Abundant pleiotropy across neuroimaging modalities identified through a multivariate genome-wide association study

Genetic pleiotropy is abundant across spatially distributed brain characteristics derived from one neuroimaging modality (e.g. structural, functional or diffusion magnetic resonance imaging [MRI]). A better understanding of pleiotropy across modalities could inform us on the integration of brain function, micro- and macrostructure. Here we show extensive genetic overlap across neuroimaging modalities at a locus and gene level in the UK Biobank (N = 34,029) and ABCD Study (N = 8607). When jointly analysing phenotypes derived from structural, functional and diffusion MRI in a genome-wide association study (GWAS) with the Multivariate Omnibus Statistical Test (MOSTest), we boost the discovery of loci and genes beyond previously identified effects for each modality individually. Cross-modality genes are involved in fundamental biological processes and predominantly expressed during prenatal brain development. We additionally boost prediction of psychiatric disorders by conditioning independent GWAS on our multimodal multivariate GWAS. These findings shed light on the shared genetic mechanisms underlying variation in brain morphology, functional connectivity, and tissue composition.

Ambulatory human chorionic gonadotrophin (hCG) testing: a verification of two hCG point of care devices

OBJECTIVES

Quantitative human chorionic gonadotropin (hCG) measurements are used to manage women classified with a pregnancy of unknown location (PUL). Two point of care testing (POCT) devices that quantify hCG are commercially available. We verified the i-STAT 1 (Abbott) and the AQT 90 FLEX (Radiometer) prior to use in PUL triage.

METHODS

Tests for precision, external quality assurance (EQA), correlation, hook effect and recovery were undertaken alongside a POCT usability assessment during this prospective multi-center verification.

RESULTS

Coefficients of variation ranged between 4.0 and 5.1 % for the three i-STAT 1 internal quality control (IQC) solutions and between 6.8 and 7.3 % for the two AQT IQC solutions. Symmetric differences in POCT EQA results when compared with laboratory and EQA stock values ranged between 3.2 and 24.5 % for the i-STAT 1 and between 3.3 and 36.9 % for the AQT. Correlation coefficients (i-STAT 1: 0.96, AQT: 0.99) and goodness of fit curves (i-STAT 1: 0.92, AQT: 0.99) were excellent when using suitable whole blood samples. An hCG hook effect was noted with the i-STAT 1 between 572,194 and 799,089 IU/L, lower than the hook effect noted with the AQT, which was between 799,089 and 1,619,309 IU/L. When hematocrit concentration was considered in sample types validated for use with each device, hCG recovery was 108 % with the i-STAT 1 and 98 % with the AQT. The i-STAT 1 scored lower on usability overall (90/130) than the AQT (121/130, p<0.001, Mann-Whitney).

CONCLUSIONS

Both hCG POCT devices were verified for use in clinical practice. Practical factors must also be considered when choosing which device to use in each unit.

Beta-human chorionic gonadotrophin point of care testing for the management of pregnancy of unknown location

RESEARCH QUESTION

Does a commercially available quantitative beta-human chorionic gonadotrophin (BHCG) point of care testing (POCT) device improve workflow management in early pregnancy by performing comparably to gold standard laboratory methods, and is the performance of a validated pregnancy of unknown location (PUL) triage strategy maintained using POCT BHCG results?

DESIGN

Women classified with a PUL between 2018 and 2021 at three early pregnancy units were included. The linear relationship of untreated whole-blood POCT and serum laboratory BHCG values was defined using coefficients and regression. Paired serial BHCG values were then incorporated into the validated M6 multinomial logistic regression model to stratify the PUL as at high risk or at low risk of clinical complications. The sensitivity and negative predictive value were assessed. The timings required for equivocal POCT and laboratory care pathways were compared.

RESULTS

A total of 462 PUL were included. The discrepancy between 571 laboratory and POCT BHCG values was -5.2% (-6.2 IU/l), with a correlation coefficient of 0.96. The 133 PUL with paired 0 and 48 h BHCG values were compared using the M6 model. The sensitivity for high-risk outcomes (96.2%) and negative predictive values (98.5%) was excellent for both. Sample receipt and laboratory processing took 135 min (421 timings), compared with 12 min (91 timings) when using POCT (P < 0.0001).

CONCLUSIONS

POCT BHCG values correlated well with laboratory testing measurements. The M6 model retained its performance when using POCT BHCG values. Using the model with POCT may improve workflow and patient care without compromising on effective PUL triage.

Machine learning and radiomics for segmentation and classification of adnexal masses on ultrasound

Ultrasound-based models exist to support the classification of adnexal masses but are subjective and rely upon ultrasound expertise. We aimed to develop an end-to-end machine learning (ML) model capable of automating the classification of adnexal masses. In this retrospective study, transvaginal ultrasound scan images with linked diagnoses (ultrasound subjective assessment or histology) were extracted and segmented from Imperial College Healthcare, UK (ICH development dataset; n = 577 masses; 1444 images) and Morgagni-Pierantoni Hospital, Italy (MPH external dataset; n = 184 masses; 476 images). A segmentation and classification model was developed using convolutional neural networks and traditional radiomics features. Dice surface coefficient (DICE) was used to measure segmentation performance and area under the ROC curve (AUC), F1-score and recall for classification performance. The ICH and MPH datasets had a median age of 45 (IQR 35-60) and 48 (IQR 38-57) years old and consisted of 23.1% and 31.5% malignant cases, respectively. The best segmentation model achieved a DICE score of 0.85 ± 0.01, 0.88 ± 0.01 and 0.85 ± 0.01 in the ICH training, ICH validation and MPH test sets. The best classification model achieved a recall of 1.00 and F1-score of 0.88 (AUC:0.93), 0.94 (AUC:0.89) and 0.83 (AUC:0.90) in the ICH training, ICH validation and MPH test sets, respectively. We have developed an end-to-end radiomics-based model capable of adnexal mass segmentation and classification, with a comparable predictive performance (AUC 0.90) to the published performance of expert subjective assessment (gold standard), and current risk models. Further prospective evaluation of the classification performance of this ML model against existing methods is required.

Clinical characteristics of functioning gonadotroph adenoma in women presenting with ovarian hyperstimulation: Audit of UK pituitary centres

OBJECTIVE

Functioning gonadotroph adenomas (FGAs) are rare pituitary tumours stimulating ovarian function with potential life-threatening consequences in women. However, a lack of aggregated clinical experience of FGAs impairs management in affected women. The aim of this study is to present the clinical course of FGA-induced ovarian hyperstimulation syndrome (OHSS) cases as identified by some of the largest UK pituitary endocrine tertiary centres with a view to increasing awareness and improving diagnosis and management of women with FGA.

DESIGN

A retrospective observational study; audit of eight UK regional pituitary centres for cases of FGAs.

SETTING

Specialist neuroendocrine centres in the United Kingdom.

PATIENTS AND MEASUREMENTS

Women diagnosed with FGA-induced OHSS. Description of their clinical course.

RESULTS

Seven cases of FGA were identified in women, all causing OHSS. Mean age was 33.4 years at diagnosis. Abdominal pain, irregular periods, headache, and visual disturbances were reported at presentation by 100%, 71%, 57% and 43% of women, respectively. Three of seven women underwent ovarian surgery before FGA diagnosis. Six women underwent transsphenoidal surgery (TSS) with incomplete tumour resection in five of those, but all showed improvement or resolution in symptoms and biochemistry postoperatively.

CONCLUSION

FGA is a rare cause of spontaneous OHSS. TSS improves clinical and biochemical features of ovarian hyperstimulation in FGAs. Improved awareness of FGA will prevent inappropriate emergency ovarian surgery.

Assessing the Risk of Hypoglycemia Secondary to Propranolol Therapy for the Treatment of Supraventricular Tachycardia in Infants

Supraventricular tachycardia (SVT) is the most common arrhythmia among infants. Prevention of SVT is frequently managed through propranolol therapy. Hypoglycemia is a known adverse effect of propranolol therapy, but little research has been done on the incidence and risk of hypoglycemia in treatment of SVT in infants with propranolol. This study attempts to offer insight into the risk of hypoglycemia associated with propranolol therapy when treating infantile SVT to help inform future glucose screening guidelines. We conducted a retrospective chart review of infants treated with propranolol in our hospital system. Inclusion criteria were infants < 1 year of age who received propranolol for the treatment of SVT. A total of 63 patients were identified. Data was collected on sex, age, race, diagnosis, gestational age, nutrition source (Total Parenteral Nutrition (TPN) vs oral), weight (kg), weight for length (kg/cm), propranolol dose (mg/kg/day), comorbidities, and whether or not a hypoglycemic event was identified (< 60 mg/dL). Hypoglycemic events were identified in 9/63 (14.3%) patients. Of the patients with hypoglycemic events, 9/9 (88.9%) had comorbid conditions. Patients with hypoglycemic events had significantly lower weight and propranolol dose than those without hypoglycemic events. Weight for length also tended to increase risk for hypoglycemic events. The high incidence of comorbid conditions in the patients who had hypoglycemic events suggests that hypoglycemic monitoring may only be necessary in patients with conditions predisposing to hypoglycemia.

Cytomegalovirus viral load as predictor of the clinical course of hypoxic pneumonia in children

BACKGROUND: Children under 1 year of age with hypoxic pneumonia regularly have concurrent cytomegalovirus (CMV) viremia. In these children, the diagnosis of CMV-associated pneumonia and the prediction of an outcome are difficult. It is unclear whether quantification of blood CMV viral load (CMV-VL) can predict outcomes in these children.METHODS: This was a retrospective study including children (1-12 months of age), with detectable CMV-VL and hypoxic pneumonia admitted to the paediatric intensive care unit of Tygerberg Hospital, Cape Town, South Africa between 1 January 2014 and 31 December 2015. Clinical, radiological and biochemical data were collected.RESULTS: Of the 87 participants included (median age: 3.9 months, IQR 2.2-4.8), 35 were (40%) born prematurely. The median weight-for-age Z-score was -2.68 (IQR -3.0 to -0.83); 37 (43%) were severely underweight for age; 27 (31%) were HIV-positive, 3 were on ART. The median CMV-VL was log 4.0 (IQR 3.3-4.79); CMV_high was defined as CMV-VL > median; CMV-VL < median was classified as CMV_low. Overall survival was 90%; 12 (15.4%) remained oxygen-dependent at Day 28 post-admission. There was no difference in survival, 24-h post-admission ratio of arterial oxygen partial pressure to fractional inspired oxygen (P_aO₂:F_iO₂), oxygen dependence or ventilation duration between CMV_low and CMV_high. High-frequency oscillation ventilation duration was longer (P = 0.005) and Pneumocystis jirovecii (PJP) co-infection more frequent (P = 0.018) in CMV_high.CONCLUSION: CMV-VL is unable to predict the clinical outcome in children with hypoxic pneumonia. Specific treatment for CMV should be considered in all children at risk of CMV-associated pneumonia with detectable CMV-VL.

Time-effectiveness and convenience of transvaginal ultrasound probe disinfection using ultraviolet vs chlorine dioxide multistep wipe system: prospective survey study

OBJECTIVES

To compare the efficiency, ease of use and user satisfaction of two methods of transvaginal ultrasound probe high-level disinfection: ultraviolet-C radiation (UV-C) and a chlorine dioxide multistep wipe system.

METHODS

This was a prospective survey study. UV-C units were introduced into a busy early pregnancy assessment service and compared with a multiwipe system for disinfection. Before seeing each patient, healthcare professionals (HCPs) measured with a stopwatch the time taken to complete a cycle of disinfection using either UV-C or chlorine dioxide multistep wipes and responded to a quick-response (QR) code-linked survey. Additional essential tasks that could be completed before seeing the next patient during probe disinfection were also documented. Using another QR code-linked survey, data on ease of use, satisfaction with the system used and preferred system were collected. The ease of use and satisfaction with the system were rated on a 0 to 10 Likert scale (0 poor, 10 excellent). A free-text section for comments was then completed.

RESULTS

Disinfection using UV-C (n = 331) was 60% faster than the chlorine dioxide multiwipe system (n = 332) (101 vs 250 s; P < 0.0001). A greater number of tasks were completed during probe disinfection when using UV-C, saving a further 74 s per patient (P < 0.0001). The HCPs using UV-C (n = 71) reported greater ease of use (median Likert score, 10 vs 3; P < 0.0001) and satisfaction (median Likert score, 10 vs 2; P < 0.0001) compared with those using the multiwipe system (n = 43). HCPs reported that the chlorine dioxide system was time-consuming and environmentally unfriendly, while the UV-C system was efficient and easy to use. Overall, 98% of the HCPs preferred using the UV-C system.

CONCLUSIONS

UV-C technology is more time-efficient and allows more essential tasks to be completed during disinfection. For a 4-h ultrasound list of 15 patients, the use of UV-C would save 55 min 45 s. HCPs found UV-C preferable and easier to use. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

P-698 Pituitary functioning gonadotroph adenomas (FGA)-induced ovarian hyperstimulation syndrome (OHSS): results from tertiary neuroendocrine centres in the UK

Study question

There are no published series of OHSS due to FGA. What FGA features should clinicians look for during OHSS, and what treatments are effective?

Summary answer

FGA tumour size is always &gt;10mm. Other pituitary hormones may be deficient. Surgical resection of FGA is an effective treatment for OHSS.

What is known already

Pituitary adenomas affect 1:1000 adults and are classified as functioning or non-functioning. Non-functioning pituitary adenomas do not secrete hormones, but most commonly stain histologically gonadotroph cells. Functional pituitary adenomas secrete hormones such as prolactin causing prolactinoma. However, it is rare for a pituitary tumour to cause clinical features of excessive gonadotrophins (functioning gonadotroph adenoma; FGA).

Single case reports, but no case series, have been published on the presentation of FGA-induced OHSS in women.

Surgical excision of adenomas has been reported to cause remission of symptoms, though systematic data are lacking owing to rarity of these tumours.

Study design, size, duration

National case series from tertiary neuroendocrine units in England, Wales and Scotland.

Participants/materials, setting, methods

Eight high-volume pituitary endocrine tertiary units within England, Wales and Scotland audited their records for any cases of FGA-induced OHSS; only seven patients have been identified to date. In all cases, there had been no recent exposure to assisted reproductive technologies (ART) or drugs known to induce OHSS including gonadotrophins or selective oestrogen receptor modulators (SERMS).

Main results and the role of chance

Seven cases of FGA were identified with mean age 31.6 years (range 16-48) at diagnosis. Two-of-seven women presented acutely unwell with abdominal pain, distention and palpable mass requiring oophorectomy for ovarian torsion/ruptured ovarian cyst. The remaining five women presented with abdominal pain (n = 2), thyrotoxicosis (n = 1), menstrual irregularities/galactorrhoea (n = 1) and visual disturbances (n = 1). All women experienced intermittent pelvic pain during medical attendance. Pelvic ultrasound demonstrated enlarged multiseptated ovaries (volume ranging 27-442cm3). Ascites was noted in one woman. Six women had visual field defects due to optic chiasm compression on formal assessment. Median FSH was 26.10 u/L (8.3-33), but LH was &lt;2.5 u/L in all cases. Estradiol (E2) far exceeded the reference range in 5/7 women (2990 to &gt; 18000pmol/L);E2 was at the upper limit of normal in the remaining 2/7 women (960-1450pmol/L). Hyperprolactinaemia, hyperthyroidism and other pituitary hormones deficiency were noted in 6/7, 1/7 and 4/7 women respectively. All FGAs were macroadenomas with diameters ranging 16-48mm. Two patients were administered a somatostatin analogue prior to surgery, but FSH, E2 and tumour size did not change. Transsphenoidal surgery was performed in 6/7 women, and always improved symptomatic and biochemical features of OHSS; however, residual FGA tumour was present post-operatively in all cases studied.

Limitations, reasons for caution

It is possible that some ‘non-functioning’ gonadotroph adenomas cause subclinical problems including menstrual irregularity and mild OHSS which were never diagnosed.

We have insufficient data to determine the prognosis for future pregnancy after FGA-induced OHSS.

This study utilised historical case-notes, so some data is missing.

Wider implications of the findings

The ‘spontaneous’ presentation of OHSS may be confusing for clinicians. We report that FGA is an important cause of spontaneous OHSS which has well-defined biochemical and radiological characteristics, which may be treated effectively in the short-to-medium with pituitary surgery. Results of this study may provide greater awareness of FGA-induced OHSS.

Trial registration number

N/A

Prognostic factors for post-traumatic stress, anxiety and depression in women after early pregnancy loss: a multi-centre prospective cohort study

OBJECTIVES

To investigate prognostic factors for anxiety, depression and post-traumatic stress (PTS) symptoms 1 month after early pregnancy loss (EPL).

DESIGN

A prospective cohort study. Consecutive women were recruited, and demographic and clinical data were collected. Surveys containing the Hospital Anxiety and Depression Scale (HADS) and Post-traumatic Stress Diagnostic Scale (PDS) were emailed 1 month after a loss. Univariable logistic regression was performed to link factors with caseness of anxiety, depression or PTS according to screening measures.

SETTING

Early pregnancy units of three central London hospitals.

PARTICIPANTS

737/1116 eligible women with an EPL were recruited. 492 responded to HADS and 487 to PDS.

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcome is the area under the curve (AUC) to predict any psychological morbidity (defined as moderate/severe anxiety or depression, or meeting screening criteria for PTS) for each variable. Further outcomes are explained variation (R²) and p value for any morbidity, and AUC, explained variation, and p value for each morbidity separately.

RESULTS

Women who had a past diagnosis of a psychiatric condition were more likely to meet criteria for anxiety, depression or PTS (75% for current diagnosis vs 55% for past vs 30% for no diagnosis; AUC 0.61; R² 8.4%; p<0.0001), as were those with previous pregnancy loss (48% vs 30%; AUC 0.59; R² 4.3%; p<0.0001). Most of the assessed factors did not demonstrate potential utility in predicting psychological distress, including gestational age, overnight admission, time taken for diagnosis, pre-existing children and the diagnosis itself (miscarriage vs ectopic vs other) (AUCs≤0.54; R²≤0.9%).

CONCLUSIONS

Women with a history of mental health problems, or those with previous losses, may be at higher risk of psychological illness 1 month after pregnancy loss. However, prognostic ability was poor overall. All women should be considered at risk.

Ultrasound characteristics, serum biochemistry and outcome of ectopic pregnancies presenting during COVID-19 pandemic

OBJECTIVE

To describe and compare the characteristics of ectopic pregnancies (EPs) in the year prior to vs during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

This was a retrospective analysis of women diagnosed with an EP on transvaginal sonography conducted at a center in London, UK, providing early-pregnancy assessment, between 1 January 2019 and 31 December 2020. Women were identified via the Astraia ultrasound reporting system using coded and non-coded outcomes of EP or pregnancy outside the uterine cavity. Data related to predefined outcomes were collected using Astraia and Cerner electronic reporting systems. Main outcome measures included clinical, ultrasound and biochemical features of EP, in addition to reported complications and management.

RESULTS

There were 22 683 consultations over the 2-year period. Following consultation, a similar number and proportion of EPs were diagnosed in 2019 (141/12 657 (1%)) and 2020 (134/10 026 (1%)). Both cohorts were comparable in age, ethnicity, weight and method of conception. Gestational age at the first transvaginal sonography scan and at diagnosis were similar, and no difference in location, size or morphology of EP was found between the two cohorts. Serum human chorionic gonadotropin (hCG) levels at the time of EP diagnosis were higher in 2020 than in 2019 (1005 IU/L vs 665 IU/L; P = 0.03). The proportions of women according to type of final EP management were similar, but the rate of failed first-line management was higher during vs before the pandemic (16% vs 6%; P = 0.01). The rates of blood detected in the pelvis (hemoperitoneum) on ultrasound (23% vs 26%; P = 0.58) and of ruptured EP confirmed surgically (9% vs 3%; P = 0.07) were similar in 2019 vs 2020.

CONCLUSIONS

No difference was observed in the location, size, morphology or gestational age at the first ultrasound examination or at diagnosis of EP between women diagnosed before vs during the COVID-19 pandemic. Complication rates and final management strategy were also unchanged. However, hCG levels and the failure rate of first-line conservative management measures were higher during the pandemic. Our findings suggest that women continued to access appropriate care for EP during the COVID-19 pandemic, with no evidence of diagnostic delay or an increase in adverse outcome in our population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Evaluating the value of intrapartum fetal scalp blood sampling to predict adverse neonatal outcomes: A UK multicentre observational study

OBJECTIVE

To evaluate the value of fetal scalp blood sampling (FBS) as an adjunct test to cardiotocography, to predict adverse neonatal outcomes.

STUDY DESIGN

A multicentre service evaluation observational study in forty-four maternity units in the UK. We collected data retrospectively on pregnant women with singleton pregnancy who received FBS in labour using a standardised data collection tool. The primary outcome was prediction of neonatal acidaemia diagnosed as umbilical cord arterial pH < 7.05, the secondary outcomes were the prediction of Apgar scores<7 at 1st and 5th minutes and admission to the neonatal intensive care unit (NICU). We evaluated the correlation between the last FBS blood gas before birth and the umbilical cord blood and adjusted for time intervals. We constructed 2 × 2 tables to calculate the sensitivity, specificity, positive (PPV) and negative predictive value (NPV) and generated receiver operating curves to report on the Area Under the Curve (AUC).

RESULTS

In total, 1422 samples were included in the analysis; pH values showed no correlation (r = 0.001, p = 0.9) in samples obtained within an hour (n = 314), or within half an hour from birth (n = 115) (r=-0.003, p = 0.9). A suboptimal FBS pH value (<7.25) had a poor sensitivity (22%) and PPV (4.9%) to predict neonatal acidaemia with high specificity (87.3%) and NPV (97.4%). Similar performance was noted to predict Apgar scores <7 at 1st (sensitivity 14.5%, specificity 87.5%, PPV 23.4%, NPV 79.6%) and 5th minute (sensitivity 20.3%, specificity 87.4%, PPV 7.6%, NPV 95.6%), and admission to NICU (sensitivity 20.3%, specificity 87.5%, PPV 13.3%, NPV 92.1%). The AUC for FBS pH to predict neonatal acidaemia was 0.59 (95%CI 0.59-0.68, p = 0.3) with similar performance to predict Apgar scores<7 at 1st minute (AUC 0.55, 95%CI 0.51-0.59, p = 0.004), 5th minute (AUC 0.55, 95%CI 0.48-0.62, p = 0.13), and admission to NICU (AUC 0.58, 95%CI 0.52-0.64, p = 0.002). Forty-one neonates had acidaemia (2.8%, 41/1422) at birth. There was no significant correlation in pH values between the FBS and the umbilical cord blood in this subgroup adjusted for sampling time intervals (r = 0.03, p = 0.83).

CONCLUSIONS

As an adjunct tool to cardiotocography, FBS offered limited value to predict neonatal acidaemia, low Apgar Scores and admission to NICU.

A meta-analysis into the effect of lateral-wedged insoles with subtalar strapping versus traditional insoles in adults with medial knee osteoarthritis

To  systematically  identify,  collate,  and  analyze  the  current available evidence  for  the  effectiveness  of  lateral-wedged  insoles,  with subtalar strapping,  on  reducing  pain,  improving  function  and  improving  the femoral-tibial  angle  (FTA),  in  adults  with  medial  knee osteoarthritis compared to traditional insoles without subtalar strapping.Six computerised databases, namely Cochrane Library, CiNAHL, PEDro, BIOMED central,  PubMed  and  ScienceDirect  were  searched. The  included articles were  then  all  rated  using  the  PEDro  scale  to  determine  their meth-odological quality.  Homogeneous data were pooled in a meta-analysis using Review Manager (REVMAN) software.  Where statistical pooling of the results was not possible, findings were summarised in narrative form. Three randomised controlled trials were selected for this review. The average PEDro score was 5.7. A meta-analysis demonstrated that lateral-wedged insoles with subtalar strapping significantly reduced pain in the short-term (p=0.004). The review found that lateral-wedge insoles with subtalar strapping significantly decreased pain in the short-term and seemed to have a positive effect on the FTA in the long-term, when compared to traditional insoles without  subtalar strapping. The lateral-wedge insole with subtalar strapping may provide a financially feasible adjunctive self-management treatment for knee OA and should be considered before invasive procedures such as surgery.

Mitochondrial uncoupling protein 2 in pancreatic β-cells

Pancreatic β-cells have remarkable bioenergetics in which increased glucose supply upregulates the cytosolic ATP/ADP ratio and increases insulin secretion. This arrangement allows glucose-stimulated insulin secretion (GSIS) to be regulated by the coupling efficiency of oxidative phosphorylation. Uncoupling protein 2 (UCP2) modulates coupling efficiency and may regulate GSIS. Initial measurements of GSIS and glucose tolerance in Ucp2(-/-) mice supported this model, but recent studies show confounding effects of genetic background. Importantly, however, the enhancement of GSIS is robustly recapitulated with acute UCP2 knockdown in INS-1E insulinoma cells. UCP2 protein level in these cells is dynamically regulated, over at least a fourfold concentration range, by rapid proteolysis (half-life less than 1 h) opposing regulated gene transcription and mRNA translation. Degradation is catalysed by the cytosolic proteasome in an unprecedented pathway that is currently known to act only on UCP2 and UCP3. Evidence for proteasomal turnover of UCP2 includes sensitivity of degradation to classic proteasome inhibitors in cells, and reconstitution of degradation in vitro in mitochondria incubated with ubiquitin and the cytosolic 26S proteasome. These dynamic changes in UCP2 content may provide a fine level of control over GSIS in β-cells.

Positional relationship between leg rotation and lumbar spine during quiet standing

Healthcare professionals frequently evaluate spinal posture on visual assessment during the clinical examination. While this visual assessment of the spine has been shown to be unreliable, the use of a plumbline as to aid clinical visual assessment has also been reported. There is a "normal" sagittal contour that functions quite well in healthy people. It positions the head in space, it protects the neural axis, and it allows efficient, pain-free motion. Lumbar lordosis is routinely evaluated in most spine patients, but what constitutes a normal sagittal contour is less well defined. A key component of normal sagittal contour is lumbar lordosis. Changes in the lumbar lordosis frequently occur in pathological gait, usually in association with alterations in pelvic tilt, and commonly as a compensation for a limited range of flexion/extension at the hip joint. Recent investigations looked at the effect of hyperpronation on pelvic alignment in a standing position and supported the existence of a kinematic chain in healthy subjects, where hyperpronation can lead to an immediate shank and thigh internal rotation and change in pelvic position. While there is a wealth of research is available on the effectiveness of functional foot orthoses, the present investigation reports the effect of pronated foot position on the lumbar region of the back by employing an optoelectronic movement analysis system.

Evidence of cardiac autonomic neuropathy in dogs with diabetes mellitus

The NeuroScope, a specific and sensitive indicator of cardiac vagal tone, was used to look for differences in autonomic tone between 25 dogs with naturally occurring diabetes mellitus and 23 healthy control dogs, to determine whether there was any correlation between the dogs' cardiac vagal tone, the duration of diabetes and the adequacy of glycaemic control. The cardiac index of parasympathetic activity (cipa) was determined for each dog over a period of 2600 heartbeats. The mean, median and modal cipa values were significantly lower in the diabetic dogs than in the healthy dogs. There was no significant relationship between the cipa values and the duration of disease or the adequacy of recent glycaemic control in the diabetic dogs, but there was a significant inverse relationship between the cipa values and the bodyweight of the diabetic dogs that was not evident in the normal dogs. The conclusions were based on a 500-heartbeat interval selected from the 2600 heartbeats recorded.

Communication skills training in postgraduate medicine: the development of a new course

It has long been accepted that communication is of central importance in healthcare, and a core aspect of clinical competence. Many educational institutions and Royal Colleges now reflect this and consider communication skills a priority in postgraduate examination. The new examination "Practical Assessment of Clinical and Examination Skills" has replaced the Royal College of Physicians MRCP part 2 clinical and oral examination. This examination now consists of five clinical stations, two of which focus on communication skills. A short course for postgraduate trainees has been designed to address the communication skills requirements of the part 2 clinical examination. The aims, development, and content of the course are described. Emphasis is placed on candidates practising skills with patients and receiving feedback during the course. Evidence suggests that practice with feedback is an essential ingredient of communication skills courses, and is more effective than other methods such as observing experts or video examples, or simply discussing issues in communication. Results of a preliminary evaluation indicate that the course was perceived as valuable by candidates and that the aims, format, and content were appropriate. Although the preliminary evaluation was largely positive, it could be argued that the acid test of the effectiveness of a course is an objective evaluation of skills, observed before and after the course, a development that is being considered for future evaluation of the course. Recommendations for applying this type of training to postgraduate trainees in any branch of medicine are given.

Severe sporotrichoid infection with Mycobacterium szulgai

Mycobacterium szulgai is a nontuberculous, acid-fast bacillus or atypical mycobacteria, which prior to 1972 was not thought of as a pathogen. Since then most cases reported in the literature have been of pulmonary disease with only a few case reports of cutaneous disease. Our patient, who had an underlying, uncategorized, immunosuppressive condition, presented with multiple severe ulcers spreading proximally up the arms in a sporotrichoid pattern with more scatttered lesions on his legs. He made a full recovery with appropriate antimicrobial treatment.

Isolex 300i CD34-selected cells to support multiple cycles of high-dose therapy

BACKGROUND

We have previously reported that repeated cycles of high-dose therapy (HDT), can be supported by unmanipulated autologous PBPC. Here we investigate whether purified CD34+ cells, obtained by immunomagnetic separation using the Isolex 300i device, can support such therapy.

METHODS

Twenty-nine consecutive patients with metastatic breast cancer had PBPC mobilized and harvested following chemotherapy and G-CSF (10 microg/kg per day). Patients with > 4.0 x 10(6)/kg CD34+ cells in the apheresis product underwent CD34-selection using the Isolex 300i (v2.0) device. All cells collected were equally divided into three aliquots and cryopreserved. Patients who did not achieve this threshold had unmanipulated cells collected and stored. Patients subsequently received three cycles of HDT with paclitaxel (175 mg/m2), thiotepa (300 mg/m2) and either ifosfamide (10 g/m2) or cyclophosphamide (4 g/m2). It was intended for patients to receive CD34-selected cells to support each of the three cycles of HDT (i.e 1/3 for each cycle) and to compare hemopoietic recovery between patients receiving CD34-selected cells or unmanipulated cells.

RESULTS

Thirteen of the 29 patients (45%) did not mobilize sufficient CD34+ cells to undergo CD34-selection. The remaining 16 patients underwent CD34-selection with a median purity of 84.3% (range: 16.3-96.1%) and yield of 34% (range: 1-60%). Fifteen of these patients proceeded to HDT and 42 of the planned 45 cycles were administered. Nine patients had all three HDT cycles supported by CD34-selected cells. The median number of CD34-selected cells (x 10(6)/kg) infused per cycle was 1.5 (range: 0.04-3.01). Three of the 15 patients required infusion of 'back-up' unmanipulated cells because of delayed neutrophil recovery. Of the 13 patients whose PBPCs did not undergo CD34+ cell selection, 11 proceeded to HDT with a median of 3.2 x 10(6)/kg (range: 2.0-4.4) unselected cells infused per cycle and 31 of 33 planned cycles were delivered. When hemopoietic recovery was compared between cycles of HDT supported by CD34-selected (n = 34) and unmanipulated cells (n = 31), there was a modest slowing in the patients receiving CD34-selected cells; time to ANC > 1.0 x 10(9)/L = 11 days versus 10 days (P = 0.0122) and platelets > 20 x 10(9)/L = 14 days versus 13 days (P = 0.0009). No difference in recovery to 50 x 10(9)/L was observed (P = 0.54).

CONCLUSION

We have demonstrated that Isolex 300i CD34-selected cells are capable of supporting multiple cycles of HDT. However, we were unable to acquire sufficient CD34+ cells to perform this processing in 45% (13/29) of patients and further improvements in yield are required to overcome the modest delay in neutrophil and platelet recovery.

Frequency and clinical implications of fluid dynamically significant diffuse coronary artery disease manifest as graded, longitudinal, base-to-apex myocardial perfusion abnormalities by noninvasive positron emission tomography

BACKGROUND

Diffuse coronary atherosclerosis is the substrate for plaque rupture and coronary events. Therefore, in patients with mild arteriographic coronary artery disease without significant segmental dipyridamole-induced myocardial perfusion defects, we tested the hypothesis that fluid dynamically significant diffuse coronary artery narrowing is frequently manifest as a graded, longitudinal, base-to-apex myocardial perfusion abnormality by noninvasive PET.

METHODS AND RESULTS

In this study, 1001 patients with documented coronary artery disease by coronary arteriography showing any visible coronary artery narrowing underwent rest-dipyridamole PET perfusion imaging. Quantitative severity of dipyridamole-induced, circumscribed, segmental PET perfusion defects was objectively measured by automated software as the minimum quadrant average relative activity indicating localized flow limiting stenoses. Quantitative severity of the graded, longitudinal, base-to-apex myocardial perfusion gradient indicating fluid dynamic effects of diffuse coronary artery narrowing was objectively measured by automated software as the spatial slope of relative activity along the cardiac longitudinal axis.

CONCLUSIONS

In patients with mild arteriographic disease without statistically significant dipyridamole-induced segmental myocardial perfusion defects caused by flow-limiting stenoses compared with normal control subjects, there was a graded, longitudinal, base-to-apex myocardial perfusion gradient significantly different from normal control subjects (P=0. 001) that was also observed for moderate to severe dipyridamole-induced segmental perfusion defects (P=0.0001), indicating diffuse disease underlying segmental perfusion defects; 43% of patients with or without segmental perfusion defects demonstrated graded, longitudinal, base-to-apex perfusion abnormalities beyond +/-2 SD of normal control subjects, indicating diffuse coronary arterial narrowing by noninvasive PET perfusion imaging.

Improving continuity of care across psychiatric and emergency services: combining patient data within a participatory action research framework

Presented with the concerns of emergency department nurses about providing appropriate and co-ordinated care for patients seeking mental health services, a Monash University School of Nursing, Victoria, Australia, research team chose a participatory action research strategy. Jointly executed with staff from the Peninsula Health Care Network, the research process brought together in a number of fora multiple disciplines involved in the care and management of psychiatric patients. The participatory action research process itself was the first step in remedial action. Through it, participants and management gained a firmer view of the issues facing Frankston Hospital Emergency Department staff in dealing with psychiatric patients, and in securing their access to suitable pathways of care. Other research outcomes included: a compilation of summary statistics showing patterns of use by psychiatric patients of Frankston Hospital's Emergency Department; beginning discussions about pathways of care for these patients; and the development of a screening tool to be used by the triage nurse for at-risk psychiatric patients presenting to the Emergency Department.

Molecular cytogenetic delineation of the critical deleted region in the 5q- syndrome

The 5q- syndrome is a distinct type of myelodysplastic syndrome (MDS) characterised by refractory anaemia, morphological abnormalities of megakaryocytes, and del(5q) as the sole cytogenetic abnormality. In contrast to patients with therapy-related MDS with 5q deletions, 5q- syndrome patients have a favourable prognosis and a low rate of transformation to acute leukaemia. We have previously delineated a common deleted region of 5.6 Mb between the gene for fibroblast growth factor acidic (FGF1) and the subunit of interleukin 12 (IL12B) in two patients with 5q- syndrome and small deletions, del(5)(q31q33). The present study used fluorescence in situ hybridisation (FISH) analysis of these and a third 5q- syndrome patient with a small deletion, del(5)(q33q34), to refine further the critical deleted region. This resulted in the narrowing of the common deleted region within 5q31.3-5q33 to approximately 3 Mb, flanked by the adrenergic receptor beta 2 (ADRB2) and IL/2B genes. The common region of loss in these three 5q- syndrome patients includes the macrophage colony-stimulating factor-1 receptor (CSF1R), secreted protein, acidic, cysteine-rich (SPARC), and glutamate receptor (GR1A1) genes. This 5q- syndrome critical region is telomeric to and distinct from the other critical regions on 5q associated with MDS and acute myeloid leukaemia.

Creating a practice partnership: a clinical application of case management

Using the framework of case management, a team partnership was developed for the head and neck surgery population undergoing reconstruction with free tissue transfers ("free flaps"). The focus of the partnership was to improve care coordination from surgery scheduling through discharge. Practice agreements were negotiated, pre-printed on a clinical path, and further supported by pre-printed physician's orders, teaching materials, and a variance tracking tool. In the 6 months since implementing this partnership, patients have recovered more quickly, reducing length of stay by 25% and costs by 15% to 20%.

Lectin/Antibody "sandwich" ELISA for quantification of circulating mucin as a diagnostic test for pancreatic cancer

Pancreatic cancer in the nonjaundiced patient can be difficult to diagnose, even with the aid of modern scanning techniques. Studies have shown that mucus glycoproteins (mucins) are frequently detectable in the serum of patients with pancreatic cancer (1,2), and these mucins may express a wide range of different carbohydrate structures The detection and quantification of mucin can be used in serological diagnosis of the disease.

Genomic imprinting in the rat: linkage of Igf2 and H19 genes and opposite parental allele-specific expression during embryogenesis

Igf2 and H19 are closely linked imprinted genes in both mice and humans that are expressed from opposite parental alleles. In this study we demonstrate that these two genes are also closely linked in the rat, with the H19 gene mapping to within 145 kb of Igf2 on rat chromosome 1. We identified polymorphisms in H19 and Igf2 transcripts in two inbred rat strains and determined the expression of the parental alleles in F1 offspring. The H19 gene was shown to be expressed exclusively from the maternal allele in all fetal and neonatal tissues. Monoallelic expression of Igf2 from the paternal allele was found in all tissues except the leptomeninges and choroid plexus. Igf2 in the choroid plexus was monoallelic at days 13.5 and 15.5 of gestation with a switch to biallelic expression by day 18.5, demonstrating a loss of imprinting after the choroid plexus has differentiated. Biallelic expression of Igf2 was observed in the leptomeninges at all fetal and neonatal stages analyzed. These studies demonstrate conservation of imprinting of two closely linked genes transcribed from opposite parental alleles in a species other than human or mouse. A comparative approach between different species will be important in defining the mechanisms that regulate the tissue-specific expression of imprinted genes.

Differential excretion of leucocyte granule components in inflammatory bowel disease: implications for pathogenesis

1. Faecal excretion of the leucocyte primary granule component, myeloperoxidase, and of the secondary granule component, lactoferrin, were compared in inflammatory bowel disease and infective diarrhoea. 2. Faecal lactoferrin correlated with faecal myeloperoxidase in both inflammatory bowel disease (P = 0.0018; n = 32) and infective diarrhoea (P = 0.00013; n = 37), but inflammatory bowel disease was associated with a much higher faecal excretion of lactoferrin but lower excretion of myeloperoxidase than infective diarrhoea. As a consequence, the median ratio of lactoferrin/myeloperoxidase excretion (both expressed as ng/mg of protein) for inflammatory bowel disease was 7.5 (range 3.5-21.3) with similar values for ulcerative colitis (n = 18) and Crohn's disease (n = 14) compared with only 0.9 (range 0.4-2.3; P < 0.0001) for infective diarrhoea. In inflammatory bowel disease faecal lactoferrin and myeloperoxidase excretion remained increased even in clinical remission. 3. In subsequent immunohistochemical studies to assess the possible explanation for these findings, lactoferrin and myeloperoxidase were demonstrated within crypt abscesses and surface mucus, both in inflammatory bowel and in infective diarrhoea mucosal samples. There was a slight increase in the number of lactoferrin-containing cells in the mucosal samples from ulcerative colitis and in the submucosa of samples from Crohn's disease compared with infective diarrhoea, but these changes were not sufficient to account for the marked increase in faecal lactoferrin excretion in inflammatory bowel disease. 4. In all mucosal samples, including those from normal mucosa, lactoferrin was also shown to be contained within mast cells. 5. These results could best be explained by a different mechanism for leucocyte activation in inflammatory bowel disease compared with infective diarrhoea, and are compatible with selective secretion of secondary granule components, which include lactoferrin but not myeloperoxidase, as a result of leucocyte activation by N-formylated bacterial peptides in inflammatory bowel disease.

CAM 17.1--a new diagnostic marker in pancreatic cancer

CAM 17.1-Ab is a recently described monoclonal antibody that detects a mucus glycoprotein with high specificity for intestinal mucus, particularly in the colon, small intestine, biliary tract and pancreas. We investigated the expression and release of CAM 17.1 in pancreatic carcinoma cell lines and tissue specimens of normal pancreas, chronic pancreatitis and pancreatic cancer. CAM 17.1 was weakly expressed on normal ductal cells and chronic pancreatitis, whereas it was overexpressed in pancreatic cancer. Serum analysis using a new enzyme-linked antibody sandwich assay (CAM 17.1/WGA) of patients with chronic pancreatitis, pancreatic cancer or other gastrointestinal cancer and of healthy blood donors revealed a high sensitivity (67%) and excellent specificity (90%) of CAM 17.1/WGA assay in pancreatic cancer. In comparison with the tumour marker CA19-9, the sensitivity of the CAM 17.1/WGA assay was similar to the sensitivity of CA 19-9 (67% and 76%, P = 0.22), whereas the specificity of CAM 17.1/WGA assay was higher than in CA 19-9 (90% compared with 78% in chronic pancreatitis, P > 0.05).

Quantitative volumetric analysis of brain MR: normative database spanning 5 decades of life

PURPOSE

To present a normative volumetric database, spanning 5 decades of life, of cerebrospinal fluid, subarachnoid cerebrospinal fluid, total brain volume, total ventricular volume (component ventricular volumes of lateral, temporal horn, and third and fourth ventricles) and estimates of white and gray matter, based on a multispectral segmentation of brain MR. This database is presented as a reference for future studies comparing pathologic states.

METHOD

One hundred ninety-four healthy subjects, ranging in age from 16 to 65 years, received standard axial intermediate- and T2-weighted spin-echo MR images. Multispectral segmentation and volume analysis were performed using ANALYZE.

RESULTS

Normative volumetric estimates, both uncorrected and corrected for differences in total intracranial volume, were obtained for all subjects and presented by decade and sex. Age-related cerebrospinal fluid changes were evident for both male and female subjects. Most gender differences were eliminated by correction for differences in total intracranial volume. Standard and fast spin-echo acquisition methods gave comparable volume estimates. Total brain volume measurements from MR compare favorably with data from large autopsy series.

CONCLUSION

Although there may be limitations to generalizations, these normative data tables can provide a comparison index for contrasting pathologic groups with a normative sample.

Increased rate of sialylation of colonic mucin by cultured ulcerative colitis mucosal explants

Sialylation of mucus glycoproteins confers charge and increased resistance to enzymatic degradation. The hypothesis that mucus sialylation might be altered in ulcerative colitis has been studied using in vitro culture of mucosal biopsies for 24 h with 3H N-acetyl mannosamine as a specific sialic acid precursor. Rectal biopsies were obtained at colonoscopy from patients with clinically inactive ulcerative colitis (n = 9) and controls (n = 12) who were patients found to have a normal colonoscopy performed for iron deficiency anaemia or altered bowel habit. The incorporation of 3H N-acetyl mannosamine into mucin was increased in ulcerative colitis (n = 9; 150; 113.3-393.2 dpm/micrograms mucin, median and interquartile ranges), compared with controls (n = 12; 33.6; 19.7-68.4 dpm/micrograms; p < 0.01). The ratio of incorporation into mucin of 3H N-acetyl mannosamine/14C N-acetyl galactosamine was also increased in ulcerative colitis (3.27; 1.93-4.98 dpm/dpm), compared with controls (1.35; 1.24-1.7 dpm/dpm; p < 0.001) suggesting that the increased incorporation of N-acetyl mannosamine probably reflects an increase in the average extent of sialylation per mucin oligosaccharide chain rather than an increase in the number of oligosaccharide chains. This increase in mucin sialylation seems unlikely to have a pathogenic role in the development of colitis but provides further evidence for the similarity between the alterations that occur in ulcerative colitis, colonic polyposis and malignancy.

Abnormal mucosal glycoprotein synthesis in inflammatory bowel diseases is not related to cigarette smoking

Patients with ulcerative colitis are usually non- or ex-smokers in contrast to Crohn's disease where smoking is common. Abnormalities of quantity and quality of intestinal mucus have been postulated in the pathogenesis of these diseases. It is possible that smoking habit may exert its effects via changes in mucus in inflammatory bowel disease. We have therefore studied incorporation of N-acetylglucosamine into synthesized colonic mucin in explants from 85 controls with normal colonoscopic appearances and histology, including 27 smokers and 58 nonsmokers, 36 patients with ulcerative colitis and 19 with ileocolonic Crohn's disease over 24 h in tissue culture. Incorporation of N-acetylglucosamine into normal explants was 31.3 +/- (SD) 7.1 dpm/microgram biopsy protein, incorporation was increased in patients with active Crohn's disease (mean 41.2 +/- (SD) 10.4 dpm/microgram biopsy protein, p = 0.003), decreased in inactive ulcerative colitis (mean 24.1 +/- 7.8 dpm/microgram biopsy protein, p = 0.0006) but normal in active ulcerative colitis (mean 35.0 +/- 13.8 dpm/microgram biopsy protein, p = 0.44). No significant relationship was found between cigarette smoking habits and mucus synthesis in controls with normal mucosa (nonsmokers, n = 58, mean 31.0 +/- (SD) 7.52 dpm/microgram biopsy protein; smokers, n = 27, mean 31.8 +/- (SD) 6.1 dpm/microgram biopsy protein, p = 0.9). This study shows that mucus glycoprotein synthesis is reduced in inactive ulcerative colitis, rising to normal levels in active disease and that synthesis is increased in Crohn's disease. There is no effect of smoking on mucus synthesis by control biopsies suggesting that the differences seen in inflammatory bowel disease are not related to cigarette smoking.

Peanut lectin stimulates proliferation in colonic explants from patients with inflammatory bowel disease and colon polyps

BACKGROUND/AIMS

The TF antigen (galactose-beta 1,3-N-acetylgalactosamine alpha) is overexpressed in malignant and premalignant colonic epithelium. Previous studies have shown that peanut lectin (PNA), which binds TF, is mitogenic for normal human colonic epithelium. This study aimed to determine its effect on abnormal colonic epithelium.

METHODS

Crypt cell proliferation rate (CCPR) was measured using vincristine arrest and mucus synthesis by incorporation of radiolabeled N-acetyl glucosamine in colonoscopic biopsy specimens cultured with and without PNA.

RESULTS

Unstimulated CCPR was greater in patients with ulcerative colitis than in patients with histologically normal colon. PNA (25 micrograms/mL) produced a 25% average increase in CCPR in tissues from patients with ulcerative colitis, Crohn's disease, and colonic polyps. In ulcerative colitic biopsy specimens incubated with PNA, CCPR increased to more than double that of unstimulated normal colonic epithelium. In controls, the response to PNA was greater when adjacent specimens were positive for PNA (avidin-biotin) histochemistry than when they were negative. Mucus synthesis was increased by an average 75% over 24 hours by PNA.

CONCLUSIONS

Increased TF expression by premalignant epithelia may allow stimulation of proliferation by dietary galactose N-acetylgalactosamine-binding lectins. If the hyperplasia-dysplasia cancer hypothesis is correct, this could explain the increased colon cancer risk in ulcerative colitis.