Micronutrient Status in Adult Crohn's Disease during Clinical Remission: A Systematic Review

Adults with Crohn's disease (CD) may be at risk of micronutrient insufficiency in clinical remission through restrictive eating, malabsorption, abnormal losses or inflammation. This systematic review synthesises the literature on micronutrient insufficiency in CD in clinical remission in terms of the prevalence of low circulating micronutrient concentrations and as a comparison against a healthy control (HC). Studies were included if the population was predominantly in remission. A total of 42 studies met the inclusion criteria; 12 were rated as low quality, leaving 30 studies covering 21 micronutrients of medium/high quality that were included in the synthesis. Vitamins D and B12 were the most frequently reported nutrients (8 and 11); there were few eligible studies for the remaining micronutrients. The prevalence studies were consistent in reporting individuals with low Vitamins A, B6, B12 and C, β-carotene, D, Magnesium, Selenium and Zinc. The comparator studies were inconsistent in finding differences with CD populations; Vitamin D, the most reported nutrient, was only lower than the HC in one-quarter of the studies. Adult CD populations are likely to contain individuals with low levels of one or more micronutrients, with the most substantial evidence for Vitamins D and B12. The studies on other micronutrients are of insufficient number, standardisation and quality to inform practice.

234 PATIENT COLLABORATION TO DRIVE REFORM: EMBEDDING BRIDGES SELF-MANAGEMENT APPROACH IN AN ACUTE STROKE SERVICE

Background

Bridges Self-Management approach is an evidence-based set of self-management skills, practices and interventions which when implemented can deliver more collaborative and patient-centred care to people suffering stroke [1]. Our acute stroke service underwent training in this approach in 2020. In order to further embed this approach and adapt it to our local setting, patient experiences were captured to help inform ongoing service delivery and quality improvements.

Methods

Ethical approval was granted for this project. Following consent, 20 acute stroke inpatients (length of stay >/=3 days) participated in the study. Patient experiences of their time on the Stroke Unit were sought using a 10-item open-ended questionnaire, which was developed based on the guiding principles of Bridges i.e. what matters most to the person, reflecting on what was/wasn’t going well, what they believe would help them and others.

Results

Thematic analysis was used to analyse the responses, and a number of themes emerged. These include: Loss of autonomy and freedom; Environmental challenges (including boredom, sleep poverty, loss of social interaction, loss of dignity and privacy); Shock, and difficulty adjusting to diagnosis (the importance of being informed and being heard); Loneliness and the role of family and visitors in their recovery journey (coupled with a consistent desire to be in their own home).

Conclusion

Rich data emerged, providing us with a unique insight into the experience of patients. This will compel us to review our service and environment, to tailor changes that matter to patients, and deliver on the Bridges self-management principles of patient inclusion and empowerment.

Reference

1. Jones et al. Building bridges between healthcare professionals, patients and families: A coproduced and integrated approach to self-management support in stroke. Neurorehabilitation. 2016. 39(4), pp. 471–480.

235 EYES WIDE SHUT: A CASE OF BILATERAL PTOSIS FOLLOWING STROKE

Background

Bilateral ptosis is a rare manifestation of midbrain stroke. It has been reported in case studies only, with no data on incidence rate, and no published case report in Ireland to date.

Methods

This is a retrospective case study of a man admitted to an acute stroke unit following collapse and unresponsiveness. A review of his medical records and radiological database was conducted. A PUBMED database search was conducted to search for similar cases.

Results

We present the case of a man who had a witnessed collapse whilst farming and was brought to hospital and presented with a Glasgow Coma Scale of 3. Imaging showed a normal CT Brain. MRI revealed 2cm acute bilateral thalamic and midbrain infarction. Following a brief period in ICU he was transferred to the acute stroke unit for multidisciplinary care. Despite improvements in his medical status and communication efforts, his inability to open his eyes contributed to a persistently low GCS. Neurological assessment revealed bilateral ptosis, fixed dilated pupils and oculomotor paralysis. These symptoms had a profound impact on his stroke recovery, impeding assessments and interventions and engagement in all realms (swallow and communication; mobility and function, cognitive-perceptual) whilst also limiting opportunities for social interaction. Once staff became aware of the ophthalmoplegia, strategies were implemented to optimise his participation and provide opportunities of recovery. Three months post stroke, he began to experience some return of unilateral eye-opening and bilateral horizontal movements (with diplopia) which greatly improved his overall performance. He was then transferred to the rehabilitation unit where he continues to progress.

Conclusion

Bilateral ptosis post stroke is rare and has a debilitating effect on participation in all aspects of living and interaction with the environment. This presentation has previously been described as “reverse locked-in-syndrome” which accurately represents its impact.

Impact of direct-access IBD physician delivered endoscopy on clinical outcomes: a pre-implementation and post-implementation study

INTRODUCTION

Patients with suspected inflammatory bowel disease (IBD) referred from primary care often face diagnostic and treatment delays. This study aimed to compare a novel direct-access IBD endoscopy pathway with the traditional care model.

METHOD

Single centre real-world study analysing primary care referrals with suspected IBD. Group A: patients triaged to direct-access IBD endoscopy. Group B: patients undergoing traditional outpatient appointments before the availability of direct-access IBD endoscopy. Demographics, fecal calprotectin (FCP), C-reactive protein (CRP), disease activity score, endoscopy findings, treatment and follow-up were collected and statistically analysed. Ranked semantic analysis of IBD symptoms contained within referral letters was performed.

RESULTS

Referral letters did not differ significantly in Groups A and B. Demographic data, FCP and CRP values were similar. Referral to treatment time (RTT) at the time of IBD endoscopy was reduced from 177 days (Group B) to 24 days (Group A) (p<0.0001). Diagnostic yield of IBD was 35.6% (Group B) versus 62.0% (Group A) (p=0.0003). 89.2% of patients underwent colonoscopy in Group B versus 46.4% in Group A. DNA rates were similar in both groups. The direct to IBD endoscopy pathway saved 100% of initial IBD consultant clinics with a 2.5-fold increase in IBD nurse-led follow-up.

CONCLUSION

Our novel pathway resulted in an 86% reduction in RTT with associated increased diagnostic yield while saving 100% of initial IBD consultant outpatient appointments. Replication in other trusts may improve patient experience and accelerate time to diagnosis/treatment while optimising the use of healthcare resources.

A massive rock and ice avalanche caused the 2021 disaster at Chamoli, Indian Himalaya

On 7 February 2021, a catastrophic mass flow descended the Ronti Gad, Rishiganga, and Dhauliganga valleys in Chamoli, Uttarakhand, India, causing widespread devastation and severely damaging two hydropower projects. More than 200 people were killed or are missing. Our analysis of satellite imagery, seismic records, numerical model results, and eyewitness videos reveals that ~27 × 10⁶ cubic meters of rock and glacier ice collapsed from the steep north face of Ronti Peak. The rock and ice avalanche rapidly transformed into an extraordinarily large and mobile debris flow that transported boulders greater than 20 meters in diameter and scoured the valley walls up to 220 meters above the valley floor. The intersection of the hazard cascade with downvalley infrastructure resulted in a disaster, which highlights key questions about adequate monitoring and sustainable development in the Himalaya as well as other remote, high-mountain environments.

High incidence of glucocorticoid-induced hyperglycaemia in inflammatory bowel disease: metabolic and clinical predictors identified by machine learning

BACKGROUND

Glucocorticosteroids (GC) are long-established, widely used agents for induction of remission in inflammatory bowel disease (IBD). Hyperglycaemia is a known complication of GC treatment with implications for morbidity and mortality. Published data on prevalence and risk factors for GC-induced hyperglycaemia in the IBD population are limited. We prospectively characterise this complication in our cohort, employing machine-learning methods to identify key predictors of risk.

METHODS

We conducted a prospective observational study of IBD patients receiving intravenous hydrocortisone (IVH). Electronically triggered three times daily capillary blood glucose (CBG) monitoring was recorded alongside diabetes mellitus (DM) history, IBD biomarkers, nutritional and IBD clinical activity scores. Hyperglycaemia was defined as CBG ≥11.1 mmol/L and undiagnosed DM as glycated haemoglobin ≥48 mmol/mol. Random forest (RF) regression models were used to extract predictor-patterns present within the dataset.

RESULTS

94 consecutive IBD patients treated with IVH were included. 60% (56/94) of the cohort recorded an episode of hyperglycaemia, including 57% (50/88) of those with no history of DM, of which 19% (17/88) and 5% (4/88) recorded a CBG ≥14 mmol/L and ≥20 mmol/L, respectively. The RF models identified increased C-reactive protein (CRP) followed by a longer IBD duration as leading risk predictors for significant hyperglycaemia.

CONCLUSION

Hyperglycaemia is common in IBD patients treated with intravenous GC. Therefore, CBG monitoring should be included in routine clinical practice. Machine learning methods can identify key risk factors for clinical complications. Steroid-sparing treatment strategies may be considered for those IBD patients with higher admission CRP and greater disease duration, who appear to be at the greatest risk of hyperglycaemia.

Early real-world effectiveness of ustekinumab for Crohn's disease

OBJECTIVE

To understand the effectiveness of ustekinumab in treating Crohn's disease (CD) in a UK real-world setting.

DESIGN

Retrospective cohort study using prospectively maintained clinical records.

SETTING

Single UK inflammatory bowel disease centre.

PATIENTS

Adult patients with an established diagnosis of CD prescribed ustekinumab outside of clinical trials at University Hospital Southampton (UHS).

INTERVENTIONS

Ustekinumab, a monoclonal antibody to the shared p40 subunit of interleukin (IL) 12 and IL-23 as part of routine clinical care.

MAIN OUTCOME MEASURES

Effectiveness as measured by an improvement in physician's global assessment, drug persistence and improvement in biomarkers (C-reactive protein (CRP), albumin and calprotectin).

RESULTS

84 patients were included, 72 had a postinduction review and 49 had 1-year data. At postinduction clinical review, clinical response occurred in 53% of patients and clinical remission occurred in 8%. For patients on ustekinumab at 1 year, clinical response occurred in 71% and remission in 14%. Adverse events included four patients with infections requiring admission, one drug-related rash, five CD surgeries and two CD exacerbations.

CONCLUSIONS

Ustekinumab was well tolerated in a complex UK CD population and demonstrated benefit to patients in terms of clinical response and improvement of biomarkers and with some patients attaining clinical remission. No unexpected safety signals were seen.

Exogenous T3 toxicosis following consumption of a contaminated weight loss supplement

A 42-year-old male presented with a one-week history of palpitations and sweating episodes. The only significant history was of longstanding idiopathic dilated cardiomyopathy. Initial ECG demonstrated a sinus tachycardia. Thyroid function testing, undertaken as part of the diagnostic workup, revealed an un-measureable thyroid-stimulating hormone (TSH) and free thyroxine (T₄). Upon questioning the patient reported classical thyrotoxic symptoms over the preceding weeks. Given the persistence of symptoms free tri-iodothyronine (T₃) was measured and found to be markedly elevated at 48.9 pmol/L (normal range: 3.1-6.8 pmol/L). No goitre or nodular disease was palpable in the neck. Historically there had never been any amiodarone usage. Radionucleotide thyroid uptake imaging (¹²³I) demonstrated significantly reduced tracer uptake in the thyroid. Upon further questioning the patient reported purchasing a weight loss product online from India which supposedly contained sibutramine. He provided one of the tablets and laboratory analysis confirmed the presence of T₃ in the tablet. Full symptomatic resolution and normalised thyroid function ensued upon discontinuation of the supplement.

LEARNING POINTS

Free tri-iodothyronine (T₃) measurement may be useful in the presence of symptoms suggestive of thyrotoxicosis with discordant thyroid function tests.Thyroid uptake scanning can be a useful aid to differentiating exogenous hormone exposure from endogenous hyperthyroidism.Ingestion of thyroid hormone may be inadvertent in cases of exogenous thyrotoxicosis.Medicines and supplements sourced online for weight loss may contain thyroxine (T₄) or T₃ and should be considered as a cause of unexplained exogenous hyperthyroidism.

Significant re-emergence and recirculation of Schmallenberg virus in previously exposed dairy herds in Ireland in 2016

Schmallenberg virus (SBV) circulation was investigated in 25 previously exposed dairy herds in Ireland in 2016. A population of 1,550 spring-2014-born animals, which had been monitored for SBV infection in 2014 and 2015 as part of a previous SBV surveillance study, were resampled for evidence of SBV infection during 2016. A total of 366 blood samples were collected in the 25 study herds (15 samples per herd) between 3 March 2017 and 10 March 2017 (before the 2017 vector-active season) and analysed for SBV antibodies using a competitive ELISA kit (IDVet). A total of 256 animals tested seropositive, an AP of 69.9% (95% CI: 65.1-74.4) and TP of 77.7% (95% CI: 72.3%-82.8%) when correcting for imperfect test characteristics. These results demonstrate that a new epidemic of SBV circulation occurred in these previously exposed herds in Ireland in 2016.

Abuse Potential and Pharmacodynamic Characteristics of Oral and Intranasal Eluxadoline, a Mixed μ- and κ-Opioid Receptor Agonist and δ-Opioid Receptor Antagonist

Drugs with μ-opioid receptor (OR) activity can be associated with abuse and misuse. The peripherally acting mixed μ-OR and κ-OR agonist and δ-OR antagonist eluxadoline is approved in the United States for the treatment of irritable bowel syndrome with diarrhea. In two separate crossover studies, we evaluated the oral and intranasal abuse potential of eluxadoline versus placebo and the active control oxycodone. Healthy recreational opioid users received eluxadoline 100, 300, and 1000 mg, oxycodone 30 and 60 mg, and placebo (oral study), or eluxadoline 100 and 200 mg, oxycodone 15 and 30 mg, and placebos matched to eluxadoline and oxycodone (intranasal study). In the oral study, Drug Liking Visual Analog Scale (VAS) peak (maximum) effect (E_max) score (primary endpoint) was significantly greater with eluxadoline 300 and 1000 mg versus placebo, but scores were significantly lower versus oxycodone. Following intranasal insufflation of eluxadoline, Drug Liking VAS E_max scores were not statistically different versus placebo, and were significantly lower versus oxycodone. Across other subjective measures, eluxadoline was generally similar to or disliked versus placebo. Pupillometry indicated no or minimal central effects with oral and intranasal eluxadoline, respectively. Adverse events of euphoric mood were reported with oral and intranasal eluxadoline but at a far lower frequency versus oxycodone. These data demonstrate that eluxadoline has less abuse potential than oxycodone in recreational opioid users.

A comparison of the use of urinary cortisol to creatinine ratios and nocturnal salivary cortisol in the evaluation of cyclicity in patients with Cushing's syndrome

CONTEXT

Cyclical Cushing's syndrome is detected in our center by collecting sequential early morning urine (EMU) samples for cortisol to creatinine ratio over 28 d. The Endocrine Society suggests that nocturnal salivary cortisol (NSC) may be used to assess patients for cyclical Cushing's. However, there is only very limited evidence that it correlates with EMU testing or that it demonstrates cycling over 28 d.

OBJECTIVE

We sought to correlate NSC with EMU results collected the following morning and to determine whether NSC could be used to detect cyclical Cushing's.

DESIGN AND SETTING

An observation study of 28-d collections for NSC and EMU was performed in a tertiary referral center over 1 yr.

PATIENTS

A 28-d collection of NSC and EMU was performed in 10 patients with confirmed or suspected Cushing's syndrome.

MAIN OUTCOME MEASURE

The main outcome of the study was the correlation of salivary and urinary cortisol with graphical assessment of results for cycling.

RESULTS

Eleven collections were performed. One patient with cyclical Cushing's completed the collection before and after cabergoline therapy. Two hundred seventy matched salivary and urinary results were correlated (r = 0.79; P < 0.001). In two patients with cyclical Cushing's, EMU and NSC followed a similar cyclical pattern. In one patient with recurrent cyclical Cushing's, cortisol was elevated in both saliva and urine but with more prominent cycles in saliva.

CONCLUSION

NSC correlated well with EMU. NSC detected all cases of cyclical Cushing's. Therefore, NSC may prove to be an additional option or replacement for EMU in detecting cyclical Cushing's syndrome.

Establishing a general practitioner led minor injury service: mixed methods evaluation at 10 months with an emphasis on use of radiology by GPs in the out-of-hours setting

AIMS AND METHODS

A mixed methods study was conducted to evaluate a recently established general practitioner (GP) led minor injury (MI) service; it included a patient feedback study, a qualitative enquiry into the experience of the MI GPs, and analysis of use of radiology.

RESULTS

Forty-nine (81.6 %) patients surveyed were seen in 30 min or less. Forty-five (75 %) felt that the quality of the service was excellent/very good. Twenty-seven (45 %) responders felt that the X-ray service was expensive; 49 (81.6 %) patients said that they would be happy to use the service again. 271 X-rays were taken (137, 50.55 % upper limb, 95, 35.06 % lower limb, 18, 6.64 % CXR). One hundred and ninety-four (73.48 %) patients were self-financing. There was an 86.72 % (235/271) concordance between GP/radiologist findings. Issues elaborated by MI GPs at the focus group included secondary care/hospital interaction, patients' experience, professional fulfilment, competence concerns, finances, and interest in educational resources; they were unanimous in maintaining the service at 10 months.

CONCLUSIONS

This study demonstrates a positive experience by patients, and conservative evaluation of X-rays by GPs.

Toll-like receptors regulate B cell cytokine production in patients with diabetes

AIMS/HYPOTHESIS

Understanding cellular and molecular events in diabetes mellitus will identify new approaches for therapy. Immune system cells are important modulators of chronic inflammation in diabetes mellitus, but the role of B cells is not adequately studied. The aim of this work was to define the function of B cells in diabetes mellitus patients through focus on B cell responses to pattern recognition receptors.

METHODS

We measured expression and function of Toll-like receptors (TLRs) on peripheral blood B cells from diabetes mellitus patients by flow cytometry and multiplexed cytokine analysis. We similarly analysed B cells from non-diabetic donors and periodontal disease patients as comparative cohorts.

RESULTS

B cells from diabetes mellitus patients secrete multiple pro-inflammatory cytokines, and IL-8 production is significantly elevated in B cells from diabetic patients compared with those from non-diabetic individuals. These data, plus modest elevation of TLR surface expression, suggest B cell IL-8 hyperproduction is a cytokine-specific outcome of altered TLR function in B cells from diabetes mellitus patients. Altered TLR function is further evidenced by demonstration of an unexpected, albeit modest 'anti-inflammatory' function for TLR4. Importantly, B cells from diabetes mellitus patients fail to secrete IL-10, an anti-inflammatory cytokine implicated in inflammatory disease resolution, under a variety of TLR-stimulating conditions. Comparative analyses of B cells from patients with a second chronic inflammatory disease, periodontal disease, indicated that some alterations in B cell TLR function associate specifically with diabetes mellitus.

CONCLUSIONS/INTERPRETATION

Altered TLR function in B cells from diabetes mellitus patients increases inflammation by two mechanisms: elevation of pro-inflammatory IL-8 and lack of anti-inflammatory/protective IL-10 production.

Alcohol levels in the emergency department: a worrying trend

BACKGROUND

Recent tabloid media articles have highlighted the trend of increasing alcohol intoxication among the young, particularly females. We compared all the alcohol levels sent from the emergency department of Belfast City Hospital over two 12-month periods, 4 years apart, to see if there were any changes in the pattern of levels or numbers of tests sent.

METHODS

Patient details and alcohol levels for the periods 1 September 1999 to 31 August 2000 and 1 September 2003 to 31 August 2004 were obtained from our laboratories and entered into a database.

RESULTS

The number of patients with blood alcohol levels > 80 mg/100 ml rose from 526 to 1124, a rise of 113%. The number of patients with levels > 480 mg/100 ml rose from five to 29, a rise of 480%. There were more intoxicated males in every age bracket in both study periods apart from under the age of 16, in which females were in the majority. The absolute number of intoxicated females almost doubled from 203 to 401. The proportion of females in both study periods, however, was similar--38.6% and 35.7%, respectively.

CONCLUSION

These results show a trend towards more intoxicated people presenting to the emergency department of Belfast City Hospital. Males continue to account for the majority of intoxicated patients.

An 8 year study of risk factors for SIDS: bed-sharing versus non-bed-sharing

BACKGROUND

It is unclear if it is safe for babies to bed share with adults. In Ireland 49% of sudden infant death syndrome (SIDS) cases occur when the infant is bed-sharing with an adult.

OBJECTIVE

To evaluate the effect of bed-sharing during the last sleep period on risk factors for SIDS in Irish infants.

DESIGN

An 8 year (1994-2001) population based case control study of 287 SIDS cases and 831 controls matched for date, place of birth, and sleep period. Odds ratios and 95% confidence intervals were calculated by conditional logistic regression.

RESULTS

The risk associated with bed-sharing was three times greater for infants with low birth weight for gestation (UOR 16.28 v 4.90) and increased fourfold if the combined tog value of clothing and bedding was > or =10 (UOR 9.68 v 2.34). The unadjusted odds ratio for bed-sharing was 13.87 (95% CI 9.58 to 20.09) for infants whose mothers smoked and 2.09 (95% CI 0.98 to 4.39) for non-smokers. Age of death for bed-sharing and sofa-sharing infants (12.8 and 8.3 weeks, respectively) was less than for infants not sharing a sleep surface (21.0 weeks, p<0.001) and fewer bed-sharing cases were found prone (5% v 32%; p = 0.001).

CONCLUSION

Risk factors for SIDS vary according to the infant's sleeping environment. The increased risk associated with maternal smoking, high tog value of clothing and bedding, and low z scores of weight for gestation at birth is augmented further by bed-sharing. These factors should be taken into account when considering sleeping arrangements for young infants.

A multivariate "time based" analysis of SIDS risk factors

AIMS

To investigate the influence of analytical design on the variability of published results in studies of sudden infant death syndrome (SIDS).

METHODS

The results of a prospective case-control study, of 203 cases of SIDS, and 622 control infants are presented. All variables significant on univariate analysis were included in a multivariate model analysed in nine stages, starting with sociodemographic variables, then sequentially and cumulatively adding variables relating to pregnancy history, current pregnancy, birth, the interval from birth to the week prior to death, the last week, the last 48 hours, and the last sleep period. A ninth stage was created by adding placed to sleep prone for the last sleep period.

RESULTS

As additional variables are added, previously published SIDS risk factors emerged such as social deprivation, young maternal age, > or =3 previous live births, maternal smoking and drinking, urinary tract infection in pregnancy, reduced birth weight, and the infant having an illness, regurgitation, being sweaty, or a history of crying/colic in the interval from birth to the week before death, with co-sleeping and the lack of regular soother use important in the last sleep period. As the model progressed through stages 1-9, many significant variables became non-significant (social deprivation, young maternal age, maternal smoking and drinking) and in stage 9 the addition of placed to sleep prone for the last sleep period caused > or =3 previous live births and a reduced birth weight to become significant.

CONCLUSION

The variables found to be significant in a case-control study, depend on what is included in a multivariate model.

Factors relating to the infant's last sleep environment in sudden infant death syndrome in the Republic of Ireland

AIM

To identify risk factors for sudden infant death syndrome (SIDS) in the sleeping environment of Irish infants.

METHODS

A five year population based case-control study with parental interviews conducted for each case and three controls matched for age, place of birth, and last sleep period. A total of 203 SIDS cases and 622 control infants born 1994-98 were studied.

RESULTS

In a multivariate analysis, co-sleeping significantly increased the risk of SIDS both as a usual practice (adjusted OR 4.31; 95% CI 1.07 to 17.37) and during the last sleep period (adjusted OR 16.47; 95% CI 3.73 to 72.75). The associated risk was dependent on maternal smoking (OR 21.84; 95% CI 2.27 to 209.89), and was not significant for infants who were > or =20 weeks of age (OR 2.63; 95% CI 0.49 to 70.10) or placed back in their own cot/bed to sleep (OR 1.07; 95% CI 0.21 to 5.41). The use of pillows, duvets, and bedding with tog value > or =10 were not significant risk factors when adjusted for the effects of confounding variables, including maternal smoking and social disadvantage. However, the prone sleeping position remains a significant SIDS risk factor, and among infants using soothers, the absence of soother use during the last sleep period also significantly increased the SIDS risk (OR 5.83; CI 2.37 to 14.36).

CONCLUSION

Co-sleeping should be avoided in infants who are <20 weeks of age, or whose mothers smoked during pregnancy. The prone position remains a factor in some SIDS deaths, and the relation between soother use and SIDS is a complex variable requiring further study.

The quality and value of sudden infant death necropsy reporting in Ireland

BACKGROUND

Infant necropsies are important for identifying cause of death. Recently issued guidelines have recommended investigations to be performed following sudden unexpected death in infants.

AIMS

To evaluate the quality and value of infant postmortem reporting.

METHODS

Postmortem reports from 1994-1996 and 1998-2000 in Ireland were evaluated using the National Sudden Infant Death Register. Scoring was by a modification of the Rushton system based on the extent of the postmortem data. The finding of additional pathological information was also assessed.

RESULTS

Of the 274 cases registered during the selection period, reports were available for 245. Overall quality of necropsy reporting was below the minimum accepted standard in 55.5%; 47% of the necropsies were performed in regional paediatric pathology centres. The quality of necropsies performed in regional centres was significantly higher than those performed elsewhere. Although 86% of the cases were defined as sudden infant death syndrome (SIDS; no cause of death found), the finding of additional pathological information was significantly related to the extent of the necropsy. There was a significant improvement in the quality of necropsies after the postmortem guidelines were issued.

CONCLUSIONS

The overall quality of sudden unexpected infant death necropsies in Ireland is less than adequate. A minimum accepted standard of necropsy is required before a diagnosis of SIDS can be made. Although standards have improved recently, this study highlights the need to adhere to published guidelines and the importance of auditing the effect of introducing practice guidelines on clinical practice to complete the audit loop.

Outcome at school age following antenatal detection of absent or reversed end diastolic flow velocity in the umbilical artery

AIM

To determine whether fetal compromise, manifested by abnormalities of Doppler recordings of umbilical artery velocity waveforms in utero, is associated with neurodevelopmental or educational abnormalities at school age.

METHODS

A cohort of neonates born following high risk pregnancies had been previously identified for a study of the perinatal sequelae of absent (AEDFV) and reversed (REDFV) end diastolic flow velocities. Seventy six children were assessed at 5-12 years of age by a developmental paediatrician who was blinded to perinatal course and Doppler assessments. Forty children born following pregnancies with forward end diastolic flow velocities (FEDFV), were compared with 27 with AEDFV and nine with REDFV. Tests of cognitive, neurological, and sensory function were performed, and reports of behavioural and educational progress were obtained from parents and teachers.

RESULTS

There were no significant differences between FEDFV and AEDFV groups, but on tests of mental ability and neuromotor function the REDFV group had worse scores than either FEDFV or AEDFV. Comparing REDFV and FEDFV groups, the British Ability Scales general conceptual ability mean scores were 87.7 versus 101, and the Quick Neurological Screening Test mean scores were 32.8 versus 21.5.

CONCLUSIONS

Absence of EDFV is well recognised as a marker of fetal compromise which is associated with acute perinatal sequelae. This study suggests it is not associated with adverse neurodevelopmental outcome. However, we found reversal of EDFV on antenatal assessment to be associated with a wide range of problems at school age, suggesting that REDFV represents intrauterine decompensation which may have adverse effects on the developing brain.

Integrin beta 1 signaling is necessary for transforming growth factor-beta activation of p38MAPK and epithelial plasticity

Transforming growth factor-beta (TGF-beta) can induce epithelial to mesenchymal transdifferentiation (EMT) in mammary epithelial cells. TGF-beta-mediated EMT involves the stimulation of a number of signaling pathways by the sequential binding of the type II and type I serine/threonine kinase receptors, respectively. Integrins comprise a family of heterodimeric extracellular matrix receptors that mediate cell adhesion and intracellular signaling, hence making them crucial for EMT progression. In light of substantial evidence indicating TGF-beta regulation of various beta(1) integrins and their extracellular matrix ligands, we examined the cross-talk between the TGF-beta and integrin signal transduction pathways. Using an inducible system for the expression of a cytoplasmically truncated dominant negative TGF-beta type II receptor, we blocked TGF-beta-mediated growth inhibition, transcriptional activation, and EMT progression. Dominant negative TGF-beta type II receptor expression inhibited TGF-beta signaling to the SMAD and AKT pathways, but did not block TGF-beta-mediated p38MAPK activation. Interestingly, blocking integrin beta(1) function inhibited TGF-beta-mediated p38MAPK activation and EMT progression. Limiting p38MAPK activity through the expression of a dominant negative-p38MAPK also blocked TGF-beta-mediated EMT. In summary, TGF-beta-mediated p38MAPK activation is dependent on functional integrin beta(1), and p38MAPK activity is required but is not sufficient to induce EMT.

Antecedents of adherence to antituberculosis therapy

This correlational study identified antecedents of adherence to antituberculosis (anti-TB) therapy in a convenience sample of 62 English-speaking adults. From a demographic perspective, the study sample was similar to the referent population of TB patients in Georgia. A variety of parametric analyses revealed the following: The mean self-reported adherence score was 92.6% (SD = 3.3). Higher levels of self-reported adherence were associated with an annual income of $11,000 or more, education beyond high school, no current alcohol use, perceived support and absence of barriers to medication taking, strong intentions to adhere, and a high capacity for self-care. Those six variables accounted for 28% of adherence variance, F(6, 44) of 4.3, p = 0.0017. Additionally, belief in the usefulness and benefit of the medications was strongly correlated with intentions to adhere (r = 0.83, p < 0.001), and interpersonal aspects of care was significantly correlated with perceptions of medication utility (r = 0.65, p < 0.001), supports/barriers (r = 0.44, p < 0.001), intentions (r = 0.69, p < 0.001), and self-care (r = -0.42, p < 0.01). Persons who were diagnosed with both TB and human immunodeficiency virus (HIV) reported significantly lower adherence.

International Child Care Practices Study: infant sleeping environment

BACKGROUND

The International Child Care Practices Study (ICCPS) has collected descriptive data from 21 centres in 17 countries. In this report, data are presented on the infant sleeping environment with the main focus being sudden infant death syndrome (SIDS) risk factors (bedsharing and infant using a pillow) and protective factors (infant sharing a room with adult) that are not yet well established in the literature.

METHODS

Using a standardised protocol, parents of infants were surveyed at birth by interview and at 3 months of age mainly by postal questionnaire. Centres were grouped according to geographic location. Also indicated was the level of SIDS awareness in the community, i.e. whether any campaigns or messages to "reduce the risks of SIDS" were available at the time of the survey.

RESULTS

Birth interview data were available for 5488 individual families and 4656 (85%) returned questionnaires at 3 months. Rates of bedsharing varied considerably (2-88%) and it appeared to be more common in the samples with a lower awareness of SIDS, but not necessarily a high SIDS rate. Countries with higher rates of bedsharing appeared to have a greater proportion of infants bedsharing for a longer duration (>5 h). Rates of room sharing varied (58-100%) with some of the lowest rates noted in centres with a higher awareness of SIDS. Rates of pillow use ranged from 4% to 95%.

CONCLUSIONS

It is likely that methods of bedsharing differ cross-culturally, and although further details were sought on different bedsharing practices, it was not possible to build up a composite picture of "typical" bedsharing practices in these different communities. These data highlight interesting patterns in child care in these diverse populations. Although these results should not be used to imply that any particular child care practice either increases or decreases the risk of SIDS, these findings should help to inject caution into the process of developing SIDS prevention campaigns for non-Western cultures.

Characterization of the murine epidermal 12/15-lipoxygenase

The murine lipoxygenase (LO) family consists of at least seven members classified according to the HETE (hydroxyeicosatetraenoic acid) metabolite generated during arachidonic acid metabolism and the site of tissue expression. At present there are four 12-lipoxygenases that are functionally distinct, vary in cell and tissue distribution, catalytic activity and each are products of separate, linked genes. They are "platelet-type" 12-LO (P-12LO), "leukocyte-type" 12-LO (L-12LO), "epidermal-type" 12-LO (e-12LO) and the most recently discovered 12(R)-LO. In this report we characterize e-12LO, which was overexpressed in the baculovirus/insect cell expression system. The enzyme functions as a dual specificity 12/15-lipoxygenase with a 12-HETE/15-HETE product ratio of approximately 6:1 with arachidonic acid as substrate. Several other polyunsaturated fatty acids served as substrates for e-12LO such as gamma-linolenic, dihomo-gamma-linolenic and eicosapentaenoic acids. A green fluorescent protein/e-12LO fusion protein was localized to the cytosol of transfected HEK 293 cells. The e-12LO gene was expressed in mouse oocytes and early embryos. Western blot analysis revealed high level expression in postnatal day 3 mouse epidermal lysates. Together these data suggest that e-12LO plays a role in normal epidermal function and as yet an undiscovered role in early development.

The current epidemiology of SIDS in Ireland

This paper examines some epidemiological factors associated with SIDS to give a general profile of SIDS cases occurring in Ireland between the years 1993 to 1997. There has been a dramatic decrease in the incidence of the Sudden Infant Death Syndrome (SIDS) in the Republic of Ireland in the last decade from an average rate of 2.2/1000 live-births in the 1980s to 0.8/1000 live-births in the years 1993-1997, a decrease of 100 deaths a year. The fall in the SIDS rate has been seen in many countries and is felt to be associated with Reduce The Risks (RTR) of SIDS campaigns and the avoidance of the prone sleeping position. The use of the prone sleep position averaged at 6% of children being put prone in the years 1993-1997 but the prone position has progressively decreased from 13% of children being put prone in 1994 to only 2% in 1997. The profile of the Irish SIDS cases is similar to that of SIDS cases in other countries following similar RTR campaigns with a male predominance, the characteristic clustering of deaths in the first six months of life and the majority of cases (75%) occuring in the night sleep period. The loss of the seasonal variation of the time of death is also shown and factors such as lower socio-economic status, unemployment and medical card eligibility were seen in higher proportions in SIDS families than in the general population. A high percentage of SIDS mothers smoked (73%). Higher smoking rates were seen among younger and single mothers and smoking rates were inversely related to educational level and socioeconomic grouping. An urgent question that needs to be addressed is how socioeconomic disadvantage increases the SIDS risk and what factors influence socioeconomically disadvantaged families to adopt life style and parenting practices such as smoking that influence their children's health.

Investigation of prolonged neonatal jaundice

Jaundice persisting beyond 14 d of age (prolonged jaundice) can be a sign of serious underlying liver disease. Protocols for investigating prolonged jaundice vary in complexity and the yield from screening has not been assessed. In order to address these issues, we carried out a prospective study of term infants referred to our neonatal unit with prolonged jaundice over an 18 mo period. Infants were examined by a paediatrician and had the following investigations: a total and conjugated serum bilirubin, liver function tests, full blood count, packed cell volume, group and Coombs' test, thyroid function tests, glucose-6-phosphate dehydrogenase levels and urine for culture. One-hundred-and-fifty-four infants were referred with prolonged jaundice out of 7,139 live births during the study period. Nine infants were referred to other paediatric specialties. One infant had a conjugated hyperbilirubinaemia, giving an incidence of conjugated hyperbilirubinaemia of 0.14 per 1,000 live births. Diagnoses included: giant cell hepatitis (n = 1), hepatoblastoma (n = 1), trisomy 9p (n = 1), urinary tract infections (n = 2), glucose-6-phosphate dehydrogenase deficiency (n = 3) and failure to regain birthweight (n = 1).

CONCLUSIONS

In conclusion, a large number of infants referred to hospital for prolonged jaundice screening had detectable problems. The number of investigations may safely be reduced to: a total and conjugated bilirubin, packed cell volume, glucose-6-phosphate dehydrogenase level (where appropriate), a urine for culture and inspection of a recent stool sample for bile pigmentation. Clinical examination by a paediatrician has a vital role in the screening process.

Case management for dually diagnosed individuals involved in the criminal justice system

A case-management model for individuals with substance abuse and mental health disorders who are involved in the criminal justice system is described, based on the experience of a rural demonstration project. Detailed descriptions of case-management activities and the philosophy underlying this model of case management are provided. A major goal of these case-management services was to improve access to appropriate treatment for the target population. Evaluation data describing the population served, case-management implementation, and outcomes are presented along with a case vignette. Six-month follow-up data revealed significantly fewer legal problems and apparent symptom relief for participants in the project. Participants reported improvement in most life areas measured compared to the year before, and were generally satisfied with the case-management services. Barriers observed in implementing these types of services and issues for replication are outlined and discussed.

Characterization of ricin heterogeneity by electrospray mass spectrometry, capillary electrophoresis, and resonant mirror

Electrospray mass spectrometry (ES/MS), capillary-zone electrophoresis (CZE), capillary isoelectric focusing (CIEF), and multianalyte resonant mirror are used to evaluate the heterogeneity of samples of ricin toxins extracted from five horticultural varieties of Ricinus communis seeds: R. communis zanzibariensis, carmencita, impala, sanguineus, and gibsonii. The investigation is also extended to the geographical provenance of the beans. Combining mass spectrometry, CE techniques, and resonant mirror results in a powerful analytical tool capable to characterize and differentiate between different varieties of ricin toxins. Each technique complements the others, adding another level of information. This study reveals a large extent of heterogeneity for each cultivar, demonstrating that ricin toxins consist of a series of glycosylated proteins most likely originating from a multigene family. By combining these techniques, it is possible to differentiate between zanzibariensis and the other four varieties, and that variations in the functional characteristics may be observed between the different cultivars. This study demonstrates that knowledge of the variety of R. communis beans used and their geographical provenance is essential before any type of investigation of ricin toxins is carried out. Consequently, any unusual behavior observed can only be attributed to that particular cultivar studied and not automatically extended to include all R. communis varieties.

Sudden infant death syndrome--are parents getting the message?

BACKGROUND

Factors that place an infant at increased risk of sudden infant death include the prone sleep position, overheating and parental smoking, while practices such as bottle-feeding, co-sleeping and the use of pacifiers remain controversial. Major publicity campaigns have been undertaken, which have included the distribution of printed material and extensive media coverage.

AIMS

To examine if Irish parents follow the currently recommended childcare guidelines to reduce the risk of sudden infant death and to examine factors that may have impact on their acceptance.

METHODS

A random selection of 197 infants from the Birth Register of the Eastern Health Board. Parents were interviewed and a semi-structured survey questionnaire was completed.

RESULTS

Forty one per cent of infants are still placed on their side to sleep, an inherently unstable position. First time parents are more likely to place their infants on their backs. Over 60% of infants are exposed to one or more adults smoking in the home despite parental knowledge of its association with sudden infant death syndrome (SIDS). Sixty eight per cent of infants are overwrapped at night and parental understanding of what constitutes overwrapping is poor. Thirteen per cent of infants regularly co-sleep with their parents and 20% of these parents smoke. Pacifier use is common.

CONCLUSION

Future programmes should target first time parents, should provide clear information regarding appropriate infant thermal environment, and should ensure regular updating of medical personnel so that they can instruct families on best current practice. Smoking remains a significant health issue with an impact on sudden infant death.

HIV/AIDS and women

Women are the fastest growing segment of people with acquired immunodeficiency syndrome (AIDS), yet they often receive this diagnosis when the disease is in its advanced stages. New therapies have caused human immunodeficiency virus (HIV) to become a chronic and treatable disease for many of those afflicted. Primary care providers must be cognizant of the initial symptoms to facilitate early diagnosis and prompt treatment for women with HIV. Early signs of HIV in women are subtle. Providers must consider a diagnosis of HIV in women who present with vaginal infections, abnormal pap smears, or sexually transmitted diseases that are unusually severe, recurrent, and resistant to treatment efforts. These signs and symptoms, along with a corroborating history, may be early clues to HIV. Primary care providers, in conjunction with HIV specialists, must strive to decrease the incidence, morbidity, and mortality of the disease in women.

Is the presence of dyspnea a risk factor for morbidity in cancer patients?

Data collected from six home palliative care teams in Ireland were analyzed to determine the prevalence of dyspnea in the population studied and to identify factors associated with the presence of dyspnea that might impact on future care. The prevalence of mild, moderate, or severe dyspnea, as measured by the Support Team Assessment Schedule (STAS), fell from 39% at referral in 327 evaluable patients to 23%. The presence of dyspnea at referral was positively correlated with severity of patient spiritual distress (Spearman rho = 0.110, P = 0.042) and weakness (Spearman rho = 0.105, P = 0.008) at referral. In analysis of contingency tables, dyspnea was also significantly associated with low patient (chi 2 9.5, P = 0.002) and family (chi 2 50.78, P < 0.001) well-being, high staff anxiety (chi 2 4.14, P = 0.04), male sex (chi 2 8.9, P = 0.003), a diagnosis of lung cancer (chi 2 59.88, P < 0.001), and dying in hospital rather than hospice or nursing home (chi 2 18.03, P = 0.001). In adjusting for covariates using a logistic regression analysis, however, only the presence of low family well-being, a diagnosis of lung cancer, and increased likelihood of a hospital death remained significantly associated with the presence of dyspnea at referral. These data suggest that the presence of dyspnea may be associated with increased family distress, which may influence place of death.

Design and synthesis of thrombin inhibitors: analogues of MD-805 with reduced stereogenicity and improved potency

Mitsubishi's MD-805, a potent and selective inhibitor of thrombin which contains four stereogenic centers, has been the starting point for an optimization program. A systematic synthetic study resulted in thrombin inhibitors achiral at P2 and P3 but with a 10-fold increase in potency over the original lead. A number of 4-substituted piperidines were synthesized and examined as replacements for 2-carboxy-4-methylpiperidine at P2; 4-fluoroethylpiperidine (FEP) among others provided inhibitors (e.g. 45g) of increased potency. An enantioselective route was developed to 3(R)-methyl-1,2,3,4-tetrahydroquinolinesulfonyl chloride. Inhibitors containing this enantiomerically pure P3 (42d) had similar potency to the racemic material and provided support, with modeling studies, for the preparation of the gem 3,3-disubstituted compounds. A series of inhibitors containing the novel 3, 3-dimethyl-1,2,3,4-tetrahydroquinolinesulfonyl (DMTHQS) P3 (Table 5) were synthesized and showed a similar activity profile as the monomethyl series. The combination of P3-DMTHQS, P2-FEP, and P1-arginine (45g) had a K(i) of 6 nM (MD-805 K(i) = 85 nM). In animal models of both venous and arterial thrombosis, one inhibitor (42e) was shown to produce a dose-dependent inhibition of thrombus formation that in some situations was superior to that of MD-805.

A national model of care service for professionals dealing with sudden infant death

Sudden Infant Death Syndrome (SIDS) is any death occurring in an infant or young child which is unexpected by history and in which a thorough post mortem examination fails to demonstrate an adequate cause of death. The National Sudden Infant Death Register collects information on all sudden unexpected deaths in infants and young children occurring in Ireland. In this study, a comparison was made between parent's experience of professional services in the aftermath of their child's death both before and after the implementation of a National Model of Care for professionals in 1995. In addition, a random sample of 105 professionals were surveyed about their knowledge of the Model of Care services. Results were grouped according to the parental experience of the emergency services, the hospital services, the community services and the bereavement support services offered to parents. Prior to the implementation of the Model of Care Service (MOC) (1992-1994), 14 per cent of families stated that they did not find the Gardai helpful. After the Model of Care, only 7 per cent of parents expressed such dissatisfaction. Prior to the MOC, only 3 per cent of Gardai provided families with an information booklet on sudden infant death but afterwards, 23 per cent of Gardai did so. After the MOC families were more likely to have been given the opportunity to hold their infant, were given more privacy and were offered more keepsakes of their infant. Only 46 per cent of families were offered momentos of their baby prior to the MOC as compared to 84 per cent after the implementation of the MOC. They were also more likely to perceive the ancillary services such as the Gardai in a more positive light, where 22 per cent of Gardai offered the family the ISIDA support booklet compared to a previous 3 per cent. Over 50 per cent of parents were provided with a special room in the hospital following the MOC as opposed to a previous 48 per cent. Twenty-one per cent of parents prior to the MOC described the conditions in the hospital as awful, poor or fair, however 31 per cent of parents stated this after the MOC. While there have been improvements in certain areas, there still remains considerable variation in the quality of service provided to all parents. Specifically, we need to address the fact that 16 per cent of parents still report a difficulty in obtaining post-mortem information. Almost 40 per cent said they had little input into how their child was dressed or laid out at this highly emotive time. Over one-third of parents stated they were concerned about how few of their primary health providers, namely general practitioners and public health nurses called to visit them in the aftermath of this tragic event.

Oxidative stress during acute respiratory exacerbations in cystic fibrosis

BACKGROUND

Patients with cystic fibrosis experience chronic systemic oxidative stress. This is coupled with chronic inflammation of the lung involving bronchial polymorphonuclear neutrophil accumulation and activation. We hypothesised that, during periods of acute respiratory exacerbation, free radical activity and consequent damage would be most marked and that intensive treatment of the infection would result in improvement towards values found during stable periods.

METHODS

Plasma and red blood cells were collected from 12 healthy normal volunteers and from 12 patients with cystic fibrosis with an acute respiratory exacerbation (increased respiratory symptoms, reduction in forced expiratory volume in one second (FEV1) of more than 10%, and a decision to treat with intravenous antibiotics). Further samples were collected from patients following two weeks of treatment. Samples were analysed for inflammatory markers, markers of free radical damage, and aqueous and lipid phase scavengers.

RESULTS

During respiratory exacerbations FEV1 and forced vital capacity (FVC) were lower than in controls (mean differences -2.82 (95% CI -2.12 to -3.52) and -3. 79 (-3.03 to -4.55) l, respectively) but improved following treatment (mean change 0.29 (95% CI 0.18 to 0.40) and 0.33 (0.23 to 0.43) l, respectively). Inflammatory markers during exacerbations were significantly higher in patients than in controls with the following mean (95% CI) differences: C reactive protein (CRP), 46 (17 to 75) g/l; neutrophil elastase alpha1-antiprotease complexes (NEAPC), 4.4 (1.77 to 7.07) mg/l; white cell count (WCC), 5.3 (4.7 to 5.9) x 10(9)/l. These markers decreased significantly following treatment with the following mean (95% CI) changes: CRP -26 (-10 to -42) g/l; NEAPC -3.1 (-1.3 to -4.9) mg/l; WCC -1.5 (-1.3 to -1.7) x 10(9)/l. Malondialdehyde (MDA) as a marker of free radical activity was significantly higher in patients during exacerbations than in controls with a mean (95% CI) difference of 193 (107 to 279) which improved with treatment (mean change -56 (95% CI -28 to -84) nmol/mmol cholesterol). Red blood cell polyunsaturated fatty acids were significantly lower in patients than in controls with a mean difference of -4.4(95% CI -2.6 to -6.2) moles percent, but did not improve significantly after treatment. Protein carbonyls during exacerbations were not different from controls but did increase with treatment compared with levels during the exacerbation (mean change 0.39 (95% CI 0.11 to 0.67) micromol/g protein). Aqueous and lipid phase scavengers in patients during exacerbations were significantly lower than in controls with the following mean (95% CI) differences: ascorbate, -19.0 (-2.7 to -35.3) micromol/l; sulphydryls, -122 (-77 to -167) micromol/l; retinol, -237 (-47 to -427) nmol/mmol cholesterol; beta-carotene, -52.8 (-11.8 to -93.8) nmol/mmol cholesterol; luteine, -50.4 (-10.4 to -90.4) nmol/mmol cholesterol; lycopene, -90.1 (-30.1 to -150.1) nmol/mmol cholesterol. Treatment resulted in improvement with the following mean (95% CI) changes: sulphydryls, 50 (32 to 68) micromol/l; retinol, 152 (47 to 257) nmol/mmol cholesterol; alpha- and beta-carotene, 0.6 (0.0 to 1.2) and 7.6 (0.0 to 15.2) nmol/mmol cholesterol, respectively; alpha-tocopherol, 839 (283 to 1405) nmol/mmol cholesterol; and lycopene, 8.2 (0.0 to 16.2) nmol/mmol cholesterol.

CONCLUSIONS

Abnormalities of markers of inflammation, free radical activity, and radical scavengers were significantly more extreme during acute respiratory exacerbations and showed improvement with treatment. The need to provide protection from inflammation and free radical damage should therefore be dynamic and related to the inflammatory and oxidative processes.

Purification and characterization of a lysine-p-nitroanilide hydrolase, a broad specificity aminopeptidase, from the cytoplasm of Lactococcus lactis subsp. cremoris AM2

A hydrolase activity that cleaves lysyl-p-nitroanilide (Lys-pNA) has been purified from the cytoplasm of Lactococcus lactis subsp. cremoris AM2 by chromatography on DE52, DEAE Affi-Gel Blue Gel, Hydroxyapatite Bio-Gel HTP and Phenyl Sepharose. The purified aminopeptidase was found to have a native M(r) of 50,000-55,000 by gel filtration chromatography and by FPLC gel filtration on Superose 12 and to be composed of a single polypeptide chain following SDS-PAGE. Enzyme activity was almost completely inhibited by EDTA, amastatin, puromycin and bestatin, while the sulphydryl-reactive agents p-chloromercuribenzoate and iodoacetamide were inhibitory. The enzyme was found to be very unstable during the purification procedures at 4 degrees C and its stability was greatly improved when 10 ml glycerol/l and 2 mM-dithiothreitol were included in the purification buffers. The purified enzyme was found to hydrolyse a wide range of dipeptides, tripeptides and longer peptides provided that proline was not present in the penultimate position from the N-terminus or that a pyroglutamyl residue was not present at the N-terminus. While neither Asp-pNA nor Pro-pNA was hydrolysed by the purified enzyme, the release of N-terminal acidic residues from peptides was observed in addition to the release of N-terminal proline from Pro-Leu-Gly-NH2, Pro-Leu-Gly-Gly and Pro-His-Pro-Phe-His-Leu-Phe-Val-Tyr. This ability of Lys-pNA hydrolase to release N-terminal proline residues was employed in concert with a purified aminopeptidase P preparation to release alternate N-terminal amino acids from Tyr-Pro-Phe-Pro-Gly. The complementary action of these enzymes represents an alternative mechanism to that of post-proline dipeptidyl aminopeptidase for metabolism of proline-containing peptides.

Reduce the risk of cot death guidelines. The effect of a revised intervention programme. National Sudden Infant Death Register, Dublin

In March 1992 the 'Reduce the Risk of Cot Death' guidelines were launched in the Republic of Ireland. In response to epidemiological surveys conducted in 1993 and 1994 these guidelines were revised in November 1995 and a new leaflet was distributed. The study set out to compare parents interviewed in 1994 (n = 153) and 1996 (n = 132) to determine their source of information on the guidelines and the extent of parental change in infant care practice as recommended in these guidelines. In both time periods the media was the most frequent source of information with 63% (n = 97) of respondents having received advice from the media in 1994 compared to 55% (n = 72) in 1996. However a significant number of parents especially young (64%) and new (58%) mothers were uninterested or unable to access the relevant health care literature indicating a group needing a tailored educational package in the future. Medical sources especially Public Health Nurses ranked second in delivering information at 47% (n = 72) in 1994 vs 46% (n = 60) in 1996 while other sources such as family and friends were the least frequent sources of information. In 1996 more respondents (59%; n = 78) put their children to sleep on their back than in 1994 (35%; n = 54) but they used heat more frequently at night [73% (n = 96) in 1996 vs 57% (n = 87) in 1994]. There was no significant difference in the percentage of parents smoking [29% (n = 45) vs 33% (n = 43)], the uptake of breast feeding [40% (n = 61) vs 49% (n = 64)] and the way parents clothed their children [60% (n = 92) vs 58% (n = 77) used more than ten tog] between 1994 and 1996. Although in 1996 the message to reduce the risks of cot death was more specific and direct, it seems to have had less effect on further changing parents' practices. However, the overall effect of the two education programmes has been successful in yielding a low percentage (2%; n = 2) of babies sleeping prone in 1996). Smoking remains the major modifiable risk factor for SIDS in Ireland.

Human 12(R)-lipoxygenase and the mouse ortholog. Molecular cloning, expression, and gene chromosomal assignment

Expressed sequence tag information was used to clone the full-length sequence for a new human lipoxygenase from the B cell line CCL-156. A related mouse sequence with 83% nucleotide identity to the human sequence was also cloned. The human lipoxygenase, when expressed via the baculovirus/insect cell system produced an approximately 80-kDa protein capable of metabolizing arachidonic acid to a product identified as 12-hydroxyeicosatetraenoic acid by mass spectrometry. Using chiral phase-high performance liquid chromatography, the product was identified as >98% 12(R)-hydroxyeicosatetraenoic acid as opposed to the S-stereoisomer formed by all other known mammalian lipoxygenases. The single copy human 12(R)-lipoxygenase gene was localized to the chromosome 17p13 region, the locus where most other lipoxygenase genes are known to reside. By reverse transcription-polymerase chain reaction, but not by Northern blot, analysis the 12(R)-lipoxygenase mRNA was detected in B cells and adult skin. However, the related mouse lipoxygenase mRNA was highly expressed in epidermis of newborn mice and to a lesser extent in adult brain cortex. By in situ hybridization the mouse lipoxygenase gene was demonstrated to be temporally and spatially regulated during embryogenesis. Expression was induced at embryonic day 15.5 in epidermis, nasal epithelium, and surface of the tongue. These results broaden the mammalian lipoxygenase family to include a 12(R)-lipoxygenase whose biological function remains to be determined.

Preferential expression of cholesteryl ester transfer protein mRNA by stromal-vascular cells of human adipose tissue

Cholesteryl ester transfer protein (CETP) mRNA is more abundantly expressed in small mature adipocytes as compared to large, lipid-rich adipocytes [Radeau et al., J. Lipid Res. 36 (1995) 2552-2561]. In the present study, the stromal vascular fraction (SVF) of human adipose tissue was isolated and the presence of very small fat cells in this fraction confirmed by electron microscopy and by demonstrating the presence of mRNA for adipsin and for CCAAT enhancer binding protein alpha (C/EBPalpha), a marker of adipocyte differentiation. sn-Glycerol 3-phosphate dehydrogenase (GPDH) activity was present in the SVF but not in the preadipocyte fraction. Northern blot analysis of human adipose tissue demonstrated that CETP mRNA expression was significantly greater (+96%, P<0.03) in stromal-vascular cells (SVC) as compared to mature fat cells. By comparison, lipoprotein lipase mRNA expression was lower (-75%, P<0.03) in SVC while apolipoprotein E mRNA expression was not significantly different in SVC as compared to isolated adipocytes. By RT-PCR analysis, we demonstrated that CETP mRNA was expressed by human pre-adipocytes at levels less than those of SVC and adipocytes. The absence of monocytes/macrophages in SVC was confirmed by the absence of FcgammaRIII (CD16) mRNA in these fractions. These data demonstrate that CETP mRNA is most highly expressed in the immature fat cells of human adipose tissue, consistent with other experiments from this laboratory demonstrating that CETP plays an important local role in adipocyte cholesterol accumulation.

Hydrops fetalis due to ABO incompatibility

Antenatal haemolysis in association with ABO incompatibility occurs very rarely. Two cases of hydrops fetalis in black infants caused by anti-B haemolysins are reported. The greater severity of ABO incompatibility in black African peoples may have important implications for antibody screening in this ethnic group.

Cholesteryl ester transfer protein mediates selective uptake of high density lipoprotein cholesteryl esters by human adipose tissue

We have determined the role of cholesteryl ester transfer protein (CETP) in selective uptake of high density lipoprotein (HDL)-derived cholesteryl esters (CE) by human adipose tissue, using organ culture or collagenase-digested adipocytes. Incubation of the fresh tissue fragments with HDL containing [3H]CE or 125I-apoprotein (apo) A-I resulted in significant uptake of HDL-CE-derived label. Addition of recombinant CETP (rCETP) increased CE uptake in a dose-response fashion. In contrast, little association of 125I-apoA-I with adipose tissue was noted, and addition of rCETP did not alter apoA-I uptake or degradation. Incubation of adipose tissue with TP2, an anti-CETP monoclonal antibody, which inhibits neutral lipid transfer, markedly reduced selective uptake of HDL-CE. Studies using human adipocytes isolated by collagenase digestion also demonstrated selective uptake of HDL-CE and enhancement of this process by rCETP. To confirm that the association of HDL-CE-derived radioactivity with adipose tissue was not due to neutral lipid exchange between adipocytes and HDL, we measured changes in HDL composition following incubation of HDL and rCETP with isolated adipocytes. A decrease in HDL-CE concentration in the medium was observed, an effect which was markedly attenuated when incubations were carried out in the presence of monoclonal antibody TP2. Furthermore, the decrease in HDL-CE was accompanied by an increase in HDL free cholesterol, likely representing efflux of adipocyte cholesterol to HDL. There were no significant changes in phospholipid, apoA-I, or apoA-II in the medium following incubation with adipocytes. These data demonstrate a novel and important role for CETP in selective uptake of HDL-cholesteryl esters by human adipocytes and suggest that this pathway may be of quantitative physiological significance in HDL remodeling and adipocyte cholesterol accumulation.