Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

Protocolised reduction of non-resuscitation fluids versus usual care in patients with septic shock (REDUSE): a protocol for a multicentre feasibility trial

INTRODUCTION

Administration of large volumes of fluids is associated with poor outcome in septic shock. Recent data suggest that non-resuscitation fluids are the major source of fluids in the intensive care unit (ICU) patients suffering from septic shock. The present trial is designed to test the hypothesis that a protocol targeting this source of fluids can reduce fluid administration compared with usual care.

METHODS AND ANALYSIS

The design will be a multicentre, randomised, feasibility trial. Adult patients admitted to ICUs with septic shock will be randomised within 12 hours of admission to receive non-resuscitation fluids either according to a restrictive protocol or to receive usual care. The healthcare providers involved in the care of participants will not be blinded. The participants, outcome assessors at the 6-month follow-up and statisticians will be blinded. Primary outcome will be litres of fluids administered within 3 days of randomisation. Secondary outcomes will be proportion of randomised participants with outcome data on all-cause mortality; days alive and free of mechanical ventilation within 90 days of inclusion; any acute kidney injury and ischaemic events in the ICU (cerebral, cardiac, intestinal or limb ischaemia); proportion of surviving randomised patients who were assessed by European Quality of Life 5-Dimensions 5-Level questionnaire and Montreal Cognitive Assessment; proportion of all eligible patients who were randomised and proportion of participants experiencing at least one protocol violation.

ETHICS AND DISSEMINATION

Ethics approval has been obtained in Sweden. Results of the primary and secondary outcomes will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT05249088.

TNFR1, TNFR2, neutrophil gelatinase-associated lipocalin and heparin binding protein in identifying sepsis and predicting outcome in an intensive care cohort

To date no biomarkers can aid diagnosing sepsis with adequate accuracy. We set out to assess the ability of Tumor necrosis factor receptor (TNFR) 1 and 2, Neutrophil gelatinase-associated lipocalin (NGAL) and Heparin binding protein (HBP) to discriminate sepsis from non-infected critically ill patients in a large ICU cohort, and to evaluate their value to predict mortality at 30 days. Adult patients admitted to the ICU with an arterial catheter were included. Clinical data and blood samples were prospectively recorded daily. Diagnoses were set retrospectively. Descriptive statistics and logistic regression models were used. NGAL, TNFR1 and TNFR2 were higher in sepsis patients compared to other diagnoses, as well as in non-survivors compared to survivors. In addition, these biomarkers increased with increasing stages of acute kidney injury. TNFR1 and TNFR2 performed similarly to NGAL and CRP in identifying sepsis patients, but they performed better than CRP in predicting 30-day mortality in this ICU cohort. Thus, TNFR1 and TNFR2 may be particularly useful in identifying high risk sepsis patients and facilitate relevant health care actions in this group of sepsis patients.

Renal clearance of heparin-binding protein and elimination during renal replacement therapy: Studies in ICU patients and healthy volunteers

Background

Heparin-binding protein (HBP) is released by neutrophils upon activation, and elevated plasma levels are seen in inflammatory states like sepsis, shock, cardiac arrest, and burns. However, little is known about the elimination of HBP. We wanted to study renal clearance of HBP in healthy individuals and in burn patients in intensive care units (ICUs). We also wished to examine the levels of HBP in the effluent of renal replacement circuits in ICU patients undergoing continuous renal replacement therapy (CRRT).

Methods

We measured plasma and urine levels of HBP and urine flow rate in 8 healthy individuals and 20 patients in a burn ICU. In 32 patients on CRRT, we measured levels of HBP in plasma and in the effluent of the CRRT circuit.

Results

Renal clearance of HBP (median (IQR) ml/min) was 0.19 (0.08–0.33) in healthy individuals and 0.30 (0.01–1.04) in burn ICU patients. In ICU patients with cystatin C levels exceeding 1.44 mg/l, clearance was 0.45 (0.15–2.81), and in patients with cystatin C below 1.44 mg/l clearance was lower 0.28 (0.14–0.55) (p = 0.04). Starting CRRT did not significantly alter plasma levels of HBP (p = 0.14), and the median HBP level in the effluent on CRRT was 9.1 ng/ml (IQR 7.8–14.4 ng/ml).

Conclusion

In healthy individuals and critically ill burn patients, renal clearance of HBP is low. It is increased when renal function is impaired. Starting CRRT in critically ill patients does not alter plasma levels of HBP significantly, but HBP can be found in the effluent.

It seems unlikely that impaired kidney function needs to be considered when interpreting concentrations of HBP in previous studies. Starting CRRT does not appear to be an effective way of reducing HBP concentrations.

Conventional Spinal Radiography as a Supplement to the Neurologic Assessment in Myelomeningocele

In patients born with a myelomeningocele early assessment of the severity of the anomaly is mandatory for planning of therapy. Conventional spinal radiography, although a routine examination, in many hospitals has been regarded as less rewarding. However, in this retrospective investigation of 92 patients, a reasonable conformity was found between conventional radiograms and neurologic deficit at follow-up. There was no significant difference between the results of radiologic examinations carried out during the first 1 to 10 weeks after birth and the later neurologic findings. Hence, the simple radiologic assessment has proved a valuable baseline examination in these patients. In cases with discrepancy between the conventional radiologic and the neurologic findings, and in cases with a course diverging from the anticipated, more sophisticated methods of imaging are recommended.

CT Demonstration of Fistulae in Patients with Gynecologic Neoplasms

Ten women treated for gynecologic neoplasms (8 cervical carcinomas, one vaginal and one endometrial carcinoma) were found at computed tomography (CT) to have a fistula although only 5 patients had symptoms that could be related to a fistula. Five women had vesico-vaginal fistulae, 2 recto-vaginal, 2 entero-cervical and one a vulvo-pubical fistula. Three patients had recurrent malignancy at the CT examination. We regard CT as the ragiologic method of choice in diagnosing gynecologic fistulae.

Effect of Chemotherapy and Radiotherapy on Squamous Cell Carcinoma of the Esophagus

In a series of 82 patients with epidermoid carcinoma of the esophagus, 68 were available for review of barium examinations and 44 for review of CT examinations showing the effect of preoperative treatment. After 3 courses of chemotherapy — Cisplatinum and 5-fluorouracil, and 24 Gy of presurgical irradiation — Over a total of 10.5 weeks, the patients were ready for surgery. The results of the presurgical radiographic examinations were compared with the findings of histopathologic studies after surgery. Where both the CT and the barium examination showed a complete response, none of the patients had remaining macroscopic cancer. When healing with stenosis was included, CT and barium studies in combination were necessary to exclude a residual macroscopic tumor. Therefore, a combination of barium esophagography and CT is recommended to estimate the preoperative effect of treatment.

Computed Tomography of the Thymus Gland in Myasthenia Gravis

Sixteen consecutive patients with myasthenia gravis were examined by computed tomography (CT) before thymectomy. Surgical and histologic findings were compared with those obtained at CT. The results, like those of most other recent studies, indicate that CT is a reliable method for identifying thymoma. In all three patients with thymoma, and in five out of eight patients with hyperplasia, the lesion was observed at CT, giving an overall accuracy of 80 per cent. Although tymic hyperplasia is a basically histologic diagnosis an enlarged gland may give a correct diagnosis of this abnormality.

The Percentage of Migration as Indicator of Femoral Head Position

In childhood subluxation of one or both hips may develop rather insidiously. For lack of generally accepted objective methods of assessment, ambiguous interpretations of findings in serial examinations are common. Many subluxations are overlooked during the early stages. In order to overcome such disadvantages, determination of the percentage of migration seems to be a reasonably easy and reliable technique facilitating evaluation of impending dislocation. This investigation was carried out in order to establish norms applicable to patients in the pediatric age interval. The 98th percentile of migration increases with age from 16 per cent in patients <4 years of age to 24 per cent in patients ≥12 years. Higher figures represent subluxation. If the migration exceeds 80 per cent a manifest luxation is present. A difference in migration between the two hips larger than 12 per cent indicates abnormality calling for clinical and radiologic follow-up.

Digital Luminescence Mammography

In a pilot study, mammography using digital luminescence was compared to conventional film-screen mammography regarding detectability of micro-calcifications and malignant tumors. The data processing algorithms were designed by the manufacturer to produce an image with characteristics close to conventional mammograms. Three observers reviewed 99 digital and their corresponding conventional mammograms. There was no difference in the detectability of micro-calcifications between digital and conventional mammography. On the digital mammograms, however, artifacts were misjudged as micro-calcifications. In an ROC analysis regarding malignant breast tumors, no significant difference was found between the 2 systems. There was a slight, but not significant, difference between the results of different observers regarding the digital system.

Computed Tomography of Malignant Ovarian Disease

One hundred and five patients with proven malignant ovarian disease were examined with one or more abdomino-pelvic CT scans in order to evaluate clinically suspected recurrence, complete clinical remission, or the effect of therapy. The findings obtained at CT were compared with follow-up examinations including surgery in 85 patients within 3 months. CT was accurate in the evaluation of therapeutic response, but if negative not reliable enough to replace a laparotomy of patients with possible recurrence or in clinical remission.

Electrolysis with Different Electrode Materials and Combined with Irradiation for Treatment of Experimental Rat Tumors

In order to make electrolytic tumor destruction more effective new electrode materials were tested (Part I) as well as a combination of electrolysis and megavolt therapy (Part II). All tests were performed in experimental tumors implanted subcutaneously in rats. Altogether in 41 rats in 5 series (Part I) electrodes made of rhodium (Rh), copper (Cu), or brass (Zn-Cu alloy) were investigated but the effect was not found to be better than that of the previously tested platinum (Pt). Oxidation and corrosion made Rh and Cu electrodes less suitable for electrolysis compared to Pt, while brass electrodes became isolated through zinc-salt-formation and performed unsatisfactorily. The radiosensitizing properties of electrolysis were tested in 55 rats with experimental tumors (Part II). One control group had only Co-irradiation, while in 2 other groups Cu- or Pt-electrolysis of the tumors was carried out before irradiation. The combined treatment resulted in a significantly better effect on the tumors, registered as inhibition of tumor growth or disappearance of tumor. As the electrolyzed, necrotic tissue remained in the tumor the effect might not be mediated through diminished target volume. An inflammatory reaction around the electrolytic lesion with increased blood flow and higher oxygenation of the tumor could cause a more positive response to megavolt treatment.

Mammographic Follow-up after Breast Conserving Surgery and Postoperative Radiotherapy without Boost Irradiation for Mammary Carcinoma

Pre- and postoperative mammograms were reviewed in 103 women undergoing conservation surgery and irradiation for breast cancer stage I. The main reactions to radiotherapy were increased breast parenchymal density and increased skin thickness. Changes reached a peak at 9 months. No new changes were seen at 2 years, and most had regressed at this time. Following surgery, 71 of the patients displayed noticeable scar tissue in the surgical area, sometimes causing diagnostic difficulties. Two of the patients had a local recurrence of carcinoma, while 3 developed cancer in the other breast.

Gravitational waves from color-magnetic "mountains" in neutron stars

Neutron stars may harbor the true ground state of matter in the form of strange quark matter. If present, this type of matter is expected to be a color superconductor, a consequence of quark pairing with respect to the color and flavor degrees of freedom. The stellar magnetic field threading the quark core becomes a color-magnetic admixture and, in the event that superconductivity is of type II, leads to the formation of color-magnetic vortices. In this Letter, we show that the volume-averaged color-magnetic vortex tension force should naturally lead to a significant degree of nonaxisymmetry in systems such as radio pulsars. We show that gravitational radiation from such color-magnetic "mountains" in young pulsars, such as the Crab and Vela, could be observable by the future Einstein Telescope, thus, becoming a probe of paired quark matter in neutron stars. The detectability threshold can be pushed up toward the sensitivity level of Advanced LIGO if we invoke an interior magnetic field about a factor ten stronger than the surface polar field.

Are neutron stars with crystalline color-superconducting cores relevant for the LIGO experiment?

We estimate the maximal deformation that can be sustained by a rotating neutron star with a crystalline color-superconducting quark core. Our results suggest that current gravitational-wave data from the Laser Interferometer Gravitational-Wave Observatory have already reached the level where a detection would have been possible over a wide range of the poorly constrained QCD parameters. This leads to the nontrivial conclusion that compact objects do not contain maximally strained color crystalline cores drawn from this range of parameter space. We discuss the uncertainties associated with our simple model and how it can be improved in the future.

Male Rett phenotypes in T158M and R294X MeCP2-mutations

We report on three patients with MeCP2 mutation and male Rett phenotypes. Two brothers with T158M mutations and normal karyotype had a severe early onset encephalopathy, progressive microcephaly, severe feeding problems, breathing and sleep disturbances. They died at the ages of 1 year and 8 months, and 3 years and 1 month. This mutation has previously been reported in three males. The phenotypes show a strong resemblance, and might in fact represent a clinical-genetic entity of the T158M mutation within the complex of congenital encephalopathies in males with MeCP2 mutations. We also report a 3-year-old boy with a R294X mutation, normal karyotype, and a more protracted course. He was inactive and sucked poorly from start. The head growth decelerated from the age of 6 months and the feeding problems increased requiring gastrostomy. He had a rapid deterioration period at 2 years and lost sitting and hand grasping functions. He had prolonged periods with tremor and epileptic myoclonus, shifting tonus, and dystonic extension of the trunk and legs, bruxism, and irregular breathing. He was clinically stable with preserved visual and emotional contact function by the age of four years. None of the boys had dysmorphic features.

Decreasing levels of tumour necrosis factor alpha and interleukin 6 during lowering of body mass index with orlistat or placebo in obese subjects with cardiovascular risk factors

AIM

Obesity is associated with increased levels of inflammatory mediators. The objective of this study was to evaluate changes in the leucocyte derived inflammatory mediators tumour necrosis factor alpha (TNF-alpha), interleukin 6 (IL-6) and the isoprostane 8-epi-prostaglandin (PG) F2alpha during BMI lowering with orlistat (Xenical(R), Roche) or placebo.

METHODS

TNF-alpha, IL-6, and 8-epi PGF2alpha evaluated in 376 subjects aged 18-75 years with BMI 28-38 kg/m2 before and after 1 year of double-blind, randomized treatment with orlistat 120 mg or placebo three times daily.

RESULTS

Weight reduction was associated with decreasing (p < 0.001) levels of TNF-alpha and IL-6 in both orlistat and placebo groups. After 12 months, TNF-alpha was lower (p < 0.05) in the orlistat compared with the placebo group. In the orlistat group, the change in TNF-alpha correlated with change in s-glucose (r = 0.22; p = 0.01), and the change in 8-epi-PGF2alpha correlated with changes in s-cholesterol (r = 0.27; p < 0.001) and s-LDL-cholesterol (r = 0.28; p < 0.001).

CONCLUSION

Weight reduction was associated with decreasing levels of both TNF-alpha and IL-6. After 12 months of treatment, TNF-alpha levels were lower in orlistat than in placebo-treated subjects. Whether these results translate into reduced incidence of cardiovascular disease remains to be elucidated.

Thermal quantitative sensory testing in lumbar disc herniation

The most frequent clinical presentation of sciatica suggests injury of sensor root fibers alone. To evaluate whether thermal quantitative sensory testing (QST) is applicable in the study of sensory dysfunction in lumbosacral disc herniations, 36 men and 30 women with L4/5 or L5/S1 disc herniations underwent thermal QST of the L4, L5, and Si dermatomes. For both levels of disc herniation, there was a significant difference for all temperature modalities, i.e., cold, warmth and heat pain, between all dermatomes as well as between the side of the herniated disc and the corresponding asymptomatic side. However, the proportion of herniated discs classified correctly was only 48% in patients with disc herniations at the L4/5 level, while it was 71% at the L5/S1 level. We conclude that thermal QST measurements reflect and document sensory dysfunction in patients with lumbosacral disc herniation. The method offers a new means both to study the time course of a spontaneous recovery of sensory dysfunction and to evaluate the result of different treatment options. However, thermal QST seems to have the same poor predictive value for identifying the anatomic location of a herniated lumbar disc as conventional electrophysiologic methods.

The IL12B gene does not confer susceptibility to coeliac disease

Coeliac disease (CD) is a chronic inflammatory disorder where dietary gluten is not tolerated. In the lesion there are gluten reactive T cells predominantly secreting gamma-interferon. Both HLA and non-HLA genes contribute to CD susceptibility. Interleukin-12 (IL-12) regulates gamma-interferon production. The IL12B gene is located in a region (5q31.1-33.1) where there is evidence for linkage with CD. Allele 1 of an IL12B 3'UTR single-nucleotide polymorphism leads to increased expression of IL-12, and was recently implicated in susceptibility for type 1 diabetes (T1D). We found no evidence for association of allele 1 to CD by the transmission/disequilibrium test or case-control approach. No increased frequency was observed in patients belonging to families where the disease was linked to markers on chromosome 5q. Unlike T1D, allele 1 does not appear to confer susceptibility to CD.

Genome-wide linkage analysis of Scandinavian affected sib-pairs supports presence of susceptibility loci for celiac disease on chromosomes 5 and 11

Celiac disease (CD) is a common chronic inflammatory disorder of the small intestine with a multifactorial aetiology. HLA is a well-known risk factor, but other genetic factors also influence disease susceptibility. To identify the genes involved in this disorder, we performed a genome-wide scan on 106 well-defined Swedish and Norwegian families with at least two affected siblings. We investigated familial segregation of 398 microsatellite markers, and utilised non-parametric linkage analysis. The strongest linkage with disease was found to the HLA locus (6p) (P<0.000006). There were eight regions besides HLA with a point wise P value below 0.05. Among these eight regions were 11q and 5q, both of which have been suggested in several linkage studies of independent celiac disease families. We also performed a stratification analysis of families according to their HLA genotypes. This resulted in significant differences on chromosome 2q. These results indicate that 11q, 5q and possibly also 2q are true susceptibility regions in CD.

Insulin can enhance GLUT4 gene expression in 3T3-F442A cells and this effect is mimicked by vanadate but counteracted by cAMP and high glucose--potential implications for insulin resistance

It is well-established that high levels of cAMP or glucose can produce insulin resistance. The aim of this study was to characterize the interaction between these agents and insulin with respect to adipose tissue/muscle glucose transporter isoform (glucose transporter 4, GLUT4) gene regulation in cultured 3T3-F442A adipocytes and to further elucidate the GLUT4-related mechanisms in insulin resistance. Insulin (10(4) microU/ml) treatment for 16 h clearly increased GLUT4 mRNA level in cells cultured in medium containing 5.6 mM glucose but not in cells cultured in medium with high glucose (25 mM). 8-Bromo-cAMP (1 or 4 mM) or N(6)-monobutyryl cAMP, a hydrolyzable and a non-hydrolyzable cAMP analog, respectively, markedly decreased the GLUT4 mRNA level irrespective of glucose concentrations. In addition, these cAMP analogs also inhibited the upregulating effect of insulin on GLUT4 mRNA level. Interestingly, the tyrosine phosphatase inhibitor vanadate (1-50 microM) clearly increased GLUT4 mRNA level in a time- and concentration-dependent manner. Furthermore, cAMP-induced inhibition of the insulin effect was also prevented by vanadate. In parallel to the effects on GLUT4 gene expression, both insulin, vanadate and cAMP produced similar changes in cellular GLUT4 protein content and cAMP impaired the effect of insulin to stimulate (14)C-deoxyglucose uptake. In contrast, insulin, vanadate or cAMP did not alter insulin receptor (IR) mRNA or the cellular content of IR protein.

IN CONCLUSION

(1) Both insulin and vanadate elicit a stimulating effect on GLUT4 gene expression in 3T3-F442A cells, but a prerequisite is that the surrounding glucose concentration is low. (2) Cyclic AMP impairs the insulin effect on GLUT4 gene expression, but this is prevented by vanadate, probably by enhancing the tyrosine phosphorylation of signalling peptides and/or transcription factors. (3) IR gene and protein expression is not altered by insulin, vanadate or cAMP in this cell type. (4) The changes in GLUT4 gene expression produced by cAMP or vanadate are accompanied by similar alterations in GLUT4 protein expression and glucose uptake, suggesting a role of GLUT4 gene expression for the long-term regulation of cellular insulin action on glucose transport.

Stronger association with HLA-Cw6 than with corneodesmosin (S-gene) polymorphisms in Swedish psoriasis patients

Psoriasis vulgaris is strongly associated with certain human leukocyte antigens, especially in early onset. The purpose of this study was to study the HLA-Cw6 allele and its contribution to disease susceptibility in a set of 104 families with at least two affected siblings. A sequencing method was utilized to examine the two exons that build up the antigen binding site of the C locus receptor. DNA from patients homozygous for Cw6 based on haplotype information were sequenced. The results confirmed the identity of the Cw6 allele in affected individuals with the consensus sequence for Cw*0602. We screened the set of families for psoriasis patients homozygous for Cw6 and found 11 individuals with a mean age at onset of 16.1 years. The corresponding figure for the Cw6 heterozygotes was 18.45 years and for the Cw6-negatives 22.36 years. This is indicative of a gene dose effect. We performed a transmission disequilibrium test (TDT) on the Cw6 allele per se, used as a biallelic marker. The analysis resulted in a P-value of 5.3 x 10(-17) (t167/nt45). This greatly exceeds our previous results of a TDT in the region, including microsatellite markers and single nucleotide polymorphisms (SNPs) in the coding part of the S gene (corneodesmosin), which is a suggested candidate gene in the region. The maximum nonparametric linkage (NPL) value was also reached using HLA-C as a marker. We conclude that Cw6 is the allele which shows the highest degree of association with psoriasis in our set of families and we propose that it directly influences the age at onset of the disease rather than increasing the genetic load in accordance with a polygenic theory.

The CTLA4/CD28 gene region on chromosome 2q33 confers susceptibility to celiac disease in a way possibly distinct from that of type 1 diabetes and other chronic inflammatory disorders

The effect of the gene region on chromosome 2q33 containing the CD28 and the cytotoxic T-lymphocyte associated (CTLA4) genes has been investigated in several diseases with chronic inflammatory nature. In addition to celiac disease (CD), type I diabetes, Grave's disease, rheumatoid arthritis and multiple sclerosis have all demonstrated associations to the A/G single nucleotide polymorphism (SNP) in exon 1, position +49 of the CTLA4 gene. The purpose of this study was to investigate this gene region in a genetically homogeneous population consisting of 107 Swedish and Norwegian families with CD using genetic association and linkage methods. We found a significant association with preferential transmission of the A-allele of the exon 1 +49 polymorphism by using the transmission disequilibrium test (TDT). Suggestive linkage of this region to CD was moreover demonstrated by non-parametric linkage (NPL) analysis giving a NPL-score of 2.1. These data strongly indicates that the CTLA4 region is a susceptibility region in CD. Interestingly, of the several chronic inflammatory diseases that exhibit associations to the CTLA4 +49 A/G dimorphism, CD appears to be the only disease associated to the A allele. This suggests that the +49 alleles of the CTLA4 gene are in linkage disequilibrium with two distinct disease predisposing alleles with separate effects. The peculiar association found in the gut disorder CD may possibly relate to the fact that the gastrointestinal immune system, in contrast to the rest of the immune system, aims to establish tolerance to foreign proteins.

S gene (Corneodesmosin) diversity and its relationship to psoriasis; high content of cSNP in the HLA-linked S gene

Psoriasis is a heterogeneous disease in which several reports suggest the presence of a susceptibility gene in or in the proximity of the human leukocyte antigen complex in chromosome 6p. There is an association between HLA-Cw6 and young onset of the disease. The S gene (corneodesmosin), located 160 kb telomeric of HLA-C, is a strong candidate for psoriasis due to its reportedly exclusive expression in differentiating keratinocytes. We have studied this gene in a large Swedish psoriasis population and we report a strikingly high degree of polymorphism in the coding parts of the gene, 1 every 100 base pairs. We used a stratified approach to compare the polymorphic variants in patients and controls. A single nucleotide polymorphism in the coding region leading to an amino acid exchange (Ser-->Phe) that differed significantly between patients and controls was identified (position 619). Owing to a high allele frequency in a larger control group, however, and an insignificant influence of the variant on the age at onset distribution curve based on a large psoriasis population, we could not confirm that this coding single nucleotide polymorphism was involved in disease etiology. We also examined the single nucleotide polymorphism in position 1243, recently proposed to have an influence on the pathogenesis of the disease. This polymorphism showed less association to the disease as compared with the single nucleotide polymorphism at positions 619 and 722. Such a high degree of variation present also in an HLA gene which is not involved in immune response indicates the difficulty involved in assessing the role of a specific allele in the pathogenesis of a complex disease in this region. A strong association effect due to linkage disequilibrium in an extended region in the HLA complex is also a complicating factor.

A genome-wide search for genes predisposing to familial psoriasis by using a stratification approach

We have performed a genome scan, using markers spaced by 10 cM, in the search for psoriasis-susceptibility loci. The family material of 134 affected sibling pairs was ascertained on the basis of a population genetic study in which 65% of the probands had two healthy parents. Genotyping results were analyzed for non-random excessive allele-sharing between sib pairs by using GENEHUNTER ver 1.1. A stratification approach was applied to increase the homogeneity of the material by means of an operational definition of joint complaints among affected individuals. Significant linkage to the human leukocyte antigen region on chromosome 6p in a cohort including 42 families without joint complaints (nonparametric linkage score of 2.83, P=0.002) strongly supported the validity of this operational definition as it replicated results from an earlier linkage report with similar stratification criteria. New candidate regions on chromosomes 3 and 15 were identified. The highest non-parametric linkage values in this study, 2.96 (P=0.0017) and 2.89 (P=0.0020), were reached on chromosome 15 in a subgroup with joint complaints and on chromosome 3 in a subgroup without joint complaints. In addition, confirmation of previously reported loci was established on chromosomes 4q, 6p, and 17q. This study indicates that distinct disease loci might be involved in psoriasis etiology for various phenotypes.

Psoriasis susceptibility locus in chromosome region 3q21 identified in patients from southwest Sweden

We have performed a pair-wise linkage study in the search for psoriasis susceptibility regions. A preliminary scan was performed on 20 families. In this set we obtained indications of linkage on chromosome 3q21. This region was further investigated using material from a total of 104 families (set 1B) resulting in a non-parametric linkage (NPL) of 1.77. The material was stratified in families whose parental origin is in southwest Sweden (set 1C). A maximum NPL value of 2.77 was obtained in this group. A transmission disequilibrium test (TDT) was performed on the stratified material (set 1C) and a significant P value of 0.005 was obtained, at marker D3S1269. The locus was confirmed with TDT in replicate material consisting of 148 families in which a single member was affected (P value 0.0007) at marker D3S1551. Thus, we have observed a significant P value using TDT in the vicinity of markers D3S1269/D3S1551, suggesting a novel psoriasis susceptibility region.

Cytogenetic analysis of 477 psoriatics revealed an increased frequency of aberrations involving chromosome region 11q

Psoriasis is an inflammatory skin disorder affecting approximately 3% of the population. Genetic studies published so far have shown a complex genetic inheritance with heterogeneity and a putative major susceptibility locus in the HLA region on chromosome 6. We have collected a large amount of material consisting mostly of small nuclear families in order to perform a genome-wide scan for psoriasis-associated genes. In order to focus the scan properly on possible candidate regions, we performed a cytogenetic analysis of 477 unrelated psoriatics. We divided our findings into sporadic, affecting a minor fraction of the cells, and constitutional, i.e. they were present in all cells examined. We found three cases of balanced translocation, all of which involved chromosome 11q. Two of these had a breakpoint in q12-13, whilst one involved the telomeric part of chromosome 11q. In order to characterise further the breakpoint on 11q12-13, we used bacterial artificial chromosomes (BACs) analysed by fluorescent in situ hybridisation (FISH). We were able to show that the persons had a close, but not identical breakpoints; they were separated by at least 5 cM. The major atopy locus is located in this region, as well as a locus for insulin-dependent diabetes mellitus, both being conditions with a pathogenetic mechanism involving antigen presentation.

Ambulation in patients with myelomeningocele: a 12-year follow-up

Factors determining change in ambulatory status were studied over a 12-year observation time in 60 ambulating patients with myelomeningocele. There were 26 female and 34 male subjects with a median age of 22 years (range, 12-54). We used the method of Lindseth to define the neurologic level of the lesion and classified walking ability according to the criteria of Hoffer. The prevalence of spasticity and spine and lower-limb deformities was assessed. Orthopedic and neurosurgical interventions and other medical events were registered, as well as occurrence of pressure sores, musculoskeletal pain, and use of orthoses. There were 19 patients with downward transitions in ambulatory level during the follow-up time. Factors explaining deterioration in these 19 patients included deterioration of the neurologic level of lesion, spasticity, knee and hip flexion contractures, low-back pain, lack of motivation, as well as those of major medical events like stroke, recurrent septicemia, lower limb edema, and invasive surgical interventions.

Analysis of three suggested psoriasis susceptibility loci in a large Swedish set of families: confirmation of linkage to chromosome 6p (HLA region), and to 17q, but not to 4q

Psoriasis is known to be a heterogeneous disease with so far three reported major psoriasis susceptibility loci on chromosome 4q, 6p and 17q. In this study we investigated three reported gene locations by nonparametric and parametric linkage analysis in a large family set consisting of 104 families (153 sib pairs) from Sweden. We could confirm linkage to chromosome 6p. A maximum heterogeneous lod score of 2.78 was reached at locus D6S276 (alpha = 0.60). Allelic association studies within the HLA region indicated linkage disequilibrium at locus TNFbeta with a significant p value of 0.0009. Furthermore, we obtained weak evidence of linkage to the locus on chromosome 17q while no evidence of linkage could be found to the chromosome 4q region.

Genetic counselling in psoriasis: empirical data on psoriasis among first-degree relatives of 3095 psoriatic probands

The risk of getting psoriasis dependent on the occurrence of psoriasis in the family has been determined empirically. Altogether 3717 families with one or both parents who had psoriasis have been analysed with regard to the number of children with or without psoriasis. The lifetime risk of getting psoriasis if no parent, one parent or both parents have psoriasis is 0.04, 0.28 and 0.65, respectively. If there is already one affected child in the family, the corresponding risks are 0.24, 0.51 and 0.83, respectively. The risk of getting psoriasis before the age of 32 years is dependent on the age-of-onset of psoriasis in one affected parent.

Scoliosis and trunk asymmetry in upper limb transverse dysmelia

The incidence of scoliosis and trunk asymmetry were studied in 60 patients with upper limb dysmelia of the transverse type. The evaluations were based on radiographic measurements of the spine and scoliometer readings of the angle of trunk rotation (ATR), which were correlated with the side and level of the limb deficiency and also with leg length-inequality (LLI). Nineteen patients (31%) had a scoliosis between 10 and 19 degrees, whereas the curves were between 5 and 10 degrees in another 30 patients and the remainder had no measurable curve. The scoliosis seemed at least partly to be of postural origin as LLI significantly correlated with the direction of the curves, but there was no correlation between the Cobb angles and the magnitude of LLI. The scoliometer readings did not correlate with the scoliosis or LLI. Our findings indicate that most patients with upper limb transverse amputations do not develop a significant scoliosis. A scoliometer screen has a low positive predictive rate for scoliosis and the diagnosis of scoliosis requires a radiograph of the spine.

Trunk rotation in scoliosis. The influence of curve type and direction in 150 children

We compared the angle of trunk rotation (ATR) from scoliometer readings with Cobb angle measurements of the lateral deviation of the spine in 150 children referred to hospital for evaluation of scoliosis. The mean Cobb angle in thoracic curves was 16 degrees. In thoracolumbar curves 17 degrees and in lumbar curves 20 degrees. In thoracic curves and in right convex curves no patient with a Cobb angle of 25 degrees or more had an ATR below 9 degrees. In thoracolumbar and lumbar and in left convex curves, 7 degrees ATR was occasionally associated with scoliosis of 25 degrees or more. The correlation coefficient between the ATR and Cobb angle in right convex curves was 0.65 compared to 0.57 in left convex curves. We conclude that a criterion of > 7 degrees ATR for thoracic or right convex curves and one of > 6 degrees ATR for thoracolumbar and lumbar or left convex curves seem adequate for identification of patients with Cobb angles of 25 degrees or more, which reduces the need for spinal radiography and follow-up outside the school screening programs.

Radiation doses and image information in digital pelvimetry with a phosphorous screen

PURPOSE

The aim of the investigation was to determine the patient dose in digital pelvimetry by means of a phosphorous screen as compared to a screen-film combination of very high sensitivity.

MATERIAL AND METHODS

Entrance dose measurements and absorbed dose determinations in a series of patient exposures were made. In the first series the exposure reduction was achieved by reducing the mAs (tube current x exposure time) for the lateral and the a.p. views as compared with those used for the screen-film system. In the second series the tube potential, kV, was increased for both projections in order to increase the penetration capacity of the radiation.

RESULTS AND CONCLUSION

The imaging plate technique can be used in pelvimetry with a dose reduction (and a corresponding reduction of the radiation risk to the foetus) to less than 50% of that achieved with a screen-film system of the very highest sensitivity.

Evaluation of epidural sensory block by thermal stimulation, laser stimulation, and recording of somatosensory evoked potentials

BACKGROUND AND OBJECTIVES

The existence of differential sensory block during epidural analgesia has been confirmed by some authors and disputed by others. This study attempts to elucidate this issue by using quantitative methods for evaluation of sensory block.

METHODS

A single epidural injection of 20 mL 0.5% bupivacaine with epinephrine was administered at the L1-T12 level in 11 male volunteers. Sensory block was evaluated by two qualitative (pinprick and light touch) and two quantitative methods (thermal stimulation with Thermotest [Somedic, Stockholm, Sweden] and argon laser stimulation). For measurement of motor block in the lower extremities and in the rectus abdominis muscle, quantitative methods were used. Sensory block was also assessed by somatosensory evoked potentials recorded during electrical and laser stimulation at the most cranial analgesic dermatome (loss of sharpness in pinprick perception) and the anesthetic dermatome L2 (loss of light touch perception).

RESULTS

The zone of anesthesia was smaller than the zone of any other investigated variable. The cranial spread of analgesia and motor block was lower than that of laser-assessed block. Partial block of laser perception and thermal perception lasted longer than analgesia and motor block. No consistent segmental or temporal differences were found between the Thermotest and laser methods. During epidural block, prolongation of latencies and reduction in amplitudes of somatosensory evoked potentials produced at the most cranial analgesic dermatome did not differ significantly from those produced at the anesthetic dermatome.

CONCLUSIONS

No differential block of small nerve fibers was found during epidural analgesia by Thermotest and argon laser stimulation. Recording of somatosensory evoked potentials did not demonstrate significant difference between responses from the sites with most superficial and with most intense sensory block.

Differential activation of lung-specific genes by two forkhead proteins, FREAC-1 and FREAC-2

We describe the cDNA sequences for two human transcription factors, Forkhead RElated ACtivator (FREAC)-1 and -2, that belong to the forkhead family of eukaryotic DNA binding proteins. FREAC-1 and -2 are encoded by distinct genes, are almost identical within their DNA binding domains and in the COOH termini, but are otherwise divergent. Cotransfections with a reporter carrying FREAC binding sites showed that both proteins are transcriptional activators, and deletions located the activation domains to the COOH-terminal side of the forkhead domains. Expression of FREAC-1 and FREAC-2 is restricted to lung and placenta. We show that the promoters of genes for lung-specific proteins such as pulmonary surfactant proteins A, B, and C (SPA, SPB, and SPC) and the Clara cell 10-kDa protein (CC10) contain potential binding sites for FREAC-1 and FREAC-2. DNaseI footprinting verified that FREAC proteins bind to the predicted sites in the CC10 and SPB promoters. While an SPB promoter construct could be transactivated by both FREAC-1 and FREAC-2, CC10 was only activated by FREAC-1. Efficient activation of CC10 by FREAC-1 is shown to be specific for a lung cell line with Clara cell characteristics (H441) and to involve a region of the FREAC-1 protein unable to activate in other cell types.

The effect of continuous lumbar epidural infusion of ropivacaine (0.1%, 0.2%, and 0.3%) and 0.25% bupivacaine on sensory and motor block in volunteers: a double-blind study

BACKGROUND AND OBJECTIVES

In animal studies, ropivacaine has shown more pronounced sensory block than motor block, which makes it an interesting drug for postoperative pain relief. The aim of this study was to investigate the dose response of sensory and motor block during continuous epidural infusion of 0.1, 0.2, or 0.3% ropivacaine in volunteers in a double-blind manner. Bupivacaine 0.25% and isotonic saline were used as reference and control, respectively.

METHODS

Each treatment group consisted of eight healthy men. After a bolus dose of 10 mL at the L2-L3 interspace, the solution in question was infused at 10 mL/h for 21 hours. Sensory block was evaluated by the pinprick, light touch, and Thermotest methods. Motor block was measured by the Bromage scale, by average rectified electromyography in abdominal muscles, and by mechanical measurement of isometric muscle force in the lower extremities. Mobilization of the subjects was attempted throughout the investigation.

RESULTS

The number of blocked dermatomes (evaluated by pinprick) with 0.1% ropivacaine was significantly smaller than with the other test solutions (P = .002-.0008). Motor block was minimal with 0.1% ropivacaine, so that all subjects could be mobilized; it was moderate with 0.2 and 0.3% ropivacaine and most intense with 0.25% bupivacaine. The regression phase was significantly shorter with all three concentrations of ropivacaine than with bupivacaine (P < .01).

CONCLUSIONS

Ropivacaine 0.1% produced limited analgesia and minimal motor block, so that ambulation was possible throughout the investigation. With 0.2 and 0.3% ropivacaine, analgesia was more extensive, and motor block was considered moderate. Ropivacaine 0.2% should be evaluated for future postoperative pain treatment.

Scoliosis as the first sign of a cystic spinal cord lesion

We reviewed the cases of ten patients with scoliosis as the first sign of a cystic spinal cord lesion with the aim of identifying and studying early patient and curve characteristics. All patients were examined with magnetic resonance (MR) imaging of the brain and spinal cord and quantitative thermal testing (QTT). The mean Cobb angle was 22 degrees and the curves were right thoracic in seven patients, left thoracic in two, and left lumbar in one, when first seen for scoliosis. In six patients the cystic lesion was found in routine screening for syringomyelia, which is performed in all cases of congenital and juvenile scoliosis and in adolescent scoliosis before bracing. In four patients, it took up to 17 years following the initial diagnosis of scoliosis before neurologic deterioration warranted MR imaging, disclosing two Chiari I associated syrinxes and two cystic spinal cord tumors. QTT revealed a subclinically decreased sensation in two of the patients with no findings other than scoliosis. It also verified the decreased sensation in all patients in whom neurologic deterioration had complicated the clinical course of their scoliosis. More frequent spinal MR screening of patients with supposed juvenile or adolescent idiopathic scoliosis is indicated, regardless of curve type, to exclude a neurogenic cause. QTT documents subclinical as well as overt decreased sensation, and is valuable in the serial follow-up of these patients to monitor the progress or the response to treatment of the cystic lesion.

Sensory symptoms and signs and results of quantitative sensory thermal testing in patients with lacunar infarct syndromes

BACKGROUND AND PURPOSE

Quantitative data on sensory impairment in stroke patients are limited. We measured the perception thresholds for temperature and thermal pain in patients with different lacunar syndromes, correlated the results with clinical and magnetic resonance imaging (MRI) findings, and studied the long-term prognosis of sensory dysfunction.

METHODS

Quantitative thermal testing was performed by means of the Marstock method in 39 patients with lacunar syndromes (pure motor, sensorimotor, or pure sensory stroke) and MRI findings compatible with occlusion of a single perforating artery. Thresholds for cold, warmth, and heat pain were obtained bilaterally from the cheek, hand, and leg. The unaffected side was used as control. Follow-up included clinical assessments and repeated quantitative thermal testing (in 17 patients) up to 1 year after stroke onset.

RESULTS

Patients with pure sensory stroke and sensorimotor stroke (n = 22) had a significant thermal hypoesthesia on the affected side for all modalities and test locations. Patients with pure motor stroke (n = 17) exhibited thermal hypoesthesia for cold and heat pain in the hand and for cold perception in the leg. On MRI, infarcts causing pure motor and sensorimotor stroke were predominantly lenticulocapsular, while a thalamic site of infarction was found in pure sensory stroke. The prognosis of sensory impairment was favorable, except for poststroke pain syndromes in three patients.

CONCLUSIONS

Quantitative thermal testing confirmed an involvement of spinothalamic pathways in lacunar infarcts causing pure sensory and sensorimotor stroke and revealed a subclinical sensory impairment in patients with pure motor stroke. Infarction sites were similar in patients with pure motor and sensorimotor stroke.

Fish-induced variation in abdominal spine length of Leucorrhinia dubia (Odonata) larvae?

The lengths of dorsal and lateral spines on abdominal segments 4, 6 and 9 were measured on last-instar larvae of Leucorrhinia dubia (Odonata) from seven natural lentic systems containing fish and nine systems lacking fish. Larvae from systems with fish had significantly longer spines than larvae from systems without fish. In contrast, lake/pond area and pH had no effect on the length of spines. The length of the spines was not correlated with larval size, but there was a high correlation between the length of the three spines measured. Also, abundances of L. dubia larvae differed between systems, being significantly lower in systems with fish. Laboratory experiments showed that perch (Perca fluviatilis) handled long-spined larvae for significantly longer times than short-spined larvae. The results suggest that fish predators may induce morphological defences in insects.

Cloning and characterization of seven human forkhead proteins: binding site specificity and DNA bending

The forkhead domain is a monomeric DNA binding motif that defines a rapidly growing family of eukaryotic transcriptional regulators. Genetic and biochemical data suggest a central role in embryonic development for genes encoding forkhead proteins. We have used PCR and low stringency hybridization to isolate clones from human cDNA and genomic libraries that represent seven novel forkhead genes, freac-1 to freac-7. The spatial patterns of expression for the seven freac genes range from specific for a single tissue to nearly ubiquitous. The DNA binding specificities of four of the FREAC proteins were determined by selection of binding sites from random sequence oligonucleotides. The binding sites for all four FREAC proteins share a core sequence, RTAAAYA, but differ in the positions flanking the core. Domain swaps between two FREAC proteins identified two subregions within the forkhead domain as responsible for creating differences in DNA binding specificity. Applying a circular permutation assay, we show that binding of FREAC proteins to their cognate sites results in bending of the DNA at an angle of 80-90 degrees.

Polymerase chain reaction for monitoring human papillomavirus contamination of medical personnel during treatment of genital warts with CO2 laser and electrocoagulation

Genital warts and intraepithelial neoplasia caused by infection with human papillomavirus are usually treated with CO2 laser or electrocoagulation. In this study, contamination of personnel and operating theatres with human papillomavirus DNA during treatment sessions was investigated. Samples were taken from the nostrils, nasolabial folds and conjunctiva of the operating physician before and after operating sessions and from Petri dishes left open in the operating theatres. Human papillomavirus DNA was demonstrated by the polymerase chain reaction technique. The results show that there is a risk of contamination of the operator by human papillomavirus DNA, detectable with the polymerase chain reaction technique, during both CO2 laser and electrocoagulation treatment.