic application in a number of different conditions, including ophthalmology (www.exonate.com), analgesia and arthritis (www.emendatherapeutics.com).,Consultant of:

LFD is a co-inventor on patents protecting alternative RNA splicing control and VEGF-A splice variants for therapeutic application in a number of different conditions. LFD is also a founder equity holder in, and consultant to, Exonate Ltd, and Emenda Therapeutics Ltd. Both companies have with a focus on development of alternative RNA splicing control for therapeutic application in a number of different conditions, including ophthalmology (www.exonate.com), analgesia and arthritis (www.emendatherapeutics.com).

Antitumor effect of insulin-like growth factor-1 receptor inhibition in head and neck squamous cell carcinoma

OBJECTIVES

The insulin-like growth factor-1 receptor (IGF1R) has been implicated in therapeutic resistance in head and neck squamous cell carcinoma (HNSCC), and small molecule tyrosine kinase inhibitors (TKIs) of IGF1R activity may have anticancer activity. Therefore, the relationship between survival and IGF1R expression was assessed for oral cavity (OC) cancer, and the antitumor effects of two IGF1R-TKIs, OSI-906 and BMS-754807, were evaluated in HNSCC cell lines in vitro.

METHODS

Clinical outcome data and tissue microarray immunohistochemistry were used to generate IGF1R expression-specific survival curves. Immunoblot, alamarBlue proliferation assay, trypan blue exclusion viability test, clonogenic assay, flow cytometry, and reverse phase protein array (RPPA) were used to evaluate in vitro responses to IGF1R-TKIs.

RESULTS

For patients with stage III/IV OCSCC, higher IGF1R expression was associated with poorer overall 5-year survival (P = 0.029). Both BMS-754807 and OSI-906 caused dose-dependent inhibition of IGF1R and Akt phosphorylation and inhibited proliferation; BMS-754807 was more potent than OSI-906. Both drugs reduced HNSCC cell viability; only OSI-906 was able to eliminate all viable cells at 10 μM. The two drugs similarly inhibited clonogenic cell survival. At 1 μM, only BMS-754807 caused a fourfold increase in the basal apoptotic rate. RPPA demonstrated broad effects of both drugs on canonical IGF1R signaling pathways and also inhibition of human epidermal growth factor receptor-3 (HER3), Src, paxillin, and ezrin phosphorylation.

CONCLUSION

OSI-906 and BMS-754807 inhibit IGF1R activity in HNSCC cell lines with reduction in prosurvival and proliferative signaling and with concomitant antiproliferative and proapoptotic effects. Such antagonists may have utility as adjuvants to existing therapies for HNSCC.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:1470-1478, 2020.

Test of the Brink-Axel Hypothesis for the Pygmy Dipole Resonance

The gamma strength function and level density of 1^{-} states in ^{96}Mo have been extracted from a high-resolution study of the (p[over →], p[over →]^{'}) reaction at 295 MeV and extreme forward angles. By comparison with compound nucleus γ decay experiments, this allows a test of the generalized Brink-Axel hypothesis in the energy region of the pygmy dipole resonance. The Brink-Axel hypothesis is commonly assumed in astrophysical reaction network calculations and states that the gamma strength function in nuclei is independent of the structure of the initial and final state. The present results validate the Brink-Axel hypothesis for ^{96}Mo and provide independent confirmation of the methods used to separate gamma strength function and level density in γ decay experiments.

Relationship between taste thresholds and antidepressant response: Preliminary findings

Introduction

In healthy volunteers, light acting through serotonin pathways, decreases the threshold for sweet, but not salt taste; similar to SSRI paroxetine. In depressive disorders, there is deficiency of serotonin throughput, which is remedied by SSRI medications, and results in improvement in symptoms of depression. Thus, we report on taste thresholds before and after SSRI treatment.

Objectives

To study the variation in thresholds for sweet with SSRI treatment in depressed patients in short- and long-term.

Aims

To compare the threshold for sweet (test) and salt (control) after 1 and 4 weeks of SSRI escitalopram therapy in depressed patients.

Methods

The project was approved by the institutional ethics committee. Following informed consent, depressed patients were initiated on escitalopram 10 mg/d (increased to 15 or 20 mg, if required after 1 week,). Taste recognition threshold, intensity and pleasantness were measured for sweet and salt. Each tastant was made −1 to −3 (100 mM–1 mM). Regional recognition thresholds were determined at the tip of the tongue using a cotton bud well soaked in the tastant.

Results

Three males and 4 females of mean ages 39.1 years completed the study. There was significant shift to the left for sweet thresholds between days 0 and 7, and 7 and 28 [F(Dfn, Dfd) = 9.242 (4.162) P < 0.0001]. A similar shift to the left was seen for salt but day 7 only [F(Dfn, Dfd) = 6.213 (4.162)].

Conclusion

The increase in serotonin throughput as envisaged through SSRI treatment was paralleled by decrease in sweet thresholds.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Safety restraint injuries in fatal motor vehicle collisions

The presence of an apparent seat belt mark (SBM) on a car crash occupant is often used as evidence for use of a seat belt at the time of the crash and, conversely, the lack of a SBM is used as an indication that no seat belt was used. This study examined whether there are clear indications of seat belt use to be found at autopsy and evaluated the sensitivity and specificity of apparent SBM and whether the use of a seat belt and seating location affects the type and severity of injuries sustained. Information on the type of injuries sustained and seatbelt use was retrieved from autopsy reports and police reports, respectively, for cases of fatal motor vehicle collisions occurring in Sydney, Australia over a 5-year period. In this study, a SBM was only found on restrained occupants. The proportion of restrained occupants with evidence of a SBM was 36% (sensitivity), whilst unrestrained occupants showed no evidence of a SBM (100% specificity). A SBM was also found to reliably reflect the seating position of the occupant. We conclude that restrained occupants can be expected to show evidence of the seat belt in just over one third of cases and that the absence of a SBM is not necessarily an indication that no seat belt was used. Spurious SBM is very unlikely to be present if the occupant was unrestrained.

Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study

Healthcare-associated infections (HAIs) affect at least 300,000 patients annually in the UK and represent a significant, yet largely preventable, burden to healthcare systems. Hand hygiene by healthcare workers (HCWs) is the leading prevention measure, but compliance with good practice is generally low. The UK National Patient Safety Agency surveyed the public, inpatients, and HCWs, particularly frontline clinical staff and infection control nurses, in five acute care hospitals to determine whether they agreed that a greater level of involvement and engagement with patients would contribute to increased compliance with hand hygiene and reduce HAIs. Fifty-seven percent (302/530) of the public were unlikely to question doctors on the cleanliness of their hands as they assumed that they had already cleaned them. Forty-three percent (90/210) of inpatients considered that HCWs should know to clean their hands and trusted them to do so, and 20% (42/210) would not want HCWs to think that they were questioning their professional ability to do their job correctly. Most HCWs surveyed (178/254, 71%) said that HAI could be reduced to a greater or lesser degree if patients asked HCWs if they had cleaned their hands before touching them. Inviting patients to remind HCWs about hand hygiene through the provision of individual alcohol-based hand-rub containers and actively supporting an 'It's OK to ask' attitude were perceived as the most useful interventions by both patients and HCWs. However, further work is required to refute the myth among HCWs that patient involvement undermines the doctor- or HCW-patient relationship.

Safranine fluorescent staining of wood cell walls

Safranine is an azo dye commonly used for plant microscopy, especially as a stain for lignified tissues such as xylem. Safranine fluorescently labels the wood cell wall, producing green/yellow fluorescence in the secondary cell wall and red/orange fluorescence in the middle lamella (ML) region. We examined the fluorescence behavior of safranine under blue light excitation using a variety of wood- and fiber-based samples of known composition to interpret the observed color differentiation of different cell wall types. We also examined the basis for the differences in fluorescence emission using spectral confocal microscopy to examine lignin-rich and cellulose-rich cell walls including reaction wood and decayed wood compared to normal wood. Our results indicate that lignin-rich cell walls, such as the ML of tracheids, the secondary wall of compression wood tracheids, and wood decayed by brown rot, tend to fluoresce red or orange, while cellulose-rich cell walls such as resin canals, wood decayed by white rot, cotton fibers and the G-layer of tension wood fibers, tend to fluoresce green/yellow. This variation in fluorescence emission seems to be due to factors including an emission shift toward red wavelengths combined with dye quenching at shorter wavelengths in regions with high lignin content. Safranine fluorescence provides a useful way to differentiate lignin-rich and cellulose-rich cell walls without counterstaining as required for bright field microscopy.

The UK public health system: change and constancy

The public health system in the UK has evolved from medical officer posts rooted in the era of sanitary reform to a modern service embedded within the National Health Service. The challenge for today's public health function is to retain a broad-based philosophy encompassing population programmes addressing health inequalities, whilst also delivering the personalized approach to supporting lifestyle change which is being demanded increasingly.

Infection control as a major World Health Organization priority for developing countries

Healthcare-associated infection affects hundreds of millions of people worldwide and is a major global issue for patient safety. It complicates between 5 and 10% of admissions in acute care hospitals in industrialised countries. In developing countries, the risk is two to twenty times higher and the proportion of infected patients frequently exceeds 25%. A growing awareness of this problem prompted the World Health Organization to promote the creation of the World Alliance for Patient Safety. Prevention of healthcare-associated infection is the target of the Alliance First Global Patient Safety Challenge, 'Clean Care is Safer Care', launched in October 2005. After 2 years, a formal statement has been signed by 72 ministries of health as a pledge of their support to implement actions to reduce healthcare-associated infection; of these, 30 are developing countries. Additional countries, mostly from the developing world, have planned to sign by the end of 2008 and will represent in total more than three-quarters of the world's population. Given the emphasis of the proposed strategy on simple and affordable solutions, the impact of the Challenge is expected to be high in developing countries. The combined efforts expected under the Challenge have the potential to save millions of lives, prevent morbidities and long-term disability for hundreds of millions of patients, and lead to major cost savings through the improvement of basic infection control measures in any healthcare setting, regardless of resources available or level of development.

Behavioural considerations for hand hygiene practices: the basic building blocks

Hand hygiene is considered to be the most effective measure to prevent microbial pathogen cross-transmission and healthcare-associated infections. In October 2005, the World Health Organization (WHO) World Alliance for Patient Safety launched the first Global Patient Safety Challenge 2005-2006, 'Clean Care is Safer Care', to tackle healthcare-associated infection on a large scale. Within the Challenge framework, international infection control experts and consultative taskforces met to develop new WHO Guidelines on Hand Hygiene in Healthcare. The taskforce was asked to explore aspects underlying hand hygiene behaviour that may influence its promotion among healthcare workers. The dynamics of behavioural change are complex and multi-faceted, but are of vital importance when designing a strategy to improve hand hygiene compliance. A reflection on challenges to be met and areas for future research are also proposed.

300. Differential expression patterns of genes with immune and developmental relevance in individual bovine preimplantation embryos produced by nuclear transfer

The overall efficiency of cloning by somatic cell nuclear transfer (NT) remains low when compared to in-vitro fertilisation (IVF). Inefficient reprogramming of the donor nucleus and epigenetic effects are hypothesized to lead to aberrant gene expression in cloned embryos. In this work differences in gene expression, between blastocysts from IVF and NT derived pre-implantation bovine embryos, were explored using a bovine cDNA array. 439 array elements were identified as being differentially expressed. 102 elements showing upregulation and 337 elements downregulation in NT blastocysts in a pairwise comparison to IVF-derived blastocysts. A major subset (65 elements) of differentially expressed elements comprised immune-related genes, possibly a reflection of the immune-focused cDNA microarray used in this study. For example, several cytokine genes, as well as elements of the innate immune system, were showing elevated expression in NT blastocysts. In addition, two regulatory elements of the same endocrine pathway exhibited a remarkable expression pattern, where the gene for one inhibitor showed upregulation and the gene for another inhibitor showed downregulation in NT blastocysts. Of specific interest is the observation that genes belonging to two growth factor pathways are upregulated in NT embryos. These results suggest an important role for immune-related genes during embryogenesis and indicate that specific cell growth and differentiation factors are of significant interest as targets in defining the abnormalities of preimplantation NT embryo development.

Bovine mammary epithelial cells, initiators of innate immune responses to mastitis

Innate immunity plays a vital role in the protection of the bovine mammary gland against mastitis. Until recently, the migration of effector cells such as neutrophils and monocytes into the mammary gland was thought to provide the only defence against invading pathogens. However, mammary epithelial cells may also play an important role in the immune response, contributing to the innate defence of the mammary tissue through secretion of antimicrobial peptides and attraction of circulating immune effector cells. This paper reviews the innate immune pathways in mammary epithelial cells and examines their role in the initiation of an innate immune response to Gram-positive and Gram-negative bacteria.

Ultrastructure of iodine treated wood

Iodine staining has been used to study the orientation of cellulose microfibrils in wood using light microscopy. The aim of this work was to understand the exact nature of the staining reaction with iodine and to provide insight into the properties and organisation of the wood cell wall. Based on transmission electron microscopy it is apparent that precipitation of the iodine following treatment with nitric acid results in the formation of crystal cavities within the cell wall, which follow the orientation of the cellulose microfibrils. There is no evidence that iodine precipitates within “drying checks” as previously speculated. High resolution confocal reflectance microscopy of crystal cavity orientation indicates that the microfibril arrangement within pit borders can be both spiral and circular. Crystal cavities are much more abundant within the S1 layer than elsewhere. All of the cells examined had crystal cavities in the S1 region, which may be related to the reduced lignification at the S1/S2 boundary resulting in greater porosity of the cell wall at this location. Within the S2 region, clusters of crystal cavities are randomly distributed and occur in widely varying numbers among adjacent cell walls, suggesting variations in the porosity of the S2 wall within and among adjacent tracheids. Cavities form preferentially within more electron lucent regions of the cell wall. The random nature of crystal cavity formation within S2 clusters probably reflects the underlying random nature of the cell wall nanostructure. We conclude that iodine staining can provide important clues to the nanostructural properties of tracheid cell walls.

Evaluation of Carolina Rinse solution as a treatment for ischaemia reperfusion of the equine jejunum

REASONS FOR PERFORMING STUDY

Ileus and peritoneal adhesions are the most common complications following surgery for small intestinal obstruction. Carolina Rinse (CR) has been shown to decrease reperfusion injury in intestine and other organs.

HYPOTHESIS

CR decreases intestinal inflammation and subsequent scarring associated with reperfusion injury.

METHODS

CR was infused intra-arterially and applied topically just prior to reperfusion in jejunum exposed to experimental ischemia. Vascular permeability, neutrophil accumulation and serosal scarring were compared in treated and untreated intestine.

RESULTS

CR maintained a normal osmotic reflection coefficient and decreased migration of neutrophils into the serosa during reperfusion. After 10 days, treated intestine was normal in appearance with a trend toward less serosal scarring and fibroblast proliferation. There was a significant decrease in fibroplasia at biopsy sites in treated intestine.

CONCLUSIONS

Arterial perfusion combined with topical application of CR during jejunal ischaemia decreases immediate reperfusion injury and limits post operative scarring.

POTENTIAL RELEVANCE

CR should be used as a local perfusate rather than a systemic treatment; it may best be applied topically and intraluminally to avoid damaging mesenteric arteries. CR should be considered an adjunct treatment as part of overall surgical management and post operative care.

Assembly of fluorescent chimeric virus-like particles of canine parvovirus in insect cells

Canine parvovirus (CPV) is a small non-enveloped ssDNA virus composed of the viral proteins VP1, VP2, and VP3 with a T=1 icosahedral symmetry. VP2 is nested in VP1 and the two proteins are produced by differential splicing of a primary transcript of the right ORF of the viral genome. The VP2 protein can be further proteolytically cleaved to form VP3. Previous studies have shown that VP1 and VP3 are unnecessary for capsid formation and consequently, that VP2 alone is sufficient for assembly. We have hypothesized that insertion of the enhanced green fluorescent protein (EGFP) at the N-terminus of VP2 could be carried out without altering assembly. To investigate the possibility to develop fluorescent virus-like particles (fVLPs) from such chimeric VP2 proteins, the corresponding fusion construct was abundantly expressed in insect cells. Confocal imaging indicated that the EGFP-VP2 fusion product was assembled to fluorescent capsid-like complexes. In addition, electron micrographs of purified EGFP-VP2 complexes showed that they displayed a very similar size and appearance when compared to VP2 VLPs. Further, immunolabelling of purified EGFP-VP2 VLPs showed the presence of EGFP within the structure. Fluorescence correlation spectroscopy (FCS) studies confirmed that fVLPs were very similar in size when compared to authentic CPV. Finally, feeding of mammalian cells susceptible to CPV infection with these fVLPs indicated that entry and intracellular trafficking could be observed. In summary, we have developed fluorescent virus-like nanoparticles carrying a heterologous entity that can be utilized as a visualization tool to elucidate events related to a canine parvovirus infection.

Clinical evaluation of a continuous oxygen consumption monitor in mechanically ventilated patients

We measured oxygen consumption using a new noninvasive modular metabolic monitor, M-COVX trade mark, in ventilated critically ill patients. Oxygen consumption was measured continuously as part of routine monitoring for up to 24 h following mechanical ventilation in 27 patients admitted to a general intensive care unit. We explored several possible sources of error. Most errors related to inaccurate tidal volume measurement, which resulted in rejection of a median 14% (interquartile range 8-34%) of data. Water accumulation in the pneumotachograph was responsible and occurred more frequently with water bath humidifiers. After manual removal of erroneous data mean oxygen consumption values were virtually identical to calculated values in 24 of 27 patients. We conclude that in most ventilated patients averaging of continuous oxygen consumption data with the M-COVX module results in small errors.

[The meaning and implementation of clinical governance]

Under the 1999 Health Act a statutory duty of "quality" was given to National Health Service (NHS) organisations in the United Kingdom. This was matched by a comprehensive quality program. In this paper we look at the meaning of clinical governance as a mechanism for ensuring local delivery of high quality clinical care in the UK, the national structures which have been put in place to develop, reinforce and implement clinical governance and the role of the NHS Clinical Governance Support Team (CGST) in delivering clinical governance "on the ground". As part of the quality program, the CGST is working to enable national clinical governance policy to be translated into practice locally by supporting the development of better ways of working by individuals, clinical teams and health organisations to deliver a continuous, integrated approach to quality healthcare for patients.

Disease emergence and health transitions in the last millennium

For most of the first millennium, average expectation of life was only 30 or 40 years. The beginning of the 20th century saw the start of improvements, which by the century's end meant that a baby boy could expect an average 75 years of life, a baby girl even longer. The successes of the 20th century were not products of advances in medicine alone, but consequences of the great sanitary reforms that fuelled the public health movement in late Victorian Britain. However, health challenges also grew and changed: the rise in so-called modern epidemics (coronary heart disease, cancer, accidents and mental illness); the ageing of the population; the containment of the costs of rapid technological advances; the marked and intractable inequalities in health status between rich and poor, and between North and South. The dawn of a new millennium sees many of these health problems carried over from the late 20th century, whilst communicable diseases, once thought conquered, continue to pose a serious threat to human health because of their global significance. This paper traces progress in the health of the population and identifies some of the key challenges for medicine in the 21st century.

A psychotherapist in the house: a service for distressed junior doctors

A service set up specifically for junior doctors is described. Doctors used the confidential psychotherapy service for both work-related and personal issues. Job-related issues predominated. Common psychodynamic problems underlying relationship difficulties and workload pressures are described and lessons learned from the experience noted.

Adult Attachment Interview: linkages with dimensions of emotional availability for mothers and their pre-kindergarteners

Maternal attachment representations were assessed using the George, Kaplan, and Main (1985) Adult Attachment Interview (AAI), and emotional availability during observed mother-child interactions was assessed using the third edition of the Emotional Availability (EA) Scales (Biringen, Robinson, & Emde, 1998). This edition of EA included four parental scales and two child scales (Maternal Sensitivity, Structuring, Nonintrusiveness and Nonhostility; and Child Responsiveness and Child Involvement). Separate Hierarchical Multiple Regressions (HMRs) were computed to examine the prediction of the separate EA dimensions from demographic information, the AAI classification, and AAI scales. These analyses indicated that each of the EA dimensions (with the exception of maternal nonintrusiveness and nonhostility) was predicted by the AAI classification and/or AAI scales. Using three-step HMRs, the strongest prediction was for maternal sensitivity where 54% of the total variance in maternal sensitivity was explained by maternal education, AAI classification, and AAI 'state of mind' scales. Maternal nonhostility was predicted by maternal education and gender of the child, with lower-income mothers and mothers of girls demonstrating greater hostility.

Continuing improvement in cadaver donor graft survival in North American children: the 1998 annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS)

This report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) covers the years 1987-1997, and analyses data on 3,133 cadaver donor (CD) transplants performed in 2,736 patients. There has been a steady decline in the number of CD transplants in children since 1996. Kidneys recovered from donors under 10 years of age accounted for 35% of all transplants in 1987, whereas by 1996 they comprised less than 20%. Caucasian children received 54% of CD transplants, whereas African-American children received 21%. Children under 6 years of age received 17% of CD transplants. Approximately half (46%) of the patients were induced with a T-cell antibody, and at 7 years post-transplant triple therapy is used in 70% of those with a functioning graft. Cyclosporin A is the primary immunosuppressant, with 92% of the patients being maintained on it at 5 years post-transplant. Among patients receiving a transplant in 1997, 11% were initiated with another calcineurin inhibitor, tacrolimus. At 15 days post-transplant 20% of the patients have had a rejection episode and by day 45, 46% have had an acute rejection. The probability of developing a rejection within the first year was reduced from 71% in 1987-1988 to 47% in 1995-1996.

A decade of living donor transplantation in North American children: the 1998 annual report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS)

This report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) covers the years 1987-1997, and analyzes data on 2,904 living donor (LD) transplants performed in 2,779 patients. Since 1991, approximately 300 LD transplants have been performed each year at the participating centers of the NAPRTCS. Caucasian children account for 72% of all LD recipients while African-American children constitute only 11%. There has been a gradual decline in the number of transplants performed in children under the age of 6 years from a peak of 30% in 1987, to 21% in 1997. Preoperative calcineurin inhibitor therapy has dropped from 71% in 1987 to 38% in 1997. Through 1996, at six months post-transplant 97% of recipients were receiving prednisone, 88% were maintained on cyclosporin A, and 79% were receiving azathioprine. Of patients transplanted in 1997, 47% are maintained on mycophenolate and 10% are maintained on tacrolimus. By day 15, 20% of index transplant patients have had an acute rejection and by the end of the first year 47% have had a rejection episode. Among patients transplanted in 1995-1996, 40% had a rejection in the first year. Nine per cent of rejection episodes are irreversible in children under 2 years of age and 5% of the episodes are irreversible in 25-year-old children. Estimated graft survival probability at 1 year is 91%, at 3 years it is 84% and at 5 years it is 78.5%. Rejection accounts for 33% of graft loss and recurrence constitutes another 10%. Influential prognostic variables for graft survival are race (African-American vs. others, relative risk (RR) = 2.0, p < 0.001), > 5 random transfusions (RR = 1.6, p < 0.001, T cell induction therapy (RR = 0.78, p = 0.01), and later year of entry (1989-1990 vs. 1994-1995, RR = 0.95, p = 0.04). Patient survival at 1 and 3 years was 97% and 96.5%, respectively, however, the 3-year patient survival of children under 2 years was 89%. The mean height deficit baseline (n=2,677) was -1.86, at 1 year post-transplant (n=1,459) it was -1.80, and at 5 years post-transplant (n=592) it was -2,06. This report, devoted specifically to LD pediatric transplants, raises the issues regarding the use of immunosuppression such as preoperative calcineurin inhibitors and T-cell antibodies. Studies to address the high incidence of chronic rejection and recurrence of original disease are necessary. Additional areas of concern are the high infant mortality and continued growth retardation post-transplantation.

Solution structure of the MEF2A-DNA complex: structural basis for the modulation of DNA bending and specificity by MADS-box transcription factors

The solution structure of the 33 kDa complex between the dimeric DNA-binding core domain of the transcription factor MEF2A (residues 1-85) and a 20mer DNA oligonucleotide comprising the consensus sequence CTA(A/T)(4)TAG has been solved by NMR. The protein comprises two domains: a MADS-box (residues 1-58) and a MEF2S domain (residues 59-73). Recognition and specificity are achieved by interactions between the MADS-box and both the major and minor grooves of the DNA. A number of critical differences in protein-DNA contacts observed in the MEF2A-DNA complex and the DNA complexes of the related MADS-box transcription factors SRF and MCM1 provide a molecular explanation for modulation of sequence specificity and extent of DNA bending ( approximately 15 versus approximately 70 degrees ). The structure of the MEF2S domain is entirely different from that of the equivalent SAM domain in SRF and MCM1, accounting for the absence of cross-reactivity with other proteins that interact with these transcription factors.

Pretransplant dialysis status and outcome of renal transplantation in North American children: a NAPRTCS Study. North American Pediatric Renal Transplant Cooperative Study

BACKGROUND

There are no large studies of the effect of pretransplant dialysis status on the outcome of renal transplantation (Tx) in children. This study evaluated the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS) registry data for the outcome of Tx in pediatric patients who either (1) received their transplants preemptively or (2) were maintained on dialysis before receiving their transplants.

METHODS

We compared graft survival and patient survival rates, incidence of acute tubular necrosis (ATN), acute rejection episodes, and causes of graft failure in peritoneal dialysis (PD) patients with those maintained on hemodialysis (HD) and those undergoing preemptive Tx (PTx).

RESULTS

Primary Tx was performed in 2495 children (59% male; 61% Caucasian; 1090 PD, 780 HD, 625 PTx) between 1/1/1992 and 12/31/1996. The overall graft survival rates of the PD and HD groups were similar, but were less than that of the PTx group (3-year: 82% PD and HD, 89% PTx, overall P = 0.0003). Improved graft survival in the PTx group was present only in recipients of grafts from living donors. There was no difference in the overall patient survival rate at 3 years, or in time to first acute-rejection episodes in the three groups. The incidence of ATN in the first 7 days post-Tx was higher in PD and HD patients than in PTx patients (11% PD and 12% HD vs. 2% PTx, P<0.001; HD vs. PD, P = NS). The major single cause of graft failure in each group was: PD, vascular thrombosis (200%); HD, chronic rejection (27%); PTx, acute and chronic rejection (21% each).

CONCLUSION

NAPRTCS data show that graft survival is improved in patients receiving PTx, compared with those receiving PD and HD. Graft loss resulting from vascular thrombosis is more common in children who receive PD than in those receiving HD.

Temporal variability in birth prevalence of cardiovascular malformations

OBJECTIVE

To investigate changes over time in the prevalence at live birth of cardiovascular malformations and to compare "anatomical" and "physiological" diagnostic hierarchies within a population.

DESIGN

Retrospective and prospective ascertainment of all congenital cardiovascular malformations diagnosed in infancy.

SETTING

The resident population of one health region.

PATIENTS

All infants live born from 1985 to 1997 with cardiovascular malformations confirmed by echocardiography, cardiac catheterisation, surgery or autopsy.

MAIN OUTCOME MEASURES

Year to year variation in prevalence of individual malformations and of "complex", "significant", and "minor" groups.

RESULTS

2671 babies with cardiovascular malformations were confirmed in a denominator population of 477 960 live births (5.6 per 1000). There was no change over 13 years in the birth prevalence of "complex" or "significant" defects, but a highly significant increase in "minor" defects (p < 0.0001), mainly small ventricular septal defects. Termination of pregnancy increased from no cases in 1985 to 16 in 1997 with no demonstrable effect on live born babies with heart defects. A one dimensional "anatomical" diagnostic hierarchy led to under ascertainment of pulmonary atresia by 27%, coarctation of the aorta by 39%, and interruption of the aorta by 100%.

CONCLUSIONS

The apparent increase in live born cardiovascular malformations results mainly from improved diagnosis of minor defects. There has been no change over time in birth prevalence of more serious defects. Spontaneous year to year variation in numbers will make it difficult to ascribe any short term changes to any particular intervention. A two dimensional diagnostic hierarchy is offered as a standard.

Sequential assignment of proline-rich regions in proteins: application to modular binding domain complexes

Many protein-protein interactions involve amino acid sequences containing proline-rich motifs and even polyproline stretches. The lack of amide protons in such regions complicates assignment, since 1HN-based triple-resonance assignment strategies cannot be employed. Two such systems that we are currently studying include an SH2 domain from the protein Crk with a region containing 9 prolines in a 14 amino acid sequence, as well as a WW domain that interacts with a proline-rich target. A modified version of the HACAN pulse scheme, originally described by Bax and co-workers [Wang et al. (1995) J. Biomol. NMR, 5, 376-382], and an experiment which correlates the intra-residue 1Halpha, 13Calpha/13Cbeta chemical shifts with the 15N shift of the subsequent residue are presented and applied to the two systems listed above, allowing sequential assignment of the molecules.

Slit-scanning confocal microendoscope for high-resolution in vivo imaging

We discuss the design and construction of a novel imaging system in which a fiber-optic imaging bundle and miniature optical and mechanical components are used to allow confocal fluorescence microscopy in remote locations. The instrumentation has been developed specifically for cellular examination of tissue for optical biopsy. Miniaturization of various components makes the device usable in a clinical setting. The numerical aperture of the beam in the tissue is 0.5, and the field of view is 430 microm. The measured lateral resolution of the system is 3.0 microm. The axial point and the axial planar response functions of the confocal system were measured with a FWHM of 10 and 25 microm, respectively. In vitro and in vivo images obtained with cell cultures, human tissue specimens, and animal models indicate that the performance of the device is adequate for microscopic evaluation of cells.

Association between outcome and telomere DNA content in prostate cancer

PURPOSE

To perform an initial retrospective investigation of the relationship between outcome in patients with organ confined prostate adenocarcinoma and the tumor cells' content of telomere DNA.

MATERIALS AND METHODS

The case-controlled study group was composed of eighteen men diagnosed with prostatic adenocarcinoma prior to 1993. The group was selected so that approximately one half died within ten years of diagnosis and one half survived ten years or longer. Archival, paraffin-embedded tumor tissue was recovered for each patient. DNA was extracted from newly cut sections, fixed to nylon membranes and hybridized with P32-labeled centromere- and telomere-specific probes. Telomere DNA contents were quantitated from the hybridized radioactivities. The relationships between telomere DNA content and survival, and telomere DNA content and disease recurrence in men receiving prostatectomies were determined.

RESULTS

Death and disease recurrence were associated with reduced telomere DNA content (p <0.0001, p <0.0001, respectively).

CONCLUSIONS

Telomere DNA content may differentiate high-risk patients with metastatic prostate cancer from men with indolent disease who can be spared the unnecessary side effects and expense of treatment by management with "watchful waiting."