Radiology reporting of incidental osteoporotic vertebral fragility fractures present on CT studies: results of UK national re-audit

AIM

To describe a UK-wide re-audit of the 2019 Royal College of Radiologists (RCR) audit evaluating patient-related data and organisational infrastructure in the radiological reporting of vertebral fragility fractures (VFFs) on computed tomography (CT) studies and to assess the impact of a series of RCR interventions, initiated to raise VFF awareness, on reporting practice and outcomes.

MATERIALS AND METHODS

Patient specific and organisational questionnaires largely replicated those utilised in 2019. The patient questionnaire involved retrospective analysis of between 50 and 100 consecutive, non-traumatic CT studies which included the thoracolumbar spine. All RCR radiology audit leads were invited to participate. Data collection commenced from 1 April 2022.

RESULTS

Data were supplied by 129/194 (67%) departments. One thousand five hundred and eighty-six of 7,316 patients (21.7%) had a VFF on auditor review. Overall improvements were demonstrated in key initial/provisional reporting results; comment on spine/bone (93.2%, 14.4% improvement, p<0.0002); fracture severity assessment (34.7%, 8.5% improvement, p=0.0007); use of recommended terminology (67.8%, 7.5% improvement, p=0.0034); recommendations for further management (11.7%, 9.1% improvement, p<0.0002).

CONCLUSIONS

The 2022 national re-audit confirms improvements in diagnostic performance and practice in VFF reporting. Continuing work is required to build on this improvement and to further embed best practice.

Preventing post-contrast acute kidney injury and hypersensitivity reactions: UK national audit

AIM

To audit UK radiology departmental protocols related to the prevention of Iodine-based contrast media (ICM) adverse drug reactions (ADRs) and to assess their compliance with the Royal College of Radiologists (RCR) endorsed Royal Australian and New Zealand College of Radiologists' 2018 Iodinated Contrast Guidelines.

MATERIALS AND METHODS

Questionnaires were sent to all UK acute National Health Service (NHS) providers treating adult patients with an audit lead registered with the RCR (162 providers encompassing 211 hospital radiology departments). The questionnaire included three main sections: renal function screening, renal protection regimens, and hypersensitivity reactions prevention and follow-up. Data collection was conducted between April and July 2022.

RESULTS

Sixty-one per cent (129/211) of departments responded, representing 67% of eligible providers. An independent imaging services provider supplied one additional set of data (n=130 overall). Of the responding departments, for post-contrast acute kidney injury (PC-AKI), 41% and 56% had the recommended risk assessment for inpatients and outpatients, respectively. Renal function testing was often over-utilised, and their results were applied improperly. Sixty-eight per cent of departments used the advised threshold for considering renal protection. For hypersensitivity reactions, 9% of departments had the correct risk assessment. Thirty-six per cent of departments had the correct risk mitigation protocol for identified high-risk patients. The documentation and follow-up for hypersensitivity reactions were similarly inadequate.

CONCLUSION

Local protocols on preventing ICM ADRs were largely non-compliant with RCR guidelines. Departments need to update their protocols in line with current evidence to avoid iatrogenic morbidity or unnecessary tests and over-precaution.

Accelerated implementation of remote reporting during the COVID-19 pandemic

AIM

To assess, via a survey of UK radiological departments, if the COVID-19 pandemic led to a change in radiological reporting undertaken in a home environment with appropriate IT support.

MATERIALS AND METHODS

All imaging departments in the UK were contacted and asked about the provision of home reporting and IT support before and after the first wave of the pandemic.

RESULTS

One hundred and thirty-seven of the 217 departments contacted replied, producing a response rate of 61%. There was a 147% increase in the provision of remote access viewing and reporting platforms during the pandemic. Although 578 consultants had access to a viewing platform pre-pandemic, this had increased to 1,431 during the course of the first wave.

CONCLUSION

This survey represents work undertaken by UK NHS Trusts in co-ordinating and providing increased home-reporting facilities to UK radiologists during the first wave of this global pandemic. The impact of these facilities has been shown to allow more than just the provision of reporting of both elective and emergency imaging and provides additional flexibility in how UK radiologists can help support and provide services. This is a good start, but there are potential problems that now need to be overcome.

Royal College of Radiologists national audit evaluating the provision of imaging in the severely injured patient and compliance with national guidelines

AIM

To evaluate the provision of imaging in severely injured patients and com pliance with national guidelines.

MATERIALS AND METHODS

Two data collection tools were sent to all Royal College of Radiologist audit leads in radiology departments with an emergency department throughout the UK. The first focused on configuration of radiology departments, number of patients scanned for major trauma and service configuration for major trauma. The second focused on reporting times for 30 patients scanned for major trauma.

RESULTS

Eighty-five out of 191 (45%) eligible departments responded: 16 (19%) from major trauma centres, 52 (61%) from trauma units and 17 (20%) from other hospitals with an emergency department. Data were collected for 2,161 scans: 450 from major trauma centres, 1,400 from trauma units and 311 from emergency departments. Seven hundred and eighty-four (36%) scans were performed in hours and 1361 (63%) out of hours. Two hundred and forty (11%) scans had a primary survey report documented, of which 53 (22%) were unavailable to clinicians after 20 minutes. Time to final consultant report was within 1 hour for 1,033 (48%) scans and within 2 hours for an additional 540 (25%) scans. 34/85 (40%) departments have registrars first on call for major trauma who report scans out of hours and have a consultant final report the next day.

CONCLUSIONS

This study highlights significant deficiencies in care and imaging of severely injured patients within major trauma centres and trauma units. Infrastructure and staffing have been underfunded and under resourced to meet rapidly changing best practice requirements in the management of major trauma.

Female surgical trainee attrition

Why do women drop out?

Uptake of tamoxifen in consecutive premenopausal women under surveillance in a high-risk breast cancer clinic

BACKGROUND

Randomised trials of tamoxifen versus placebo indicate that tamoxifen reduces breast cancer risk by approximately 33%, yet uptake is low. Approximately 10% of women in our clinic entered the IBIS-I prevention trial. We assess the uptake of tamoxifen in a consecutive series of premenopausal women not in a trial and explore the reasons for uptake through interviews.

METHODS

All eligible women between 33 and 46 years at ≥17% lifetime risk of breast cancer and undergoing annual mammography in our service were invited to take a 5-year course of tamoxifen. Reasons for accepting (n=15) or declining (n=15) were explored using semi-structured interviews.

RESULTS

Of 1279 eligible women, 136 (10.6%) decided to take tamoxifen. Women >40 years (74 out of 553 (13.4%)) and those at higher non-BRCA-associated risk were more likely to accept tamoxifen (129 out of 1109 (11.6%)). Interviews highlighted four themes surrounding decision making: perceived impact of side effects, the impact of others' experience on beliefs about tamoxifen, tamoxifen as a 'cancer drug', and daily reminder of cancer risk.

CONCLUSIONS

Tamoxifen uptake was similar to previously ascertained uptake in a randomised controlled trial (IBIS-I). Concerns were similar in women who did or did not accept tamoxifen. Decision making appeared to be embedded in the experience of significant others.

Temporal trends in imaging and associated radiation exposure in inflammatory bowel disease

OBJECTIVES

Increasing use of diagnostic imaging in inflammatory bowel disease (IBD) has led to concerns about the malignant potential of ionising radiation in a cohort that have an increased lifetime risk of gastrointestinal malignancy. The aim was to quantify radiation exposure in IBD patients referred from primary care, determine predictors of high exposure and evaluate temporal trends in diagnostic imaging over a 20-year period.

METHODS

This was a retrospective cohort study whereby IBD patients were recruited from the outpatient clinic and evaluated retrospectively. The total cumulative effective dose (CED) received from tests was calculated for each subject. Cox regression was performed to assess factors associated with potentially harmful levels of ionising radiation defined as total CED > 50 milli-sieverts (mSv; equivalent to five CT abdomen scans).

RESULTS

The cohort included 415 patients. Median total CED was 7.2 mSv (IQR: 3.0-22.7) in Crohn's disease and 2.8 mSv (IQR: 0.8-8.9) in ulcerative colitis patients, respectively. A total of 32 patients (8%) received a CED > 50 mSv. A history of IBD-related surgery was associated with high exposure (HR 7.7). During the study period, usage of abdominal CT increased by 310%.

CONCLUSION

Approximately 1 in 13 patients in the study cohort were exposed to potentially harmful levels of ionising radiation. Strategies to minimise exposure to diagnostic medical radiation in IBD patients are required.

Abstract P1-09-05: The RAZOR trial: a phase II prevention trial of screening plus goserilin and raloxifene versus screening alone in pre-menopausal women at increased risk of breast cancer

Background: Observational studies indicate that oophorectomy at about age 40 reduces breast cancer risk by approximately a half in high risk women. Widespread use of risk reducing oophorectomy is unlikely to be acceptable to these women. We explored the feasibility of giving goserelin to produce reversible ovarian suppression together with raloxifene to maintain bone mineral density (BMD).

Objectives: The primary study objective was adherence to treatment. Secondary objectives were uptake of randomisation, side effects/quality of life and measures of effect on bone and in serum.

Methods: Recruitment was from 3 UK Family History Clinics. Consenting women at ≥ 1 in 3 lifetime risk of breast cancer were randomised to control or monthly subcutaneous goserelin 3.6 mg and raloxifene 60 mg/d orally for two years. Questionnaires (Endocrine Symptom Checklist, Trait & State Anxiety, Sexual Activity & Cancer Worry) measuring toxicity/quality of life were administered by nurses. Dual energy X-ray absorptiometry (DXA) BMD measurements were performed in the treatment arm annually. Lipids and collagen breakdown products were measured by standard methods.

Results: 75 of 511 (14.7%) women approached agreed to randomisation (38 to treatment and 37 to control). The major reason for non-entry was fear of side effects (85%). Median age was 37 and 35 years, for the experimental (A) and control arm (B), respectively. Median follow up is 8.8 years. 20/38 in arm A and 27/37 of controls completed the 24 m study. 18/38 women in arm A withdrew (13 [34%] because of side effects) and 10/37 in arm B for various reasons including the desire for risk reducing surgery (n = 4). No significant differences were seen in the Endocrine Symptom Sub-scale, State or Trait anxiety or Cancer Worry. However, Hot flushes, night and cold sweats (together p &lt;0.005), vaginal dryness (p = 0.006); loss of interest in sex, dyspareunia and reduced sexual pleasure (together p &lt; 0.005) were significantly more in arm A. Despite this, 11 of 23 women in arm A when asked would have been happy to complete a potential five years of treatment. BMD declined by 3–7% and Ctx significantly increased (p &lt; 0.005 each) but both returned to baseline by year 3. Lipids were unchanged. 4 women later developed breast cancer in arm B and 2 in arm A.

Conclusions: Uptake and adherence to treatment was relatively low in this group of women at high risk. The major reason for low uptake was fear of side effects and these were the major reason for drop out from treatment. Raloxifene did not maintain BMD. This approach to breast cancer prevention induced significant symptoms and bone loss, thus methods to ameliorate these need to be developed if ovarian suppression is to play a role in breast cancer prevention.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P1-09-05.

Explaining the decrease in mortality from abdominal aortic aneurysm rupture

BACKGROUND

A steady rise in mortality from abdominal aortic aneurysm (AAA) was reported in the 1980s and 1990 s, although this is now declining rapidly. Reasons for the recent decline in mortality from AAA rupture are investigated here.

METHODS

Routine statistics for mortality, hospital admissions and procedures in England and Wales were investigated. All data were age-standardized. Trends in smoking, hypertension and treatment for hypercholesterolaemia (statins), together with regression coefficients for mortality, were available from public sources for those aged at least 65 years. Deaths from ruptured AAA avoided in this age group were estimated by using the IMPACT equation: deaths avoided = (deaths in index year) × (risk factor decline) × β-coefficient.

RESULTS

From 1997, deaths from ruptured AAA have decreased sharply, almost twofold in men. Hospital admissions for elective AAA repair have increased modestly (from 40 to 45 per 100,000 population), attributable entirely to more procedures in those aged 75 years and over (P < 0.001). Admissions for ruptured AAA have declined from 18.6 to 13.5 per 100,000 population, across all ages, with the proportion offered and surviving emergency repair unchanged. From 1997, mortality from ruptured aneurysm in those aged at least 65 years has fallen from 65.9 to 44.6 per 100,000 population. An estimated 8-11 deaths per 100,000 population were avoided by a reduced prevalence of smoking and a similar number from an increase in the number of elective AAA repairs. Estimates for the effects of blood pressure and lipid control are uncertain.

CONCLUSION

The reduction in incidence of ruptured AAA since 1997 is attributable largely to changes in smoking prevalence and increases in elective AAA repair in those aged 75 years and over.

Use of small bowel imaging for the diagnosis and staging of Crohn's disease--a survey of current UK practice

OBJECTIVES

This study used a postal survey to assess the current use of small bowel imaging investigations for Crohn's disease within National Health Service (NHS) radiological practice and to gauge gastroenterological referral patterns.

METHODS

Similar questionnaires were posted to departments of radiology (n = 240) and gastroenterology (n = 254) identified, by the databases of the Royal College of Radiologists and British Society of Gastroenterologists. Questionnaires enquired about the use of small bowel imaging in the assessment of Crohn's disease. In particular, questionnaires described clinical scenarios including first diagnosis, disease staging and assessment of suspected extraluminal complications, obstruction and disease flare. The data were stratified according to patient age.

RESULTS

63 (27%) departments of radiology (20 in teaching hospitals and 43 in district general hospitals (DGHs)) and 73 (29%) departments of gastroenterology replied. These departments were in 119 institutions. Of the 63 departments of radiology, 55 (90%) routinely performed barium follow-though (BaFT), 50 (80%) CT, 29 (46%) small bowel ultrasound (SbUS) and 24 (38%) small bowel MRI. BaFT was the most commonly used investigation across all age groups and indications. SbUS was used mostly for patients younger than 40 years of age with low index of clinical suspicion for Crohn's disease (in 44% of radiology departments (28/63)). MRI was most frequently used in patients under 20 years of age for staging new disease (in 27% of radiology departments (17/63)) or in whom obstruction was suspected (in 29% of radiology departments (18/63)). CT was preferred for suspected extraluminal complications or obstruction (in 73% (46/63) and 46% (29/63) of radiology departments, respectively). Gastroenterological referrals largely concurred with the imaging modalities chosen by radiologists, although gastroenterologists were less likely to request SbUS and MRI.

CONCLUSION

BaFT remains the mainstay investigation for luminal small bowel Crohn's disease, with CT dominating for suspected extraluminal complications. There has been only moderate dissemination of the use of MRI and SbUS.

Advances in prostate cancer immunotherapy

Metastatic prostate cancer remains incurable. Harnessing the body's own immune system to control or eradicate tumours has long been an attractive concept. Only recently has the field of tumour immunology provided the basic science behind the mechanisms of tumour genesis, molecular basis of the recognition of tumour associated antigens and the interactions of the antigen-presenting cells with effector cells. This research has been translated into numerous clinical immunotherapy strategies, which have reached the oncology clinic and which should provide options for our patients.

The influence of 4G/5G polymorphism in the plasminogen activator inhibitor-1 gene promoter on the incidence, growth and operative risk of abdominal aortic aneurysm

BACKGROUND

a single base pair deletion/insertion (4G/5G) polymorphism in the plasminogen activator inhibitor (PAI-1) promoter appears to influence PAI-1 synthesis (increased PAI-1 and inhibition of fibrinolysis with the 4G allele) and survival after severe trauma.

OBJECTIVE

to identify whether the 4G/5G polymorphism influences the natural history of abdominal aortic aneurysm (AAA).

METHODS

Four hundred and sixty patients with small AAA were genotyped for the 4G/5G polymorphism. AAA growth was assessed from serial ultrasonographic measurements, subject to linear regression analysis. Mortality following eventual elective surgery was recorded.

RESULTS

the frequency of the 3 genotypes (4G4G, 4G5G and 5G5G) was in Hardy-Weinberg equilibrium and similar to that in a healthy population. The mean aneurysm growth rate was 0.37, 0.35 and 0.44 cm/year respectively for patients of 4G4G, 4G5G and 5G5G genotype respectively, p = 0.07. The 30d mortality following open elective aneurysm repair was 8% (7/87), 8% (11/145) and 0% (0/56) for patients of 4G4G, 4G5G and 5G5G genotype respectively, giving a higher mortality for those carrying a 4G allele p = 0.03.

CONCLUSIONS

polymorphism of the PAI-1 gene promoter does not influence the development of AAA, although AAA growth is faster for patients of 5G5G genotype. However, this genotype (5G5G), which is associated with enhanced fibrinolysis, appears protective following open aneurysm repair. This effect of PAI-1 genotype on survival following surgery is likely to have widespread significance in vascular and general surgery.

Fathers' coping style, antenatal preparation, and experiences of labor and the postpartum

BACKGROUND

In recent years the trend for fathers in Western postindustrial countries to attend childbirth has increased. This study examined the interaction between fathers' information-seeking coping predispositions and their level of attendance at antenatal classes with respect to their experiences of attending childbirth. Associations between fathers' childbirth experiences, their relationship with their baby, and level of depressive symptomatology at 6 weeks postpartum were also examined.

METHODS

A quantitative methodology was employed in which 78 fathers completed several questionnaires, some within 6 days of childbirth and others at 6 weeks postpartum.

RESULTS

Fathers who were characterized as high blunters (avoiders) of threat information, from antenatal classes reported that experiencing childbirth was less fulfilling than fathers with similar coping styles who did not attend classes. Fathers' reports of fulfillment and delight while attending childbirth were negatively related to their level of depressive symptomatology at 6 weeks postpartum. Levels of distress were associated with subsequent depressive symptoms, but their effect was removed when preexisting depressive symptoms were partialled out. Fathers whose children were born by cesarean delivery used significantly more negative adjectives to describe their baby at 6 weeks postpartum compared with those born by vaginal delivery. More married fathers attended antenatal classes and reported lower levels of depressive symptomatology than unmarried fathers.

CONCLUSIONS

Although fathers' attendance at antenatal classes may have positive consequences for them and their partner, for some fathers, attendance at classes may be associated with less positive reports of experiencing childbirth. The way in which men experience childbirth may have some influence on their subsequent emotional well-being.

The European Board of Surgery Qualification (EBSQ) was born in 1996

The EU has sent delegates to the Section of Surgery, UEMS and the EBS for some years. The EBSQ is the only way to harmonise surgical standards across the EU. It is recognised that standards very across Europe and although CCST must be recognised across Europe, in practice there are 15 CCSTs of different standards. UK and Ireland have surgical training programmes and standards which are admired and the EBSQ has been centred in London and the sterling area. There is therefore a unique opportunity to influence European surgery. What is far from certain is whether UK trainee surgeons will feel the need to take EBSQ, for them it is very much an optional extra.

The impact of genetic counselling on risk perception in women with a family history of breast cancer

Women with a family history of breast cancer generally self-refer because they have a feeling that their risk is high. However, they have, in general, only a hazy notion of the population risk of breast cancer and their own risk in relation to this. It is probable that they are helped by genetic counselling and, if at substantial risk, by annual mammography. However, the psychological impact of assigning true risk and the value of mammography need to be evaluated. We have assessed risk perception by questionnaire in 517 new referrals to a family history clinic and 200 women returning to the clinic at least 1 year after counselling. Correct assignment of population lifetime risk of breast cancer was 16% in the uninformed precounsel group and 33% in the post-counsel group, likewise personal risk was correct in 11% and 41% respectively. Post-counsel women were significantly more likely to retain information if they were sent a post-clinic letter or if they assessed their personal risk as too high initially.

Community leg ulcer clinics: cost-effectiveness

This study investigates the cost-effectiveness and efficacy of a new service provided by community leg ulcer clinics, and compares it with treatment in existing hospital-based venous ulcer care clinics. Data were provided prospectively from district nurses and retrospectively from patients. Success in treatment was assessed as a percentage of ulcers completely healed after 12 weeks of treatment, analysed by the up-table method. Treatment success of 22% at 12 weeks using existing methods compared with 80% in community clinics. Costs were estimated to be 433,600 pounds and 169,000 pounds respectively. These findings indicate that community leg ulcer clinics were more effective and less expensive than the previous system of care.

Isolation and characterization of enniatins from Fusariumavenaceum DAOM 196490

Dried mycelia from a 15 L stirred-jar fermentation culture of Fusariumavenaceum (DAOM 196490) were extracted with dichloromethane and partitioned between hexane and methanol/water. Recrystallization of the hexane fraction yielded 6.750 g of a crude mixture of enniatins. Fast atom bombardment mass spectrometry showed, in accord with previous studies, that enniatin A was the predominant enniatin present, with smaller amounts of enniatins A1 and B1. HPLC purification of 500 mg of the enniatin mixture resulted in the isolation of 300 mg of enniatin A, 114 mg of enniatin A1, 9 mg of enniatin B1, and 46 mg of a new, N-methylleucine-containing enniatin (A2). This is the first reported isolation of a pure N-methylleucine-containing enniatin from Fusarium, though the existence of such compounds had previously been inferred from hydrolysis and NMR data. The purification and complete characterization of enniatins A1, B1, and A2 are reported.

Antiplatelet drugs in femoropopliteal vein bypasses: a multicenter trial

To evaluate the influence of antiplatelet drugs on patency in femoropopliteal vein bypasses, 48 vascular surgeons recruited 549 patients to a randomized double-blind trial of aspirin (300 mg) + dipyridamole (150 mg) or placebo twice daily starting 2 days before surgery and continuing indefinitely. Graft occlusion measured objectively by independent coordinators and cardiovascular events (myocardial infarction or stroke) were studied, expressed by life table, and analyzed statistically by log rank and confidence intervals (95% CI). Randomization achieved comparable groups with 60% of grafts inserted for rest pain or gangrene. Operative complications on aspirin plus dipyridamole included 18 reoperations for bleeding and 12 hematomas compared with 9 and 14, respectively, on placebo (NS). Most of the 172 graft failures occurred early with failure rates of 43/1000 patient-months in the first 3 months, reducing to 17/1000 at 6 to 12 months, and under 10/1000 in subsequent years. Cumulative graft patency on placebo was 72%, 62%, and 60% at 1, 2, and 3 years, respectively, compared with 78%, 70%, and 61% on aspirin plus dipyridamole. The difference in patency of 6.1% (95% CI, -3% to 15.5%) at 1 year and 8.0% (95% CI, -5% to 21%) at 2 years failed to achieve significance (p = 0.43). On mean follow-up of 34 months, 53 (132/1000 patient-years) cardiovascular events (myocardial infarction or cerebrovascular accident) occurred in patients on placebo compared with only 35 (73/1000) on aspirin plus dipyridamole, a significant difference of 59/1000 (p = 0.004). Antiplatelet therapy had little influence on femoropopliteal vein patency, but subsequent myocardial infarction and stroke was reduced in these patients with peripheral vascular disease.

The influence of smoking and plasma factors on prosthetic graft patency

The effects of smoking and plasma risk factors on the patency of prosthetic femoro-popliteal bypass grafts were investigated in 93 patients entered into a multicentre trial of prosthetic graft materials (70 patients had patent grafts and 23 patients had occluded grafts 2 years after surgery). The smoking markers thiocyanate and fibrinogen were significantly higher in patients with occluded grafts, whereas LDL-cholesterol was significantly higher in patients with patent grafts 2 years after bypass. Based on smoking markers, graft patency in smokers was 57% at 2 years by life table, compared to 78% in non-smokers. P less than 0.05. Fibrinogen was an important variable, predicting graft occlusion with graft patency in patients with below median fibrinogen levels, being 84% at 2 years by life table compared to 51% in those with above median fibrinogen levels, P less than 0.025. Although increased levels of LDL-cholesterol have been associated with accelerated atherosclerosis, patients with above median levels of LDL-cholesterol had improved graft patency (83%) at 2 years compared to patency in patients with below median LDL-cholesterol (60%), P less than 0.05. The plasma risk factors associated with the failure of prosthetic grafts are similar to those associated with the failure of saphenous vein grafts, indicating that higher fibrinogen levels and smoking may contribute to an hypercoagulable state. Greater efforts are needed to stop patients smoking after vascular reconstruction.

Lipids and apolipoprotein profiles in men with aneurysmal and stenosing aorto-iliac atherosclerosis

The plasma lipids, lipoproteins and apolipoproteins have been compared in two groups of men with aorto-iliac atherosclerosis: Aneurysmal disease (n = 42) and stenosing disease (n = 86). The mean age of the men aneurysmal disease was 67.5 +/- 5.8 years and the mean age of the men with stenosing disease was 65.0 +/- 6.1 years: There was no significant different in body mass indices or smoking habits between the groups. The patients with aneurysmal disease had lower levels of plasma cholesterol than patients with stenosing disease (5.53 +/- 1.17 versus 6.11 +/- 1.20 mmol/L, P less than 0.05), but carried more cholesterol in VLDL compared to patients with stenosing disease (1.00 +/- 0.90 versus 0.60 +/- 65 mmol/L, P less than 0.05). Significantly lower concentration of apolipoprotein AI and HDL-cholesterol in patients with aneurysmal disease (ApoAI 1.01 +/- 0.31 versus 1.18 +/- 0.31 mmol/L, P less than 0.02, HDL 0.93 +/- 0.53 versus 1.13 +/- 0.34, P less than 0.05) was another characteristic difference between these two groups of patients with peripheral arterial disease. Otherwise, there were no obvious differences in the levels of plasma triglyceride, VLDL-triglyceride, LDL-cholesterol, and apolipoproteins B, C-III and E between the two groups. Although lipid and apolipoprotein profiles may not discriminate between aneurysmal and stenosing disease, different types of lipoprotein particles may contribute to the atherosclerotic process characterising both diseases.

Pilot study of a screening test for peripheral arterial disease in middle aged men: fibrinogen as a possible risk factor

A simple one minute exercise test was used as a screening test for asymptomatic peripheral arterial disease in a sample of 100 men in their sixth decade with no previous referrals for cardiovascular disease. Other investigations included resting ECG, non-invasive carotid artery assessment, and plasma biochemical analysis. Of these 100 men (mean age 56), 10 had evidence of peripheral disease on exercise testing, four had ischaemic changes on resting ECG, and one showed evidence of carotid artery stenosis. A total therefore of 15 out of 100 (15%) had asymptomatic arterial disease. These 15 men had increased concentrations of plasma fibrinogen (4.3(0.7) g.litre-1) compared with men with no evidence of arterial disease (3.5(0.7) g.litre-1; p less than 0.01). The one minute exercise test is a useful screening test for peripheral arterial disease, and this pilot study suggests that raised plasma fibrinogen concentrations may be an important risk factor.

Simultaneous analysis of nivalenol and deoxynivalenol in cereals by liquid chromatography

A sensitive method is described for determination of nivalenol (NIV) and deoxynivalenol (DON) in cereals by using reverse phase liquid chromatography and UV detection at 222 nm. The sample is extracted with acetonitrile-water (85 + 15) and an aliquot is purified by passage through a combined column of cation exchange resin and alumina-carbon (20 + 1). Analysis at this stage is possible with some samples but the method recommends passing an aliquot through a carbon minicolumn after evaporation and solubilization in methanol. Interference from coextracted compounds at this point is negligible. Recoveries of both NIV and DON from spiked extracts taken through the full method were in the range 83-94%. The relative standard deviation, based on 5 replicate determinations from each of 2 corn samples, was approximately 5% for both NIV and DON. With a 10 microL injection, the minimum contamination (3 X signal/noise ratio) able to be detected in cereal samples was about 0.015 micrograms NIV/g and 0.05 micrograms DON/g. The cleaned up extracts are also suitable for analysis by gas chromatography.

Effects of feeding white Leghorn hens diets that contain deoxynivalenol (vomitoxin)-contaminated wheat

A short-term (10 weeks, Experiment 1) and a long-term experiment (24 weeks, Experiment 2) were done to determine effects of incorporating either white winter wheat, naturally contaminated with 1 mg deoxynivalenol (DON)/kg, or spring wheats, containing up to 6.5 mg DON/kg, into the diets of White Leghorn hens. Based on chemical analysis, the diets in Experiment 1 contained less than .05 to .7 mg DON/kg, while those in Experiment 2 contained from .2 to 4.9 mg/kg. Incorporation of winter or spring wheat in the experimental diets had no effect (P greater than .05) on feed intake and efficiency, egg production and yield, the number of soft shell and cracked eggs observed in the laying house, body weight at the completion of the experimental period, fertility, hatchability of fertile eggs, and the proportion of malformed embryos and pips. In addition, presence of DON-contaminated wheat did not influence (P greater than .05) the organ weight to body weight ratio for a randomly selected sample of hens necropsied at the completion of each experiment. There was little evidence of lesions in the oral cavity, esophagus, proventriculus and gizzard, hemorrhaging in the viscera or skeletal muscles, or of changes in the appearance of spleen, heart, and kidney. However, the livers from DON hens were fatty in appearance. Furthermore, vomiting (emesis), diarrhea, or changes in behaviour were not apparent and mortality, normally very low, was not increased during either experiment. Inverse linear relationships were obtained in Experiment 1 between dietary DON concentrations and egg weight (P less than .05), shell weight and thickness (P less than .01), and percent shell (P less than .05). Although egg and shell variables measured in Experiment 2 were not significantly influenced (P greater than .05) by DON treatment, trends towards lower values with higher dietary DON levels were evident. Egg specific gravity, nondestructive deformation, and quasistatic compression fracture strength of the egg's shell were not influenced (P greater than .05) by dietary DON levels. The results from these experiments indicate that laying hens can tolerate diets containing up to 5 mg DON/kg from white winter or spring wheat for extended periods of time without serious adverse effects on health and productivity.

Toxigenic Potential of Some Fusarium Isolates from Southeast Asia

The isolation and characterization of 10 isolates of six Fusarium spp. from plant and soil samples collected in Southeast Asia is reported. The ability of these isolates to produce trichothecenes both in liquid cultures (CZ, GYEP, and MYRO) and on rice was assessed, and their toxigenic potential was examined by skin assay and gavage studies with culture filtrates. Although culture filtrates of all the isolates caused minor damage to test animals, only that of F. equiseti DAOM 189762 produced trichothecenes.

Subacute toxicity of dietary 3-acetyldeoxynivalenol in mice

3-Acetyldeoxynivalenol was incorporated into a semisynthetic diet at levels of 2.5, 5, 10 or 20 ppm and fed to mice for up to 48 days. Body weights and feed consumption were determined, and blood samples for hematological evaluation were taken. Selected tissues were examined microscopically and the humoral immune response was assessed using the Jerne plaque assay. 3-Acetyldeoxynivalenol caused a dose-related depressed feed consumption within the first seven days and reduced body weight until day 14 when fed at levels up to 10 ppm. When fed at a level of 20 ppm, an initial depression in body weight gain and a general malaise were followed by a return to normal. At necropsy, no macroscopic or microscopic lesions could be found. The immune response was not significantly affected after seven or 14 days, but at 21 days, a dose-dependent enhanced response was observed. The findings indicate that, after an initial period of reduced feed intake, animals are apparently able to overcome the toxic effects of 3-acetyldeoxynivalenol.

Pathology of acute 3-acetyldeoxynivalenol toxicity in mice

Mice were killed 2, 4, 6, 12, 24, 48 and 96 hours after intragastrical administration of 0, 5, 10, 20, or 40 mg/kg body weight of 3-acetyldeoxynivalenol. The animals became clinically ill after 12 hours and some animals in the highest dose group died. Histological examination of duodenal crypts, thymus and spleen revealed, in all dose groups, presence of the characteristic lesions that are known to be produced by trichothecenes, but the intensity of lesions in the 40 mg group corresponded to lesions known to be caused by 4 mg/kg of T-2 toxin. A rabbit skin bioassay with 3-acetyldeoxynivalenol gave negative results on one occasion and a mild reaction to 100 to 500 micrograms/mL on another. It is concluded that 3-acetyldeoxynivalenol is considerably less toxic than T-2 toxin, but causes acute effects in the dividing cells of the body in a manner characteristic of trichothecenes.

13C NMR study of the biosynthesis of toxins by Fusarium graminearum

13C NMR spectroscopic investigations on the biosynthesis of mycotoxins produced by Fusarium graminearum (M69) were carried out through the incorporation of [1-13C]- and [2-13C]acetate precursors. The major secondary metabolites produced by this species in still culture were deoxynivalenol (3,7,15-trihydroxy-12,13-epoxytrichothec-9-en-one), 15-acetyldeoxynivalenol, zearalenone, and butenolide. [1-13C]- and [2-13C]acetate were incorporated in alternate carbon atoms in zearalenone, consistent with the head to tail condensation of nine acetate units. The trichothecenes were enriched in a manner consistent with the condensation of three mevalonate units. 13C/13C couplings, observed between C-5 and C-12, as well as between C-6 and C-15 of 15-acetyldeoxynivalenol, confirms the current hypothesis of formation of the trichothecene ring system by cyclization of farnesyl pyrophosphate. The incorporation pattern in ergosterol is also consistent with a mevalonate origin, while the adjacent incorporation of acetate methyl groups in butenolide suggests a glutamate precursor. The degree of enrichment in the secondary metabolites, which ranged from 3 to 10% at each carbon site, was observed in the 13C NMR spectra of the crude fungal extracts to be dependent on the timing of acetate addition to the culture. The specific toxins produced together with the quantity of each, were also found to be dependent on the timing of acetate addition. Competition between the three biosynthetic pathways of secondary metabolism, i.e. polyketide, mevalonate, and amino acid for the labeled acetate in this organism is a complex function of culture conditions.

Ingestion of vomitoxin (deoxynivalenol)-contaminated wheat by nonlactating dairy cows

Our objective was to determine if there were serious deleterious effects of wheat naturally contaminated with vomitoxin (deoxynivalenol) on nonlactating dairy cows. Comparisons were between two Quebec spring wheat sources contaminated with Fusarium graminearum in a feeding trial involving 10 nonlactating Holstein dairy cattle offered good quality hay for ad libitum intake supplemented with wheat-oats concentrate (1 kg concentrate/100 kg body weight). Initially, for 3 wk all cows were fed hay plus wheat-oats containing 1.5 mg vomitoxin/kg. Each week thereafter two more cows, chosen at random, were switched to a second wheat-oats concentrate containing higher mycotoxin concentration (6.4 mg vomitoxin/kg). After the last two cows had been on the latter diet for 6 wk, all cows were returned to the previous wheat-oats concentrate containing the lower mycotoxin concentration (1.5 mg vomitoxin/kg). No unusual symptoms of illness that might be attributed to the mycotoxin-contaminated wheat were observed. In body weight gains, the data reflected a linear growth pattern with no apparent effect of changing from low to high vomitoxin content in the concentrate. Generally, consumption of the wheat-oats ration containing 6.4 mg vomitoxin/kg was lower than the 1.5 mg vomitoxin/kg concentrate. The progressive, linear decrease of hay consumption was not affected by source of contaminated wheat-oats diet.

The tolerance of White Leghorn and broiler chicks, and turkey poults to diets that contained deoxynivalenol (vomitoxin)-contaminated wheat

Three experiments were done to determine the effects of giving White Leghorn chickens, broiler chickens, and turkey poults diets that contained white winter or spring wheat contaminated with 4-deoxynivalenol (DON). Diets that contained .35 and .7 mg DON/kg from winter wheat did not (P greater than .05) influence feed intake, body weight gain, feed/gain ratio, and organ weight/body weight ratios of Leghorn and broiler chickens, and poults when fed between 7 and 21 days in Experiment 1. Dietary DON levels up to 4.6 mg/kg increased the feed intakes (P less than .01) and daily body weight gains (P less than .05) of Leghorn chickens between 7 and 35 days of age in Experiment 2 but had little effect (P greater than .05) on these variables for broiler chickens between 7 and 52 days of age in Experiment 3. Within Experiments 2 and 3, feed/gain ratios and organ weight/body weight ratios were similar among the Leghorn and broiler chickens, respectively. The dressing percent and chilled carcass weights of eviscerated broiler chickens were not affected (P greater than .05) by DON in the diets of Experiment 3. Mortality was low (less than 3.3%) for the three experiments and necropsy examination indicated that the birds died from several causes unrelated to the dietary treatment. There was no evidence of emesis during the experiments or of overt changes in the appearance of the oral cavity, heart, liver, spleen, kidney, proventriculus, gizzard, and intestines of a random sample of birds killed by carbon dioxide asphyxiation and necropsied. Differences occurred between the analyzed and calculated DON contents of the experimental diets; possible reasons for these differences are discussed. The results of these experiments indicate that young chickens and turkey poults can tolerate diets that contain DON up to at least 5 mg/kg from white winter or spring wheat.