The effect of manually facilitated flexion of the thoracic spine on the interspinous space among horses with impinging dorsal spinous processes of the thoracic vertebrae

Impinging dorsal spinous processes (IDSP) are typically diagnosed and graded using radiography, during which the effect of the horses' thoracolumbar posture on the interspinous spaces is not commonly considered. Posture can be altered from a spontaneous, relatively extended, or lordotic, position by manual facilitation of thoracic flexion ('thoracic lift'). This study aimed to ascertain if the thoracic vertebral interspinous space distances were increased by using facilitated thoracic flexion to alter the posture in horses diagnosed with IDSP. Seven horses of mixed breed and sex, median age 9.1 years (interquartile range, 7.2-12.4 years), with a diagnosis of thoracic IDSP with no history of spinal surgery, were included in the study. Two sets of radiographs were obtained. The initial set was taken in the horses' spontaneous posture and the second in the manually facilitated flexed posture. Each image was anonymised allowing blinded measurement of the interspinous spaces. Analysis was performed using Hodges-Lehmann median differences estimates. An increase in the median interspinous space distance was achieved after manual facilitation of thoracic flexion at every thoracic intervertebral space (5th-18th thoracic [T] vertebra). The greatest median increase was seen between T7-T8 and T12-T13 (3.1 mm and 3.0 mm, respectively) whereas the lowest median increase was seen between T17-T18 (0.7 mm). In this study, thoracic interspinous space distances could be increased by using manual facilitation to alter the thoracic posture in horses with IDSP, which could affect grading and decision making.

Artificial intelligence-based risk stratification of atrial fibrillation among women with peripartum cardiomyopathy compared to other cardiomyopathies

Background

Atrial fibrillation (AF) is diagnosed in up to 50% of patients with heart failure. However, the prevalence of AF among patients with peripartum cardiomyopathy (PPCM) ranges from only 2–10%, with the lowest rates in Black women. An artificial intelligence enhanced electrocardiogram (AI-ECG) has previously been shown to be effective in detecting AF while in sinus rhythm, and for AF risk prediction in a population-based study.

Purpose

Our objective was to evaluate the use of an AI-ECG for AF risk stratification among women of reproductive age (18 to 49 years) with PPCM compared to other forms of cardiomyopathy.

Methods

We identified 59 reproductive age women with a diagnosis of PPCM between January 2007, and October 2018 and included matched controls in a 3:1 fashion. Matching was performed based on sex, age, race, and left ventricular ejection fraction. We excluded patients with a diagnosis of AF prior to cardiomyopathy diagnosis date. AI-ECG prediction probabilities were generated for ECGs performed within a 30-day window prior to the patient's first cardiomyopathy diagnosis date for the entire study cohort.

Results

A total of 236 patients were included in the final analysis (59 cases, 177 controls). Overall, the median age at cardiomyopathy diagnosis was 31.7 years (IQR: 18.5, 49.4), 76.3% were White, 8.5% were Black, and 15.3% represented other or unknown race. Over the period studied, 3.4% of women with PPCM developed AF compared to 5.6% of women with other cardiomyopathies. The frequency of positive AI-ECG predictions for AF was more common among women with other cardiomyopathies (40.7%) compared to women with PPCM (20.3%). The predicted odds ratio for AF development following a cardiomyopathy diagnosis based on AI-ECG results was 0.37 (95% CI: 0.18, 0.73) for PPCM compared to other cardiomyopathies (p=0.006).

Conclusion

We demonstrated that an AI-ECG model for AF prediction may play a potential role in arrhythmia risk stratification/prediction among young women with PPCM who have a demonstrable lower risk for AF compared to women with other cardiomyopathies. Mechanisms for lower AF risk among patients with PPCM remain unknown. Further studies evaluating mechanistic pathways will be essential.

Funding Acknowledgement

Type of funding sources: None.

Relationship between cardiovascular symptoms, health status assessment and cardiomyopathy in the obstetric population

Background

Pregnancy related cardiomyopathy is a significant cause of maternal morbidity and mortality globally. A presumed overlap between normal pregnancy-associated symptoms and clinical symptoms of cardiomyopathy contributes to delays in diagnosis and increased risk of maternal mortality.

Purpose

We sought to evaluate the association between patient-reported cardiovascular symptoms and the presence of cardiomyopathy among pregnant and postpartum patients. We hypothesize that individual cardiovascular symptoms are unrelated to the presence of cardiomyopathy. We also evaluated the use of a novel adaptation of a validated health status questionnaire in relation to cardiomyopathy.

Methods

We enrolled 48 pregnant (>13 weeks) and postpartum (up to 12 months) participants in a prospective study between October 2021 and February 2022. All study participants completed a baseline questionnaire, which included current cardiovascular symptoms, an assessment of health status using an adapted version of the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), followed by a resting transthoracic echocardiogram on the same day. We defined cardiomyopathy as a left ventricular ejection fraction (LVEF) <50% based on 2-D echocardiography. Fisher's exact and Wilcoxon rank-sum tests were employed to evaluate the association between reported cardiovascular symptoms, the adapted KCCQ-12 (KCC-A) score, and cardiomyopathy.

Results

At the time of enrollment, 67% were pregnant and 33% postpartum. Forty-eight percent identified as White, 31% as Black, 10% as Asian, and 10% as other race. The median age was 31 years (Q1: 28, Q3: 35) and 6% had an LVEF <50%. We found no statistically significant association between four reported cardiovascular symptoms (shortness of breath, orthopnea, fast breathing, and episodes of “asthma” that did not improve with inhalers or other treatment) and cardiomyopathy or medial E/e' ratio. KCC-A scores were low in the study population overall (median 52; Q1:40, Q3: 61). We demonstrated a significantly lower KCC-A score among women with LVEF <50% (median 24; Q1: 15, Q3: 44) compared to women with LVEF ≥50% (median 54; Q1: 44, Q3: 61) p=0.02.

Conclusions

We showed no significant association between individual cardiovascular symptoms and cardiomyopathy in an obstetric population. However, we demonstrate for the first time that an adapted KCCQ-12 questionnaire for health status assessment could potentially identify women with a high-likelihood of cardiomyopathy during the peripartum period who may benefit from additional evaluation including echocardiography. Larger studies are needed to validate this finding.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): This study was funded by a research grant from the Miami Heart Research Institute, Florida Heart Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health

Explainable artificial intelligence (XAI): closing the gap between image analysis and navigation in complex invasive diagnostic procedures

Literature review

Cystoscopy is the gold standard for initial macroscopic assessments of the human urinary bladder to rule out (or diagnose) bladder cancer (BCa). Despite having guidelines, cystoscopic findings are diverse and often challenging to classify. The extent of the false negatives and false positives in cystoscopic diagnosis is currently unknown. We suspect that there is a certain degree of under-diagnosis (like the failure to detect malignant tumours) and over-diagnosis (e.g. sending the patient for unnecessary transurethral resection of bladder tumors with anesthesia) that put the patient at risk.

Conclusions

XAI robot-assisted cystoscopes would help to overcome the risks/flaws of conventional cystoscopy. Cystoscopy is considered a less life-threatening starting point for automation than open surgical procedures. Semi-autonomous cystoscopy requires standards and cystoscopy is a good procedure to establish a model that can then be exported/copied to other procedures of endoscopy and surgery. Standards also define the automation levels—an issue for medical product law. These cystoscopy skills do not give full autonomy to the machine, and represent a surgical parallel to ‘Autonomous Driving’ (where a standard requires a human supervisor to remain in the ‘vehicle’). Here in robotic cystoscopy, a human supervisor remains bedside in the ‘operating room’ as a ‘human‐in‐the‐loop’ in order to safeguard patients. The urologists will be able to delegate personal- and time-consuming cystoscopy to a specialised nurse. The result of automated diagnostic cystoscopy is a short video (with pre-processed photos from the video), which are then reviewed by the urologists at a more convenient time.

377 Expanding the Use of Wide-Awake Local Anaesthesia Non-Tourniquet (WALANT) Technique in The Management of Hand Trauma Patients During the COVID 19 Pandemic

Aim

COVID19 produced a unique challenge to the management of hand trauma. There was reduced theatre capacity and inpatient beds as staff and resources were lost to make way for the critically unwell¹, however the burden of patients (albeit reduced) requiring emergency procedures remained². During 1^stUK peak we adopted a one-stop hand trauma clinic where patients were assessed by senior surgeons and immediately operated on under local anaesthesia with Adrenalin, a model mirrored by other units across the UK during this time^3,4. Subsequent to surgery they were either seen on the same day for advice with a hand therapist or booked for immediate hand therapy follow up.

Method

A retrospective review of 158 cases operated on over a 4-month COVID19 period compared to the same 4-month period 1 year previously. Indications for surgery and type of anaesthesia were recorded. Follow up and complication rates were reviewed for the COVID19 patients.

Results

There were similarities in the demographic of patients across both cohorts and in mechanism of injury, with trauma the highest indication for surgery. The comparable data sets showed only 21% of patients treated used WALANT pre-COVID19 versus 100% of patient during COVID19.

Conclusions

WALANT is a viable model by which to perform emergency hand trauma surgery in a low cost and low resource setting. Previously this model was not utilised to full effect in our hospital. The results demonstrate the adaptability of WALANT in an adverse and dynamic situation, such as COVID19, thus highlighting benefits to patient care and service provision.

Stereotactic Ablative Radiation Therapy for Large (≥5 cm) Non-small Cell Lung Carcinoma

AIMS

Stereotactic ablative radiation therapy (SABR) is a standard of care for medically inoperable early stage non-small cell lung carcinoma. Tumours greater than 5 cm have been excluded from randomised trials using SABR and, hence, it is not used as a standard for larger lung tumours. However, improvements in radiation therapy techniques and the success of SABR in treatment of early stage disease may allow safe delivery of ablative doses to larger tumours. We analysed our experience with tumours ≥5 cm to determine the efficacy and toxicity profile of SABR in this setting.

MATERIALS AND METHODS

We evaluated survival, control rates, patterns of failure and toxicity in patients with a tumour diameter larger than 5 cm that had no nodal or distant metastases treated with SABR technology. Patients had been treated in two centres since 2009 and were retrospectively analysed. All patients had positron emission tomography staging, were discussed at a tumour board and were documented to have no nodal or distant metastatic disease. Treatment outcomes were analysed using Kaplan-Meier estimates and compared using the Log-rank test. Cox regression was used to investigate the association between the survival outcomes and predictor variables.

RESULTS

In total, 86 patients were identified. Six patients had no follow-up imaging. Therefore, 80 patients were available for analysis. All patients were reclassified according to the updated AJCC eighth edition. The median follow-up was 19.6 months. No patients received neoadjuvant or concurrent systemic therapy. One patient received adjuvant systemic therapy. The median age at treatment was 77 years (range 58-91). Eighty-four per cent were stage T3N0M0 and 16% were staged T4N0M0. The median tumour diameter was 5.8 cm (range 5.0-9.3 cm). The median gross tumour volume, measured on a single phase of the respiratory cycle, was 45.7 cm³ (range 12.1-203.3 cm³). The median overall survival was 20.9 months (95% confidence interval 12.6-29.1 months). One-, 2- and 3-year overall survival was 71%, 48% and 32%, respectively. The median local failure-free survival was 19.5 months (95% confidence interval 14.4-24.6). The median disease-free survival was 15.1 months (95% confidence interval 9.9-20.4 months). Local control at 1, 2 and 3 years was 85% (95% confidence interval 76-94%), 71% (95% confidence interval 58-84%) and 57% (95% confidence interval 40-74%), respectively. Forty-four patients (55%) had any treatment failure (local, mediastinal, intrapulmonary or distant metastases). Out-of-field intrapulmonary disease progression was the most common mode of failure, occurring in 21 patients (26%). Local failure occurred in 19 patients (24%) - alone or in combination with other progression. Distant metastases occurred in 20 patients (25%). Neither histological subtype, tumour size nor gross tumour volume had a statistically significant effect on local failure-free survival. Two patients experienced grade 3 late dyspnoea. There were no other reported grade 3 or higher acute or late toxicities.

CONCLUSION

SABR for larger lung tumours ≥5 cm results in high local control and acceptable survival in patients with medically inoperable large non-small cell lung carcinoma treated with radiation alone. Such patients should be considered for SABR owing to fewer treatment fractions and acceptable toxicity. Local control analysis reveals a sustained pattern of local failure emphasising the need for long-term follow-up. Improvements in technical strategies are required to further improve local control.

Medicine, media and the law: The effect on training in obstetrics and gynaecology

The inextricable link between medicine and the legal profession has flourished in the 21st century, with countless newspaper articles and social media content on medical cases visible at every juncture. This is particularly true in the speciality of obstetrics and gynaecology, with one of the highest rates of litigation of all medical specialities. We aimed to evaluate the influence of media and the legal environment on the career of trainees in obstetrics and gynaecology. Under the auspices of the Irish national training body, we distributed a 26-item questionnaire to doctors-in-training (DIT) working in obstetrics and gynaecology in the Republic of Ireland. Descriptive statistics and Chi-squared analyses were performed on the anonymised data. 151 DIT responded to the questionnaire, with a response rate of 86.2 % (sample size = 175). The majority were female (79.9 %, n = 121), Irish (85.5 %, n = 106) and had no children (67.0 %, n = 83). 86.7 % (n = 131) felt that the media did not have a positive impact on patients receiving care, and, further, unfairly represented the speciality (94.1 %; n = 142). Additionally, DIT felt that medico-legal issues had a negative impact on issues such as retention and recruitment. These two areas were implicated in over three quarters of DIT considering leaving the speciality. This study demonstrates that DIT perceive media scrutiny and litigation to have a negative effect on the speciality of obstetrics and gynaecology. Further support integrated into specialist training, is needed to ensure that trainees are adequately equipped to deal with both mainstream and social media as well as interactions they may have with the legal profession as they progress through their career.

Undercarboxylated osteocalcin has no adverse effect on endothelial function in rabbit aorta or human vascular cells

Undercarboxylated osteocalcin (ucOC) improves glucose metabolism; however, its effects on endothelial cell function are unclear. We examined the biological effect of ucOC on endothelial function in animal models ex vivo and human cells in vitro. Isometric tension and immunohistochemistry techniques were used on the aorta of male New Zealand white rabbits and cell culture techniques were used on human aortic endothelial cells (HAECs) to assess the effect of ucOC in normal and high-glucose environments. Overall, ucOC, both 10 and 30 ng/ml, did not significantly alter acetylcholine-induced blood vessel relaxation in rabbits (p > .05). UcOC treatment did not cause any significant changes in the immunoreactivity of cellular signalling markers (p > .05). In HAEC, ucOC did not change any of the assessed outcomes (p > .05). UcOC has no negative effects on endothelial function which is important to reduce the risks of off target adverse effects if it will be used as a therapeutic option for metabolic disease in the future.

Conservative management of complete traumatic pancreatic body transection; A case report

•

Pancreatic trauma is associated with considerable morbidity and mortality.

•

Traditionally, cases that involved injury to the pancreatic duct were almost always managed operatively.

•

Much of the morbidity and mortality associated is related to operative complications.

•

This case highlights that where possible, in instances where there is no bile leak or active haemorrhage, a conservative management approach may be safe and effective.

Introduction

Isolated pancreatic body transection secondary to blunt abdominal trauma is a very rare injury associated with poor outcomes. Almost all previously reported cases were managed by emergency distal pancreatectomy, which is associated with high morbidity and mortality. To our knowledge, this is the first reported case of complete transection of the pancreas at the body that was successfully treated by conservative management in an adult patient.

Presentation of case

A 19-year-old male was found to have complete transection of the pancreatic body on computed tomography (CT) following blunt force abdominal trauma. Given that he was haemodynamically stable without evidence of haemorrhage or bile leakage on imaging, a trial of conservative management was initiated. He remained well through his admission, gradually improving clinically and biochemically with stable appearances on serial imaging. He remains asymptomatic as of six months since discharge from the hospital and continues to be monitored in the outpatient setting.

Discussion

Management of pancreatic trauma with ductal injury has typically been with emergency distal pancreatectomy, which is associated with high morbidity and mortality. The decision to operate should not be purely based on radiological findings, and should take into account clinical status, haemodynamic stability, coexisting injuries and evidence of active haemorrhage or bile leak.

Conclusion

In select cases, it is reasonable to trial conservative management in isolated traumatic pancreatic body fracture by means of close clinical observation and serial imaging. This may allow the patient to avoid a high-risk emergency distal pancreatectomy.

Skin Cancer Excision Is More Efficient and Cost Effectivein a Specialist Secondary Care Service

Aim To compare the relative efficiencies of skin excisions in primary and secondary care. Methods We compared the benign: malignant ratio for specimens referred by General Practice, General Surgery and the Skin Cancer Service to the regional pathology laboratory over one month. We used cost minimization analysis to compare the relative efficiencies of the services. Results 620 excisions were received: 139 from General Practice, 118 from General Surgery and 363 from the Skin Cancer Service. The number (%) of malignant lesions was 13 (9.4%) from General Practice, 18 (15.2%) from General Surgery and 137 (37.7%) from the Skin Cancer Service. Excision was cheaper in General Practice at €84.58 as compared to €97.49 in the hospital day surgical unit. However, the cost per malignant lesion excised was €1779.80 in general practice versus €381.78 in the Skin Cancer Service. Conclusion Our results indicate that moving skin cancer treatment to General Practice may result in an excess of benign excisions and therefore be both less efficient and less cost effective.

Endocannabinoids in aqueous humour of patients with or without diabetes

Objective

The primary aim was to determine endocannabinoid (EC) concentrations of 2-arachidonoylglycerol (2-AG), oleoylethanolamine (OEA), palmitoylethanolamine (PEA) and anandamide (AEA) in the aqueous humour of patients, and to investigate any differences in gender and diabetic or ocular disease status.

Methods and Analysis

Adult participants (age >18 years) listed for a routine cataract surgery were recruited. For patients with diabetes, results from their most recent retinopathy grading were recorded. A sample of aqueous humour was removed from the anterior chamber of the patients and snap-frozen in liquid nitrogen. Levels of 2-AG, PEA, OEA and AEA were measured by liquid chromatography-tandem mass spectrometry.

Results

Aqueous humour samples were taken from 93 patients (female:male=58:35), with a mean age±SD of 72.7±9.5 years. Following gender-specific analysis, the mean aqueous concentration of AEA in female patients without diabetes was significantly higher than in female patients with diabetes (0.20±0.03 nM vs 0.07±0.02 nM, p=0.001). Among female patients with diabetes, the aqueous concentration of 2-AG was higher in those with diabetic retinopathy compared with those with no retinopathy (0.30+0.16 nM vs 0.04±0.01 nM, p=0.0025). The aqueous level of the sum of EC was higher in those with ocular comorbidity (2.49±0.73 vs 1.44±0.17, p=0.0002).

Conclusion

There were gender, diabetes status and comorbidity differences in aqueous humour EC levels. Since EC receptors are present in ocular tissues, including the retina (neurons, glia and endothelial cells), differential levels of ECs in the aqueous humour of patients with and without diabetes may provide a novel therapeutic target for diabetic retinopathy.

A Phase II Toxicity End Point Trial (ICORG 99-09) of Accelerated Dose-escalated Hypofractionated Radiation in Non-small Cell Lung Cancer

AIMS

The objective of this phase II clinical trial was to prospectively evaluate the safety and efficacy of accelerated hypofractionated three-dimensional conformal radiation therapy (3DCRT) in localised non-resectable/non-operable non-small cell lung cancer (NSCLC).

MATERIALS AND METHODS

Sixty patients with stage I-III NSCLC were enrolled in a prospective single-arm All Ireland Co-operative Oncology Research Group (ICORG 99-09) toxicity end point phase II trial. The protocol allocated patients between three radiation schedule dose levels (60, 66 or 72 Gy, in 20, 22 and 24 fractions, respectively, 3 Gy daily, five fractions per week) according to combined lung V_25Gy (V_25Gy ≤ 30%) with built-in early stopping toxicity rules. The primary end point was toxicity with evaluation of dose-limiting toxicity. The secondary objectives included radiological tumour response rate at 3 months after the completion of radiation therapy and the thoracic progression-free survival time.

RESULTS

Sixty patients were recruited from August 1999 to June 2009. Forty-nine patients were included in the primary per-protocol analysis. Eleven patients were not evaluable. In the first 30 evaluable patient cohort, severe oesophageal toxicity was reported in two patients (2/49; 4% experiencing grade 5 oesophageal late toxicity, related to the 97% oesophageal length). The trial was temporarily closed and was then reopened to validate an oesophageal dose volume constraint (DVC) of limiting the length of oesophagus fully encompassed by the 97% isodose to less than 1 cm (applied to 21 patients). The trial prospectively showed the safety of the oesophageal DVC, with no oesophageal toxicity above grade 3 thereafter. Thirty-nine per cent of patients had disease progression at 3-4 months after radiotherapy, 22% had stable disease, 20% had a complete response and 14% had a partial response. The median overall survival was 13.6 months (95% confidence interval 10.5-16.7) and overall survival at 1 and 3 years was 57% and 29%, respectively.

CONCLUSION

A strategy using accelerated hypofractionated 3DCRT is feasible and reasonably safe for patients with inoperable NSCLC. It is safe to deliver for centrally located tumours if DVCs are applied to the oesophagus, which is the primary dose-limiting toxicity. Further studies are required to assess the efficacy of hypofractionated regimens for centrally located tumours using an oesophageal DVC and monitoring for oesophageal toxicity.

RECAST (Remote Ischemic Conditioning After Stroke Trial): A Pilot Randomized Placebo Controlled Phase II Trial in Acute Ischemic Stroke

BACKGROUND AND PURPOSE

Repeated episodes of limb ischemia and reperfusion (remote ischemic conditioning [RIC]) may improve outcome after acute stroke.

METHODS

We performed a pilot blinded placebo-controlled trial in patients with acute ischemic stroke, randomized 1:1 to receive 4 cycles of RIC within 24 hours of ictus. The primary outcome was tolerability and feasibility. Secondary outcomes included safety, clinical efficacy (day 90), putative biomarkers (pre- and post-intervention, day 4), and exploratory hemodynamic measures.

RESULTS

Twenty-six patients (13 RIC and 13 sham) were recruited 15.8 hours (SD 6.2) post-onset, age 76.2 years (SD 10.5), blood pressure 159/83 mm Hg (SD 25/11), and National Institutes of Health Stroke Scale (NIHSS) score 5 (interquartile range, 3.75-9.25). RIC was well tolerated with 49 out of 52 cycles completed in full. Three patients experienced vascular events in the sham group: 2 ischemic strokes and 2 myocardial infarcts versus none in the RIC group (P=0.076, log-rank test). Compared with sham, there was a significant decrease in day 90 NIHSS score in the RIC group, median NIHSS score 1 (interquartile range, 0.5-5) versus 3 (interquartile range, 2-9.5; P=0.04); RIC augmented plasma HSP27 (heat shock protein 27; P<0.05, repeated 2-way ANOVA) and phosphorylated HSP27 (P<0.001) but not plasma S100-β, matrix metalloproteinase-9, endocannabinoids, or arterial compliance.

CONCLUSIONS

RIC after acute stroke is well tolerated and appears safe and feasible. RIC may improve neurological outcome, and protective mechanisms may be mediated through HSP27. A larger trial is warranted.

CLINICAL TRIAL REGISTRATION

URL: http://www.isrctn.com. Unique identifier: ISRCTN86672015.

Remote conditioning or erythropoietin before surgery primes kidneys to clear ischemia-reperfusion-damaged cells: a renoprotective mechanism?

Acute kidney injury is common, serious with no specific treatment. Ischemia-reperfusion is a common cause of acute kidney injury (AKI). Clinical trials suggest that preoperative erythropoietin (EPO) or remote ischemic preconditioning may have a renoprotective effect. Using a porcine model of warm ischemia-reperfusion-induced AKI (40-min bilateral cross-clamping of renal arteries, 48-h reperfusion), we examined the renoprotective efficacy of EPO (1,000 iu/kg iv.) or remote ischemic preconditioning (3 cycles, 5-min inflation/deflation to 200 mmHg of a hindlimb sphygmomanometer cuff). Ischemia-reperfusion induced significant kidney injury at 24 and 48 h (χ(2), 1 degree of freedom, >10 for 6/7 histopathological features). At 2 h, a panel of biomarkers including plasma creatinine, neutrophil gelatinase-associated lipocalin, and IL-1β, and urinary albumin:creatinine could be used to predict histopathological injury. Ischemia-reperfusion increased cell proliferation and apoptosis in the renal cortex but, for pretreated groups, the apoptotic cells were predominantly intratubular rather than interstitial. At 48-h reperfusion, plasma IL-1β and the number of subcapsular cells in G2-M arrest were reduced after preoperative EPO, but not after remote ischemic preconditioning. These data suggest an intrarenal mechanism acting within cortical cells that may underpin a renoprotective function for preoperative EPO and, to a limited extent, remote ischemic preconditioning. Despite equivocal longer-term outcomes in clinical studies investigating EPO as a renoprotective agent in AKI, optimal clinical dosing and administration have not been established. Our data suggest further clinical studies on the potential renoprotective effect of EPO and remote ischemic preconditioning are justified.

Fluctuations and Correlations of Pure Quantum Turbulence in Superfluid 3He-B

We describe the first measurements of line-density fluctuations and spatial correlations of quantum turbulence in superfluid 3He-B. All of the measurements are performed in the low-temperature regime, where the normal-fluid density is negligible. The quantum turbulence is generated by a vibrating grid. The vortex-line density is found to have large length-scale correlations, indicating large-scale collective motion of vortices. Furthermore, we find that the power spectrum of fluctuations versus frequency obeys a -5/3 power law which verifies recent speculations that this behavior is a generic feature of fully developed quantum turbulence, reminiscent of the Kolmogorov spectrum for velocity fluctuations in classical turbulence.

A highly sensitive canine telemetry model for detection of QT interval prolongation: Studies with moxifloxacin, haloperidol and MK-499

INTRODUCTION

Preclinical evaluation of delayed ventricular repolarization manifests electrocardiographically as QT interval prolongation and is routinely used as an indicator of potential risk for pro-arrhythmia (potential to cause Torsades de Pointes) of novel human pharmaceuticals. In accordance with ICH S7A and S7B guidelines we evaluated the sensitivity and validity of the beagle dog telemetry (Integrated Telemetry Services (ITS)) model as a preclinical predictor of QT interval prolongation in humans.

METHODS

Cardiovascular monitoring was conducted for 2 h pre-dose and 24 h post-dosing with moxifloxacin (MOX), haloperidol (HAL), and MK-499, with a toxicokinetic (TK) evaluation in a separate group of dogs. In both cardiovascular and TK studies, MOX (0, 10, 30 and 100 mg/kg), HAL (0, 0.3, 1, 3 mg/kg) and MK-499 (0, 0.03, 0.3 and 3 mg/kg) were administered orally by gavage in 0.5% methylcellulose. Each dog received all 4 doses using a dose-escalation paradigm. Inherent variability of the model was assessed with administration of vehicle (0.5% methylcellulose) alone for 4 days.

RESULTS

Significant increases in QT(c) were evident with 10, 30 and 100 mg/kg of MOX (C(max)< or =40 microM), 0.3, 1 and 3 mg/kg of HAL (C(max)< or =0.36 microM) and 0.3 and 3 mg/kg of MK-499 (C(max)< or =825 nM) with peak increases of 45 (20%), 31 (13%), and 45 (19%) ms, respectively (p< or =0.05).

DISCUSSION

In conclusion, we have demonstrated that the ITS-telemetry beagle dog exhibits low inherent intra-animal variability and high sensitivity to detect small but significant increases in QT/QT(c) interval ( approximately 3-6%) with MOX, HAL and MK-499 in the same range of therapeutic plasma concentrations attained in humans. Therefore, this dog telemetry model should be considered an important preclinical predictor of QT prolongation of novel human pharmaceuticals.

Contrasting mechanical anisotropies of the superfluid 3He phases in aerogel

There has been much recent interest in how impurity scattering may affect the phases of the p-wave superfluid 3He. Impurities may be added to the otherwise absolutely pure superfluid by immersing it in aerogel. Some predictions suggest that impurity scattering may destroy orientational order and force all of the superfluid phases to have an isotropic superfluid density. In contrast to this, we present experimental data showing that the response of the A-like phase to superfluid flow is highly anisotropic, revealing a texture that is easily modified by flow.

Cardiovascular monkey telemetry: Sensitivity to detect QT interval prolongation

INTRODUCTION

Preclinical evaluation of delayed ventricular repolarization manifests electrocardiographically as QT interval prolongation and is routinely used as an indicator of potential risk for pro-arrhythmia (potential to cause Torsades de Pointes) of novel human pharmaceuticals. In accordance with ICH S7A and S7B guidelines we evaluated the sensitivity and validity of the monkey telemetry model as a preclinical predictor of QT interval prolongation in humans.

METHODS

Cardiovascular monitoring was conducted for 2 h pre-dose and 24 h post-dosing with Moxifloxacin (MOX), with a toxicokinetic (TK) evaluation in a separate group of monkeys. In both studies, MOX was administered orally by gavage in 0.5% methylcellulose at 0, 10, 30, 100, 175 mg/kg. Each monkey received all 5 doses using a dose-escalation paradigm. Inherent variability of the model was assessed with administration of vehicle alone for 4 days in all 4 monkeys (0.5% methylcellulose in deionized water).

RESULTS

MOX had no significant effect on mean arterial pressure, heart rate, PR or QRS intervals. MOX produced significant dose-related increases in QTc at doses of 30 (Cmax=5.5+/-0.6 microM), 100 (Cmax=16.5+/-1.6 microM), and 175 (Cmax=17.3+/-0.7 microM) mg/kg with peak increases of 22 (8%), 27 (10%), and 47 (18%) ms, respectively (p<or=0.05; compared to vehicle).

DISCUSSION

In conclusion, we have developed a reproducible, sensitive and reliable primate telemetry model in rhesus monkeys, which exhibits low inherent intra-animal variability and high sensitivity to detect small but significant increases in QT/QTc interval (approximately 4%) with MOX in the same range of therapeutic plasma concentrations attained in humans. Therefore, the primate telemetry model should be considered an important preclinical predictor of QT prolongation of novel human pharmaceuticals.

Effect of montelukast compared with inhaled fluticasone on airway inflammation

BACKGROUND

Inhaled corticosteroids are currently regarded as the gold standard in anti-inflammatory therapy, however, leukotriene receptor antagonists have been ascribed anti-inflammatory properties.

OBJECTIVE

We directly compared the anti-inflammatory effects of inhaled fluticasone propionate (FP, 100 microg Diskus, twice daily) and oral montelukast (MON 10 mg, nocte) in bronchial biopsies of patients with asthma in a double-blind, double-dummy, parallel-group design.

METHODS

Bronchial biopsies, serum and urine samples were collected from 36 atopic asthmatics before and after 8 weeks of treatment. Activated T cells (CD25+), eosinophils (MBP+) and mast cells (tryptase+) were analysed by immunohistochemistry. Serum eosinophil cationic protein (ECP) and IL-5 were analysed by radio and enzyme immunoassay (EIA), respectively. Urinary 9alpha-11beta-PGF2 and leukotriene E4 (LTE4) were measured by EIA.

RESULTS

A comparison of changes from baseline [FP/MON ratio (95% confidence interval)] of activated T cells was not different when subjects were treated with FP compared to treatment with MON [1.00 (0.18-4.86); P=0.924]. Following treatment, mast cells in the FP group were significantly lower than in the group treated with MON [0.39 (0.16-0.97); P=0.041]. There was no difference in the number of eosinophils in the lamina propria following either treatment [0.54 (0.05-2.57); P=0.263]. However, treatment with FP resulted in a significantly greater decrease in serum ECP, compared to treatment with MON [0.37 (0.25-0.71); P=0.002].

CONCLUSIONS

FP appears to be superior to MON as an anti-inflammatory therapy in mild asthmatics.

The complexities of the cardiovascular actions of cannabinoids

The cardiovascular actions of cannbinoids are complex. In general they cause vasorelaxation in isolated blood vessels, while in anaesthetised animals they cause multiphasic responses which involve an early bradycardia and long-lasting hypotension. However, in conscious animals, the picture is one of bradycardia followed by pressor responses. Clearly, the responses to cannabinoids are dependent on the experimental conditions and synthetic cannabinoids and endocannabinoids exhibit different pharmacologies. In terms of mechanisms involved in the vascular responses to cannabinoids, the following have been implicated: the involvement of 'classical' cannabinoid receptors, the involvement of a novel endothelial cannabinoid receptor, the release of nitric oxide, the release of endothelium-derived hyperpolarising factor (EDHF), the activation of vanilloid receptors, metabolism of endocannabinoids to vasoactive molecules, and both peripheral inhibition and central excitation of the sympathetic nervous system.

Fluticasone induces T cell apoptosis in the bronchial wall of mild to moderate asthmatics

BACKGROUND

Cytokines which signal via the gamma chain of the interleukin (IL)-2 receptor and the interferons (IFNs) have been shown to enhance T cell survival in vitro by rescuing cells from apoptosis.

METHODS

A study was undertaken to determine whether treatment with inhaled fluticasone propionate (FP; 250 microg twice daily) for 2 weeks could modulate production of IL-15 or IFN-beta and thereby affect T cell survival in bronchial tissue of 10 patients with mild/moderate asthma. Bronchial biopsy specimens were taken before and on completion of treatment.

RESULTS

The mean (95% CI) number of T cells per unit area decreased in the asthmatic group following 2 weeks of treatment with FP (from 7.0 (5.6 to 8.4) to 4.5 (4.0 to 5.1); p = 0.001). There was an increase in the percentage of T cells undergoing apoptosis following FP treatment as assessed by T cell/TUNEL staining (from 4.5 (2.6 to 6.4) to 8.7 (6.6 to 10.8); p = 0.0001). The percentage of cells staining for IL-15 and IFN-beta in the lamina propria, determined by an alkaline phosphatase biotin streptavidin technique, decreased significantly from baseline values of 31.6 (23.4 to 39.7) to 19.6 (12.5 to 26.7), p = 0.039 for IL-15 and from 18.9 (13.5 to 24.4) to 9.5 (5.9 to 13.1), p = 0.007 for IFN-beta following 2 weeks of treatment with FP. However, only the decrease in the percentage of cells staining for IL-15 was significantly correlated with an increased number of apoptotic T cells following treatment (p = 0.008).

CONCLUSION

These findings support a novel mechanism for the ability of inhaled corticosteroids to decrease T cell numbers, possibly by downregulation of the cytokine IL-15.

Interface pressure sensor for IVRA and other biomedical applications

The fabrication and testing of a minimally intrusive (2 mm high, 10 mm diameter) biomedical interface pressure sensor are described. Such sensors are needed for the implementation of improved safety features in the next generation of automated intravenous regional anaesthesia (IVRA) systems. The sensor utilizes a structured elastomer as a deflection element sandwiched between the plates of a parallel plate capacitor device. Simple mechanical modifications allow sensitivity and zero offset adjustment. The sensor is housed in a package machined from an engineering polymer. The device is easily calibrated using either a bench-top or an on-body calibration procedure. The device is particularly sensitive to cuff artefacts arising from variations in cuff-wrap tightness and folding of the cuff. As such, it offers some promise for detecting potential hazard conditions which can occur during conventional IVRA procedures. For the purpose of unit conversion, 1 Pa = 1 N/m2, 1 MPA = 1 N/mm2 and 40 kPa approximately equal to 300 mmHg.

Release of inflammatory mediators from eosinophils following a hyperosmolar stimulus

Airway dehydration and subsequent hyperosmolarity of periciliary fluid are considered critical events in exercise-induced bronchoconstriction (EIB). It has been shown that an in vitro hyperosmolar stimulation of basophils and mast cells with mannitol can induce the release of histamine and leukotrienes. The aim of this study was to establish if a hyperosmolar challenge could trigger activation of eosinophils to release chemokines and lipid mediators. Peripheral blood eosinophils were isolated from seven asthmatic and six non-asthmatic subjects. Hyperosmolar stimulation of eosinophils with mannitol (0.7 M), resulted in a significant increase in LTC4 levels compared to baseline in both asthmatic (15.2+/-4.6 vs. 70.1+/-9.5; P = 0.0002) and control subjects (14.3+/-4.0 vs. 55.6+/-5.6; P = 0.0001). ECP levels did not increase significantly above baseline following mannitol stimulation in either group. This study shows that eosinophils can be activated by a hyperosmolar stimulus. Therefore it seems reasonable to suggest that eosinophils could contribute to EIB.

Human herpesvirus 8 (HHV-8) detected in two patients with Kaposi's sarcoma-like pyogenic granuloma

AIMS

To report the finding of human herpesvirus 8 (HHV-8) in two patients with Kaposi's sarcoma (KS)-like pyogenic granuloma. This form of pyogenic granuloma closely resembles KS histologically and it has been reported that immunohistochemistry in such lesions may be positive for smooth muscle actin and factor VIII related antigen, which are typically negative in KS. In both patients the lesions were positive for CD31, CD34, smooth muscle actin, and factor VIII related antigen, a profile typical of KS-like pyogenic granuloma. The lesions were tested for the presence of HHV-8 DNA, which to date has been consistently found in all types of KS.

METHODS

The lesions were tested for the presence of HHV-8 DNA using the polymerase chain reaction (PCR). A known HHV-8 positive KS specimen was used as the positive control. Six samples of non-KS vascular skin lesions were used as negative controls for the PCR reaction.

RESULTS

Both lesions were positive on PCR for HHV-8 and the specificity of product was confirmed by direct sequencing. None of the six control vascular skin lesions was positive for HHV-8. These results strongly indicate KS as the true diagnosis and are supported by the reported clinical course in both cases.

CONCLUSIONS

Techniques targeting HHV-8 DNA for detection to confirm a diagnosis of KS are both sensitive and specific. In cases where the differential diagnosis includes KS-like pyogenic granuloma, caution should be taken not to diagnose solely on the basis of immunohistochemistry phenotype. In such cases, PCR targeting HHV-8 DNA sequences is a better diagnostic tool.

Carpal tunnel syndrome: the correlation between outcome, symptoms and nerve conduction study findings

A retrospective study was performed on 62 patients who had undergone carpal tunnel decompression surgery. Each patient was assessed in clinic, their case notes were reviewed and their electrophysiological results were analysed and graded according to severity. The median preoperative duration of symptoms was 2 years. No relationship was found between the nature or duration of pre-operative symptoms and the severity of the electrophysiological impairment. Furthermore, no relationship could be identified between pre-operative nerve conduction impairment and either successful outcome of surgery (defined as complete symptom relief) or time to resolution of symptoms after surgery.

Activated, cytotoxic CD8(+) T lymphocytes contribute to the pathology of asthma death

This study investigates the presence of CD8(+) T lymphocytes and their possible association with viral infection in bronchi of victims of fatal asthma. Postmortem samples from the peribronchial region of the lung were obtained from seven patients who died an asthma death (AD), seven asthmatic patients who died of unrelated causes (AUC), and seven postmortem cases with no history of lung disease (control subjects). Using immunohistochemical techniques, the CD8(+) cytotoxic T-cell population in peribronchial tissue was characterized in three patient groups. The percentage of CD8(+) cells expressing the activation marker CD25 was higher in the AD group than in both the AUC and control groups (11.91 +/- 1.92% versus 3.93 +/- 1.63% and 1.09 +/- 0.56%, respectively (p < 0.001). Perforin expression, a marker of cytotoxicity, was highest in the AD group (9.16 +/- 1.5%) compared with 1.39 +/- 0.9; 1.8 +/- 0.6% in the AUC and control groups respectively (p < 0.001). Expression of interleukin-4 (IL-4) and interferon gamma (IFN-gamma) by CD8(+) T cells was higher in the AD group than the control group (p < 0.05). Furthermore, the IFN-gamma/IL-4 ratio in the AD group was less than half that of the control group (1.46 +/- 0.2 versus 3.2 +/- 0.1; p = 0.02). Using polymerase chain reaction (PCR), viral genome for rhinovirus (RV) was detected in lung tissue from three of the seven cases in the AD group. Two of these cases also had detectable respiratory syncytial virus (RSV). Viral genome for RSV was detected in five of the AUC group and in one of these cases, RV was also detected. No viral genome was detected in the lungs of the control group. In conclusion, this study provides novel evidence of an aberrant CD8(+) T-cell population, possibly in response to viral infection in subjects who die of acute asthma.

Kinin-mediated anaphylactoid reaction implicated in acute intra-operative pulseless electrical activity

A 65-year-old patient undergoing total hip replacement under general anaesthesia suffered acute pulseless electrical activity with a fatal outcome. A kinin-mediated analphylactoid reaction following administration of a polygeline plasma expander (Haemaccel) was implicated by in vitro testing. This case report illustrates the diagnostic difficulties posed by non-histaminoid anaphylactoid reactions and the resistance to epinephrine of kinin-mediated hypotension.

IFN-gamma but not IL-4 T cells of the asthmatic bronchial wall show increased incidence of apoptosis

BACKGROUND

Previous observations have established that IFN-gamma production is depressed in CD4+ T cells from atopic asthmatics compared with non-asthmatics.

OBJECTIVE

The aim of this study was to determine if decreased IFN-gamma production could be due to a dissociation between levels of apoptosis within the T cell subsets of the asthmatic bronchial wall.

METHODS

Twenty asthmatics (10 atopic and 10 non-atopic) and eight non-atopic non-asthmatics underwent bronchoscopy. Cryostat sections of these biopsies were investigated using immunohistological techniques to determine the relative number of CD4/FAS+ and CD4/Bcl-2+ cells. Detection of IFN-gamma+ and IL-4+ was combined with TUNEL staining to determine the proportions of the Th1 and Th2 cells undergoing apoptosis.

RESULTS

Experiments revealed raised proportions of activated CD4+ T cells as assessed by expression of HLA-DR and CD25+ expression in the asthmatic samples. Expression of Bcl-2 by the CD4+ cell population was significantly reduced in the asthmatic compared with the control group (P = 0.002). There was no significant difference in the expression of CD4+ Fas-ligand or the number of CD4+ undergoing apoptosis in the asthmatic and non-asthmatic groups. However, the IFN-gamma+ (P = 0.04) but not IL-4+ T cells in the asthmatic biopsies had significantly higher proportions of apoptotic cells compared with the control group.

CONCLUSION

The evidence supports the hypothesis that Th1/Th2 imbalance in asthmatic inflammation may be a result of premature apoptosis within the Th1 subset.

Benefits of high altitude allergen avoidance in atopic adolescents with moderate to severe asthma, over and above treatment with high dose inhaled steroids

Some patients with severe asthma cannot be controlled with high doses of inhaled steroids (ICS), which may be related to ongoing environmental allergen exposure. We investigated whether 10 weeks of high altitude allergen avoidance leads to sustained benefits regarding clinical and inflammatory markers of disease control in adolescents with persistent asthma despite treatment with high dose ICS. Eighteen atopic asthmatic adolescents (12-18 yr, 500-2000 microg ICS daily) with established house dust mite allergy, participated in a parallel-group study. Quality of life (PAQL), lung function, bronchial hyperresponsiveness (BHR) to adenosine and histamine, induced sputum and urine samples were collected repeatedly from 10 patients during a 10-week admission period to the Swiss Alps (alt. 1560 m) and at 6 weeks after return to sea level. Results were compared with those in eight patients, studied in their home environment at sea level for a similar time period. Throughout the study, asthma medication remained unchanged in both groups. During admission to high altitude, PAQL, lung function, BHR to adenosine and histamine, and urinary levels of eosinophil protein X (U-EPX), leukotriene E4 (U-LTE4) and 9alpha11beta prostaglandin F2 (U-9alpha11beta PGF2) improved significantly (P < 0.05), with a similar tendency for sputum eosinophils (P < 0.07). Furthermore, the changes in PAQL and BHR to adenosine and histamine were greater in the altitude than in the control group (P < 0.05). At 6 weeks after renewed allergen exposure at sea level, the improvements in PAQL (P < 0.05), BHR to adenosine (P < 0.07) and histamine (P < 0.05), as well as U-EPX (P < 0.05) and U-LTE4 (P < 0.05) were maintained. A short period of high altitude allergen avoidance, on top of regular treatment with ICS and long-acting beta2-agonists, results in improvement of asthma, as assessed by clinical and inflammatory markers of disease severity. These findings indicate that short-term, rigorous allergen avoidance can improve the long-term control of severe asthma over and above what can be achieved even by high doses of inhaled steroids.

Brown-Vialetto-Van Laere syndrome: case report and literature review

We describe a case of the Brown-Vialetto-Van Laere syndrome, which is a rare disorder characterized by progressive pontobulbar palsy associated with sensorineural deafness. More than 30 cases have been reported since the first case was described in 1894. We review the literature of this condition, comparing our case with those reported in the literature and emphasizing important features to improve our understanding of this syndrome.