Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

AIMS

The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation.

METHODS AND RESULTS

Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (in-hospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, pre-hospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin.

CONCLUSION

The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality.

Coronary sinus narrowing for the treatment of refractory angina: a multicentre prospective open-label clinical study (the REDUCER-I study)

BACKGROUND

The REDUCER-I study is a prospective (with a retrospective component), open-label, multi-centre, international, post-market study, which collects long-term data of patients with refractory angina treated with the Reducer. Here we present the overall clinical outcomes of the first 228 patients enrolled.

AIMS

The aim of this study is to examine the safety and efficacy of the coronary sinus (CS) Reducer in improving angina severity and quality of life in patients suffering from angina pectoris, refractory to medical and interventional therapies.

METHODS

REDUCER-I is a multicentre, non-randomised observational study. Enrolled patients had refractory angina pectoris Canadian Cardiovascular Society (CCS) class II-IV and were treated with Reducer implantation.

RESULTS

In the first 228 patients (81% male, 68.3±9.6 years), the procedural success rate was 99%, with only one adjudicated possible procedural or device-related MACE. Mean CCS class decreased from 2.8±0.6 at baseline, to 1.8±0.7 at two years. Improvement in ≥1 CCS class was observed in 82%, and in ≥2 CCS classes in 31% of patients at two years. At baseline, 70% of the cohort were reported to be in CCS class III-IV; this portion was reduced to 15% at follow-up. Additional measured parameters of functional class and quality of life were also improved.

CONCLUSIONS

Interim results from the ongoing REDUCER-I study confirm the high safety profile of this therapy in patients suffering from refractory angina. The results also demonstrate sustained improvement in angina severity and in quality of life up to two years.

International Prospective Registry of Acute Coronary Syndromes in Patients With COVID-19

Background

Published data suggest worse outcomes in acute coronary syndrome (ACS) patients and concurrent coronavirus disease 2019 (COVID-19) infection. Mechanisms remain unclear.

Objectives

The purpose of this study was to report the demographics, angiographic findings, and in-hospital outcomes of COVID-19 ACS patients and compare these with pre–COVID-19 cohorts.

Methods

From March 1, 2020 to July 31, 2020, data from 55 international centers were entered into a prospective, COVID-ACS Registry. Patients were COVID-19 positive (or had a high index of clinical suspicion) and underwent invasive coronary angiography for suspected ACS. Outcomes were in-hospital major cardiovascular events (all-cause mortality, re–myocardial infarction, heart failure, stroke, unplanned revascularization, or stent thrombosis). Results were compared with national pre–COVID-19 databases (MINAP [Myocardial Ischaemia National Audit Project] 2019 and BCIS [British Cardiovascular Intervention Society] 2018 to 2019).

Results

In 144 ST-segment elevation myocardial infarction (STEMI) and 121 non–ST-segment elevation acute coronary syndrome (NSTE-ACS) patients, symptom-to-admission times were significantly prolonged (COVID-STEMI vs. BCIS: median 339.0 min vs. 173.0 min; p < 0.001; COVID NSTE-ACS vs. MINAP: 417.0 min vs. 295.0 min; p = 0.012). Mortality in COVID-ACS patients was significantly higher than BCIS/MINAP control subjects in both subgroups (COVID-STEMI: 22.9% vs. 5.7%; p < 0.001; COVID NSTE-ACS: 6.6% vs. 1.2%; p < 0.001), which remained following multivariate propensity analysis adjusting for comorbidities (STEMI subgroup odds ratio: 3.33 [95% confidence interval: 2.04 to 5.42]). Cardiogenic shock occurred in 20.1% of COVID-STEMI patients versus 8.7% of BCIS patients (p < 0.001).

Conclusions

In this multicenter international registry, COVID-19–positive ACS patients presented later and had increased in-hospital mortality compared with a pre–COVID-19 ACS population. Excessive rates of and mortality from cardiogenic shock were major contributors to the worse outcomes in COVID-19 positive STEMI patients.

Safety and efficacy of coronary sinus narrowing in chronic refractory angina: Insights from the RESOURCE study

INTRODUCTION

Refractory angina (RA) is considered the end-stage of coronary artery disease, and often has no interventional treatment options. Coronary sinus Reducer (CSR) is a recent addition to the therapeutic arsenal, but its efficacy has only been evaluated on small populations. The RESOURCE registry provides further insights into this therapy.

METHODS

The RESOURCE is an observational, retrospective registry that includes 658 patients with RA from 20 centers in Europe, United Kingdom and Israel. Prespecified endpoints were the amelioration of anginal symptoms evaluated with the Canadian Cardiovascular Society (CCS) score, the rates of procedural success and complications, and MACEs as composite of all-cause mortality, acute coronary syndromes, and stroke.

RESULTS

At a median follow-up of 502 days (IQR 225-1091) after CSR implantation, 39.7% of patients improved by ≥2 CCS classes (primary endpoint), and 76% by ≥1 class. Procedural success was achieved in 96.7% of attempts, with 3% of procedures aborted mostly for unsuitable coronary sinus anatomy. Any complication occurred in 5.7% of procedures, but never required bailout surgery nor resulted in intra- or periprocedural death or myocardial infarction. One patient developed periprocedural stroke after inadvertent carotid artery puncture. At the last available follow-up, overall mortality and MACE were 10.4% and 14.6% respectively. At one, three and five years, mortality rate at Kaplan-Meier analysis was 4%, 13.7%, and 23.4% respectively.

CONCLUSIONS

CSR implantation is safe and reduces angina in patients with refractory angina.

Protein and chemotherapy profiling of extracellular vesicles harvested from therapeutic induced senescent triple negative breast cancer cells

Triple negative breast cancer (TNBC) is an aggressive subtype with relatively poor clinical outcomes and limited treatment options. Chemotherapy, while killing cancer cells, can result in the generation of highly chemoresistant therapeutic induced senescent (TIS) cells that potentially form stem cell niches resulting in metastases. Intriguingly, senescent cells release significantly more extracellular vesicles (EVs) than non-senescent cells. Our aim was to profile EVs harvested from TIS TNBC cells compared with control cells to identify a potential mechanism by which TIS TNBC cells maintain survival in the face of chemotherapy. TIS was induced and confirmed in Cal51 TNBC cells using the chemotherapeutic paclitaxel (PTX) (Taxol). Mass spectrometry (MS) analysis of EVs harvested from TIS compared with control Cal51 cells was performed using Ingenuity Pathway Analysis and InnateDB programs. We demonstrate that TIS Cal51 cells treated with 75 nM PTX for 7 days became senescent (senescence-associated β-galactosidase (SA-β-Gal) positive, Ki67-negative, increased p21 and p16, G2/M cell cycle arrest) and released significantly more EVs (P=0.0002) and exosomes (P=0.0007) than non-senescent control cells. Moreover, TIS cells displayed an increased expression of the multidrug resistance protein 1/p-glycoprotein. MS analysis demonstrated that EVs derived from senescent Cal51 cells contained 142 proteins with a significant increased fold change compared with control EVs. Key proteins included ATPases, annexins, tubulins, integrins, Rabs and insoluble senescence-associated secretory phenotype (SASP) factors. A fluorescent analogue of PTX (Flutax-2) allowed appreciation of the removal of chemotherapy in EVs from senescent cells. Treatment of TIS cells with the exosome biogenesis inhibitor GW4869 resulted in reduced SA-β-Gal staining (P=0.04). In summary, this study demonstrates that TIS cells release significantly more EVs compared with control cells, containing chemotherapy and key proteins involved in cell proliferation, ATP depletion, apoptosis and the SASP. These findings may partially explain why cancer senescent cells remain viable despite chemotherapeutic challenge.

The biomechanical, chemical and physiological adaptations of the eggs of two Australian megapodes to their nesting strategies and their implications for extinct titanosaur dinosaurs

Megapodes are galliform birds endemic to Australasia and unusual among modern birds in that they bury their eggs for incubation in diverse substrates and using various strategies. Alectura lathami and Leipoa ocellata are Australian megapodes that build and nest in mounds of soil and organic matter. Such unusual nesting behaviours have resulted in particular evolutionary adaptations of their eggs and eggshells. We used a combination of scanning electron microscopy, including electron backscatter diffraction and energy-dispersive X-ray spectroscopy, to determine the fine structure of the eggshells and micro-CT scanning to map the structure of pores. We discovered that the surface of the eggshell of A. lathami displays nodes similar to those of extinct titanosaur dinosaurs from Transylvania and Auca Mahuevo egg layer #4. We propose that this pronounced nodular ornamentation is an adaptation to an environment rich in organic acids from their nest mound, protecting the egg surface from chemical etching and leaving the eggshell thickness intact. By contrast, L. ocellata nests in mounds of sand with less organic matter in semiarid environments and has eggshells with weakly defined nodes, like those of extinct titanosaurs from AM L#3 that also lived in a semiarid environment. We suggest the internode spaces in both megapode and titanosaur species act as funnels, which concentrate the condensed water vapour between the nodes. This water funnelling in megapodes through the layer of calcium phosphate reduces the likelihood of bacterial infection by creating a barrier to microbial invasion. In addition, the accessory layer of both species possesses sulphur, which reinforces the calcium phosphate barrier to bacterial and fungal contamination. Like titanosaurs, pores through the eggshell are Y-shaped in both species, but A. lathami displays unique mid-shell connections tangential to the eggshell surface and that connect some adjacent pores, like the eggshells of titanosaur of AM L#4 and Transylvania. The function of these interconnections is not known, but likely helps the diffusion of gases in eggs buried in environments where occlusion of pores is possible.

Implementation of an inter-agency transition model for youth with spina bifida

BACKGROUND

To address gaps in transfer of care and transition support, a paediatric hospital and adult community health care centre partnered to implement an inter-agency transition model for youth with spina bifida. Our objective was to understand the enablers and challenges experienced in the implementation of the model.

METHODS

Using a descriptive, qualitative design, we conducted semi-structured interviews, in-person or over the phone, with 12 clinicians and nine key informants involved in implementing the spina bifida transition model. We recruited all 21 participants from an urban area of Ontario, Canada.

RESULTS

Clinicians and key informants experienced several enablers and challenges in implementing the spina bifida transition model. Enablers included dedicated leadership, advocacy, funding, inter-agency partnerships, cross-appointed staff and gaps in co-ordinated care to connect youth to adult services. Challenges included gaps in the availability of adult specialty services, limited geographical catchment of adult services, limited engagement of front-line staff, gaps in communication and role clarity.

CONCLUSIONS

Although the transition model has realized some initial successes, there are still many challenges to overcome in transferring youth with spina bifida to adult health care and transitioning to adulthood.

Child and youth experiences and perspectives of cerebral palsy: a qualitative systematic review

BACKGROUND

Cerebral palsy (CP) is one of the most common causes of physical disability in childhood, and many children with CP access rehabilitation services throughout their lives. The aim of this qualitative systematic review was to synthesize the experiences and perspectives of youth living with CP to inform the development of rehabilitation and social programmes.

METHODS

A thematic qualitative synthesis integrating qualitative evidence was undertaken where six electronic databases (MEDLINE, Embase, Healthstar, Cumulative Index to Nursing and Allied Health Literature, Proquest and PsychInfo) were searched from 1980 to September 2014.

RESULTS

Thirty-three articles involving 390 youth, aged from 2 to 25 years, across six countries were included. Themes were classified according to the International Classification of Functioning Child and Youth Version framework. Youth's accounts focused on social inclusion and the physical environment (i.e. services and supports, transportation, accessibility, accommodations, safety and weather), the role of family and peers and participation (i.e. leisure and recreation, school and civic engagement). Youth described how body structure and function (i.e. pain and physical functioning, mental health, fatigue and unpredictability of body function) affected them - often disrupting their biographies. Some youth described personal factors such as independence, coping and body image that affected their ability to cope with their condition. There was much less focus on youth's experiences of mobility, activities of daily living and assistive devices.

CONCLUSIONS

Youth with CP experience pain, fatigue and impairments to body function, along with social exclusion, which can affect their biographies. However, youth had strategies to revise their biographies to maintain personal and social normalcy.

The experiences of participating in winter among youths with a physical disability compared with their typically developing peers

BACKGROUND

Having a physical disability and using a wheelchair can create difficulties in navigating the physical and built environment, especially during winter when snow and ice become problematic. Little is known about the experiences of winter among youth who use an assistive mobility device. This study aimed to understand how youth with a physical disability experience winter, compared with typically developing peers.

METHODS

A purposive sample of 25 youths (13 with a physical disability; 12 typically developing) completed a 2-week weather journal and photographs in two Canadian cities during winter. These data were used to guide semi-structured interviews with participants.

RESULTS

Youths with disabilities experienced many similar challenges in winter, such as health and safety concerns and accessibility issues, compared with typically developing youth - but to a greater extent. Youths with disabilities reported more challenges going outdoors during winter and negative psychosocial impacts, including loneliness and increased dependence, compared with peers without a disability. They also, however, described developing several adaptive strategies to cope with these challenges.

CONCLUSIONS

There is a strong need to remove physical and environmental barriers to facilitate the participation and inclusion of youth with disabilities in winter.

A complex transition: lessons learned as three young adults with complex care needs transition from an inpatient paediatric hospital to adult community residences

BACKGROUND

Whether young adults with complex care needs live at home with their family, in institutional or group home settings finding appropriate care as they transition from paediatric to adult systems can be difficult. Our objective was to understand the experiences, barriers and enablers entailed in transitioning three young adults with complex care needs from an institutional paediatric hospital setting to an adult community residence.

METHOD

A descriptive design involving in-depth, semi-structured, qualitative interviews and a review of 14 h of meeting minutes. Interviews were conducted over the phone, in participants' homes, and at a paediatric rehabilitation hospital. Twenty-three participants, including 10 clinicians, 11 community partners, two young adults (21-23 years old) with complex care needs from [metropolitan area] Ontario, Canada.

RESULTS

Our findings indicate that clinicians, community partners and young adults with complex care needs encountered several enablers and barriers influencing their transition from a paediatric hospital to adult supportive housing. Enablers included structural factors (leadership, advocacy, timing/funding), availability of care (inter-agency partnerships), organization of care (model of care, inter-professional teamwork, extension of roles), and relational factors (communication, development of trust and rapport, family involvement). Barriers included structural factors (timing, funding), availability of care (appropriateness of housing), organization of care (changes in model of care, teamwork, role clarity), relational factors (communication, trust/rapport, family involvement) and personal factors (transition readiness).

CONCLUSIONS

There are several challenges to overcome in preparing long-term hospitalized young adults with complex care needs to transition to adult supportive housing; however, these challenges may be overcome with targeted supports in several key areas.

Efficacy of a device to narrow the coronary sinus in refractory angina

BACKGROUND

Many patients with coronary artery disease who are not candidates for revascularization have refractory angina despite standard medical therapy. The balloon-expandable, stainless steel, hourglass-shaped, coronary-sinus reducing device creates a focal narrowing and increases pressure in the coronary sinus, thus redistributing blood into ischemic myocardium.

METHODS

We randomly assigned 104 patients with Canadian Cardiovascular Society (CCS) class III or IV angina (on a scale from I to IV, with higher classes indicating greater limitations on physical activity owing to angina) and myocardial ischemia, who were not candidates for revascularization, to implantation of the device (treatment group) or to a sham procedure (control group). The primary end point was the proportion of patients with an improvement of at least two CCS angina classes at 6 months.

RESULTS

A total of 35% of the patients in the treatment group (18 of 52 patients), as compared with 15% of those in the control group (8 of 52), had an improvement of at least two CCS angina classes at 6 months (P=0.02). The device was also associated with improvement of at least one CCS angina class in 71% of the patients in the treatment group (37 of 52 patients), as compared with 42% of those in the control group (22 of 52) (P=0.003). Quality of life as assessed with the use of the Seattle Angina Questionnaire was significantly improved in the treatment group, as compared with the control group (improvement on a 100-point scale, 17.6 vs. 7.6 points; P=0.03). There were no significant between-group differences in improvement in exercise time or in the mean change in the wall-motion index as assessed by means of dobutamine echocardiography. At 6 months, 1 patient in the treatment group had had a myocardial infarction; in the control group, 1 patient had died and 3 had had a myocardial infarction.

CONCLUSIONS

In this small clinical trial, implantation of the coronary-sinus reducing device was associated with significant improvement in symptoms and quality of life in patients with refractory angina who were not candidates for revascularization. (Funded by Neovasc; COSIRA ClinicalTrials.gov number, NCT01205893.).

Looking at tardigrades in a new light: using epifluorescence to interpret structure

The use of epifluorescence microscopy coupled with ultraviolet (UV) autofluorescence is suggested as a means to view and interpret tardigrade structures. Endogenous fluorochromes are a known component of tardigrade cuticle, claws and bucco-pharyngeal apparatus. By imaging the autofluorescence from tardigrades, it is possible to document these structures in detail, including the subdivisions and boundaries of echiniscid (heterotardigrade) plates and the nature and spatial relationships of the texture (pores, granules, papillae and tubercles) on the various plates. This allows the determination of taxonomic features not easily seen with other microscopic techniques.

Change in paternity and select perinatal outcomes: causal or confounded?

Select social, behavioural and maternal characteristics were evaluated to determine if they were confounding factors in the association between paternity change and pre-eclampsia, small for gestational age (SGA) and pre-term delivery, in a sample of 1,409 women. Multivariate logistic regression analysis was used to determine if any of these risk factors modified the association between changing paternity and the selected perinatal outcomes. Results of the analysis showed that women who changed partners were more likely to possess potentially confounding risk factors compared with those who had not. Paternity change was 2.75 times more likely to be associated with the development of pre-eclampsia (95% CI 1.33; 5.68) and 2.25 times more likely to be associated with an SGA infant on weight (95% CI 1.13; 4.47), after adjusting for selected risk factors. Paternity change remains a significant risk factor for pre-eclampsia and SGA in the presence of select risk factors.

Strategies for improving disability awareness and social inclusion of children and young people with cerebral palsy

BACKGROUND

Children and youth with disabilities are at a higher risk of being socially excluded or bullied while at school compared with their typically developing peers. This study explored disabled children's suggestions for improving social inclusion.

METHODS

Fifteen children with cerebral palsy were interviewed or took part in a group discussion about social inclusion and bullying. All interviews and focus groups were audio-recorded and transcribed verbatim.

RESULTS

The children and youth described several strategies to help improve social inclusion at school including: (1) disclosure of condition and creating awareness of disability; (2) awareness of bullying; (3) developing a peer support network and building self-confidence; and (4) suggestions on what teachers can do.

CONCLUSIONS

It is recommended that children's suggestions be considered within the classroom context to enhance the social inclusion and participation of children with disabilities.

Impacts of stage-specific acute pesticide exposure on predicted population structure of the soft-shell clam, Mya arenaria

A combined laboratory and modeling approach was used to assess the impact of selected pesticides on early life stages of the soft-shell clam, Mya arenaria. Clams were exposed for 24h as veligers or pediveligers to the broad-spectrum herbicide hexazinone [3-cyclohexyl-6-(dimethylamino)-1-methyl-1,3,5-triazine-2,4(1h,3h)-dione; Velpar], the phenoxyacetic acid herbicide, 2,4-D (2,4-dichlorophenoxyacetic acid; Agway Super BK 32), or phosmet (Imidan). In addition, juvenile clams were exposed for 24h to 2,4-D and their growth monitored for 21 months. Laboratory experiments indicated veligers were more sensitive to acute pesticide exposure than pediveligers, with 2,4-D exposed veligers exhibiting the lowest survival among all treatments. Relative to controls, juvenile clams exposed to 0.5 ppm 2,4-D had enhanced survival following the initial 3 months of grow out. Juveniles exposed to 0.5, 5 and 10 ppm 2,4-D showed an initial growth delay relative to control clams, but at 21 months post-exposure these clams were significantly larger than control clams. Data from the larval and juvenile exposures were used to generate a stage-specific matrix model to predict the effect of pesticide exposure on clam populations. Impacts on simulated clam populations varied with the pesticide and stage exposed. For example, 2,4-D exposure of veligers and pediveligers significantly reduced predicted recruitment as well as population growth rate compared to controls, but juvenile exposure to 2,4-D did not significantly reduce population growth rate. With the exception of veligers exposed to 10 ppm, hexazinone exposure at the both veliger and pediveliger stages significantly reduced predicted recruitment success compared to 0 ppm controls. Hexazinone exposure also reduced modeled population growth rates, but these reductions were only slight in the pediveliger exposure simulations. Veliger and pediveliger exposure to phosmet reduced modeled population growth rate in a dose-dependent fashion. Changes in modeled population stable stage distributions were also observed when veligers were exposed to any pesticide. These results suggest that both the stage of exposure and the specific toxicant are important in predicting effects of pesticide exposure on soft-shell clam populations, with earlier life stages showing greater sensitivity to the pesticides tested.

Continuous selective bilateral antegrade cerebral perfusion through anomalous innominate artery for repair of root, ascending aortic and arch aneurysm – challenges, vagaries and opportunities of bovine arch variant anatomy and review of literature

We describe the repair of a root, ascending aortic and arch aneurysm in a 69-year-old man with a bioprosthetic Shelhigh conduit and cylinder, employing continuous bilateral antegrade cerebral perfusion through an anomalous innominate artery with a bovine arch variant anatomy. The origin of both the innominate artery and the left common carotid artery from a common stem from the arch in this bovine arch variant puts the whole cerebral circulation at risk, on one hand, yet provides an opportunity of continuous bilateral antegrade cerebral perfusion through the right brachial, right axillary, right subclavian or innominate artery, during arch reconstruction under lower body, deep hypothermic circulatory arrest. Safety and adequacy of selective cerebral perfusion through the right axillary artery in patients with normal arch vessel origin depends on an intact circle of Willis. In this bovine arch variant, both cerebral hemispheres can be perfused through the right brachial, right axillary, right subclavian or the innominate artery, independent of the integrity of the circle of Willis, because of the origin of the left common carotid artery from the innominate artery, except for the area supplied by the left vertebral artery. Although this is the first report of innominate artery perfusion for arch reconstruction for aneurysm in a bovine arch variant, we believe the method described has important implications for cerebral protection in light of the generally reported incidence of bovine arch from 13 to 35 percent.

Using atomic force microscopy to study chromatin structure and nucleosome remodeling

Atomic force microscopy (AFM) is a technique that can directly image single molecules in solution and it therefore provides a powerful tool for obtaining unique insights into the basic properties of biological materials and the functional processes in which they are involved. We have used AFM to analyze basic features of nucleosomes in arrays, such as DNA-histone binding strength, cooperativity in template occupation, nucleosome stabilities, nucleosome locations and the effects of acetylation, to compare these features in different types of arrays and to track the response of array nucleosomes to the action of the human Swi-Snf ATP-dependent nucleosome remodeling complex. These experiments required several specific adaptations of basic AFM methods, such as repetitive imaging of the same fields of molecules in liquid, the ability to change the environmental conditions of the sample being imaged and detection of specific types of molecules within compositionally complex samples. Here, we describe the techniques that allowed such analyses to be carried out.

Anatomical and gene expression mapping of the ventral pallium in a three-dimensional model of developing human brain

Combining gene expression data with morphological information has revolutionized developmental neuroanatomy in the last decade. Visualization and interpretation of complex images have been crucial to these advances in our understanding of mechanisms underlying early brain development, as most developmental processes are spatially oriented, in topologically invariant patterns that become overtly distorted during brain morphogenesis. It has also become clear that more powerful methodologies are needed to accommodate the increasing volume of data available and the increasingly sophisticated analyses that are required, for example analyzing anatomy and multiple gene expression patterns at individual developmental stages, or identifying and analyzing homologous structures through time and/or between species. Three-dimensional models have long been recognized as a valuable way of providing a visual interpretation and overview of complex morphological data. We have used a recently developed method, optical projection tomography, to generate digital three-dimensional models of early human brain development. These models can be used both as frameworks, onto which normal or experimental gene expression data can be mapped, and as objects, within which topological morphological relationships can be investigated in silico. Gene expression patterns and selected morphological structures or boundaries can then be visualized individually or in different combinations in order to study their respective morphogenetic significance. Here, we review briefly the optical projection tomography method, placing it in the context of other methods used to generate developmental three dimensional models, and show the definition of some CNS anatomical domains within a Carnegie stage 19 human model. We also map the telencephalic EMX1 and PAX6 gene expression patterns to this model, corroborating for the first time the existence of a ventral pallium primordium in the telencephalon of human embryos, a distinct claustroamygdaloid histogenetic area comparable to the recently defined mouse primordium given that name [Puelles L, Kuwana E, Puelles E, Bulfone A, Shimamura K, Keleher J, Smiga S, Rubenstein JLR (2000) Pallial and subpallial derivatives in the embryonic chick and mouse telencephalon, traced by the expression of the genes Dlx-2, Emx-1, Nkx-2.1, Pax-6, and Tbr-1. J Comp Neurol 424:409-438; Puelles L, Martínez S, Martínez-de-la-Torre M, Rubenstein JLR (2004) Gene maps and related histogenetic domains in the forebrain and midbrain. In: The rat nervous system, 3rd ed (Paxinos G, ed), pp 3-25. San Diego: Academic Press].

An investigation of language used by children to describe discomfort expected and experienced during dental treatment

OBJECTIVES

A study of dental pulp testing has shown that children's linguistic comprehension and chronological age independently influence their descriptions of pain. The present study sought first to demonstrate this for expectations and experience of routine dental treatment, and secondly, to determine whether the effect of age was the result of previous dental and medical experience.

SAMPLE

Forty-six children between 6 and 17 years of age attending two paediatric dental clinics for routine invasive procedures comprised the study sample.

METHODS

To describe their expectations of forthcoming treatment, each child selected words from a published list, and gave ratings on scales describing the degree of severity as 'sore' or 'tingly'. They also completed the Child Dental Anxiety Scale and the Spielberger State-Trait Anxiety Scale for Children. After treatment, they described the treatment with the same list and scales, then completed the British Picture Vocabulary Scale and a dental-medical history questionnaire.

RESULTS

The children, especially the most anxious ones, chose more words from the list for their expectations than for their experience of treatment, suggesting, as in previous studies, that they expected more discomfort than they experienced. Ratings of 'sore' and 'tingly' did not show this discrepancy. For both expectations and experience of treatment, the children with the largest vocabularies chose the fewest words, thus being more discriminating in their choices. However, vocabulary had no effect on ratings of 'sore' and 'tingly'. There were no significant relationships among age, estimates of discomfort and medical-dental histories.

CONCLUSIONS

The results suggest that a list of adjectives provides the most discriminating measure of discomfort. They also show that it is necessary to take into account children's linguistic development to evaluate their estimates of pain so as not to entertain the belief of many clinicians that children exaggerate such reports.

Adhaeribacter aquaticus gen. nov., sp. nov., a Gram-negative isolate from a potable water biofilm

A Gram-negative bacterium was isolated from a freshwater biofilm developed on a stainless steel surface under a fluid velocity of 0·26 m s−1. The strain, MBRG1.5T, was cultivated on R2A agar and formed pink colonies. Light microscopy and negative staining in a transmission electron microscope showed that the cells were rod-shaped, approximately 2·8–4·1 μm long by 0·9–1·7 μm wide in size and produced large quantities of extracellular fibrillar material. Additionally, following growth in batch culture, transmission electron microscopy showed that many cells plasmolysed. Stationary-phase cells were more variable in size and shape. The DNA G+C content was 40·0 mol%. The most abundant fatty acids were 15 : 0 iso (22·5 %), followed by 16 : 1ω5c (16·9 %) and 15 : 0 iso 2-OH (16·5 %). Phylogenetic analysis of the 16S rRNA gene showed that the strain was a member of the family ‘Flexibacteraceae’ of the Cytophaga–Flavobacterium–Bacteroides group. Phenotypic and genotypic analyses indicated that the strain could not be assigned to any recognized genus; therefore a novel genus and species, Adhaeribacter aquaticus gen. nov., sp. nov., is proposed, with MBRG1.5T (=DSM 16391T=NCIMB 14008T) as the type strain.

Induction of the mar operon by miscellaneous groceries

AIM

To investigate the potential of non-antibacterial consumer products to act as inducers of the multiple antibiotic resistance (mar) operon of Escherichia coli SPC105.

METHODS AND RESULTS

Wells were cut into chemically defined agar medium (CDM) contained within Petri dishes. Molten agar slurries were prepared by mixing known quantities of 35 consumer products with molten CDM and these were pipetted into each well. Plates were overlaid with molten CDM (5 ml), containing 40 microg ml(-1) X-gal and approx. 1000 CFU ml(-1) of an overnight culture of E. coli SPC105 containing a chromosomal marOII::lacZ fusion. After incubation (37 degrees C, 24 h), plates were examined for zones of growth inhibition and the presence of a blue coloration, indicative of mar (marOII::lacZ) induction. Of the 35 products tested (nine herbs and spices, 19 food and drinks and seven household products), 24 (69%) of the items produced inhibitory zones and 22 (63%) of the items induced mar expression. Apple puree was inhibitory but did not induce marOII::lacZ. Mustard, chilli and garlic were shown to be powerful inducers of marOII::lacZ. Overall six products were shown to be powerful marOII::lacZ inducers. None of these made hygiene claims.

CONCLUSIONS

In addition to induction by specific biocides and antibiotics, mar is induced by the exposure of bacteria to natural substances, many of which are common to a domiciliary setting.

SIGNIFICANCE AND IMPACT OF THE STUDY

Concern that the overuse of antibacterials within consumer products might select for mar-mediated resistance is shortsighted and fails to recognize the ubiquity of inducers in our environment.

Randomised crossover trial to assess the tolerability of LHRH analogue administration

Luteinising hormone releasing hormone (LHRH) analogues are routinely used in the treatment of patients with advanced prostate cancer. This randomised crossover trial was conducted to compare patient comfort and tolerability between two commonly used LHRH analogues: goserelin acetate and leuprorelin acetate. A total of 50 patients were randomised into two groups, each receiving 6-monthly injections of leuprorelin acetate (a liquid presentation) and goserelin acetate (a depot pellet) and crossing over between treatments. Patients completed a simple visual analogue score for the discomfort felt from the injections. An analysis of variance model was used, and the results found that patients do tolerate leuprorelin acetate (0.589) better than goserelin acetate (1.343) (P < 0.001, CI = 95%).

Development of a questionnaire to measure concern for dental appearance

100 adults, selected for cosmetic dental treatment in a general dental practice, completed a 42-item questionnaire designed, on the basis of previous research and the author's clinical experience, to measure concern for dental appearance. This had high internal consistency and was reduced to a questionnaire of 23 items with internal consistency shown by a standardised Cronbach alpha of .84. An exploratory factor analysis with varimax rotation identified six factors, the main one appearing to be a measure of concern for dental appearance. The high internal consistency suggests that the total score for the revised questionnaire is a measure of a construct, concern for dental appearance. Although the simplest measure of that may be contained in the items for the first factor, a much larger sample would be necessary to confirm the complex factor structure and so the questionnaire's total score is probably the more reliable measure at present. A study is summarised showing that the total score provides a measure that, in statistical regression analysis, may predict the intentions of adults to take care of the appearance of their teeth.

Psychological influences on acceptance of postsurgical treatment in cancer patients

OBJECTIVE

Many cancer patients fail to complete treatment for reasons that are unclear in previous research which, nevertheless, suggested hypotheses for this study about the characteristics of the patients and their consultations.

METHOD

158 adults with breast cancer or other cancers who had been chosen for postsurgical treatment in the Lister Hospital or the Mount Vernon Hospital had completed published questionnaires to assess either (n=74) personal attributes or circumstances viz. locus of health control, health habits, support, affiliative drive, anxiety, depression, or (n=84) their attitudes to cancer or their consultations, viz. the Mental Attitudes to Cancer Scales, Trust in Physicians, Perceived Empathy, and Satisfaction With Recent and Diagnostic Consultations.

RESULTS

32% then failed to complete treatment. In logistic multiple regression analyses, only diagnosis (P=.0001), gender (P=.005), and treatment center (P=.0002) predicted this although the effect of gender was not significant among patients without breast cancer. Among the patients without breast cancer intended for the Mount Vernon Hospital, a National Cancer Centre, fewer completed treatment than those did not complete.

CONCLUSION

The breast cancer patients, unlike women with other cancers, and patients referred to the local hospital rather than the regional cancer center, were more likely to complete treatment. Thus, uptake of treatment may be favored by accessibility and familiarity of its source and by the unique impact in women of breast cancer and the wider public attention given to that illness. Research on patients' expectations, fears, and corresponding experiences of treatment, rather than personal attributes, should clarify failure to complete cancer treatment especially in patients without breast pathology.

Characterisation of Wnt gene expression during the differentiation of murine embryonic stem cells in vitro: role of Wnt3 in enhancing haematopoietic differentiation

The first haematopoietic stem cells in mammalian and non-mammalian vertebrates are derived from mesoderm, therefore genes that are important in mesoderm patterning and formation might also play an essential role in haematopoietic stem cell commitment and differentiation. Several members of the Wnt gene family are expressed in very specific patterns in embryonic mesoderm and have previously been shown to act as haematopoietic growth factors. In order to investigate in detail the role that such secreted proteins play in the biology of early haematopoietic commitment we have used in vitro differentiation of murine embryonal stem (ES) as a model system. Using reverse-transcriptase polymerase chain reaction analysis we identified several candidate Wnt genes whose expression pattern was consistent with a role in generation, maintenance and/or differentiation of early haematopoietic progenitor cells including three genes previously shown to have a role in haematopoiesis (Wnt5a, Wnt2b and Wnt10b). The most interesting candidate was Wnt3, because of its strong and regulated expression during in vitro differentiation of murine ES cells as well as its early embryonic expression in mesoderm. Overexpression of Wnt3 was sufficient to cause a consistent increase in the number of embryoid bodies committing to haematopoiesis further strengthening the evidence that this protein can enhance haematopoietic commitment during in vitro differentiation of ES cells. In addition, overexpression of Wnt3 caused a marked upregulation of Brachyury expression, thus providing some evidence that Brachyury may be one of the target genes for the Wnt3 signalling pathway.

Hydrogen peroxide formation during iron deposition in horse spleen ferritin using O2 as an oxidant

The reaction of Fe2+ with O2 in the presence of horse spleen ferritin (HoSF) results in deposition of FeOH3 into the hollow interior of HoSF. This reaction was examined at low Fe2+/HoSF ratios (5-100) under saturating air at pH 6.5-8.0 to determine if H2O2 is a product of the iron deposition reaction. Three methods specific for H2O2 detection were used to assess H2O2 formation: (1) a fluorometric method with emission at 590 nm, (2) an optical absorbance method based on the reaction H2O2 + 3I- + 2H+ = I3- + 2H2O monitored at 340 nm for I3- formation, and (3) a differential pulsed electrochemical method that measures O2 and H2O2 concentrations simultaneously. Detection limits of 0.25, 2.5, and 5.0 microM H2O2 were determined for the three methods, respectively. Under constant air-saturation conditions (20% O2) and for a 5-100 Fe2+/HoSF ratio, Fe2+ was oxidized and the resulting Fe3+ was deposited within HoSF but no H2O2 was detected as predicted by the reaction 2Fe2+ + O2 + 6H2O = 2Fe(OH)3 + H2O2 + 4H+. Two other sets of conditions were also examined: one with excess but nonsaturating O2 and another with limiting O2. No H2O2 was detected in either case. The absence of H2O2 formation under these same conditions was confirmed by microcoulometric measurements. Taken together, the results show that under low iron loading conditions (5-100 Fe2+/HoSF ratio), H2O2 is not produced during iron deposition into HoSF using O2 as an oxidant. This conclusion is inconsistent with previous, carefully conducted stoichiometric and kinetic measurements [Xu, B., and Chasteen, N. D. (1991) J. Biol. Chem. 266, 19965], predicting that H2O2 is a quantitative product of the iron deposition reaction with O2 as an oxidant, even though it was not directly detected. Possible explanations for these conflicting results are considered.

Patient Care Bridge--mobile ICU for transit care of the critically ill

We describe the development and introduction of a Patient Care Bridge--a mobile ICU for the transit care of the critically ill. This stretcher-mounted Patient Care Bridge is being used for intensive transit care of the critically ill in Northland, New Zealand. It carries all the basic intensive care monitoring accoutrements, is lightweight and is suited for pre-hospital, inter-hospital and intra-hospital transit care. It is ideal for patient evacuation from the scene of motor vehicle and sporting accidents, surface transportation of patients by surface ambulance and aeroevacuation of patients by the Helicopter Emergency Medical Service. This economic and space efficient unit has been used for transfer of more than one thousand critically ill patients.

Autosomal dominant sacral agenesis: Currarino syndrome

Autosomal dominant sacral agenesis is characterised by a partial agenesis of the sacrum typically involving sacral vertebrae S2-S5 only. Associated features include anorectal malformation, a presacral mass, and urogenital malformation. Together, these features have been defined as the Currarino syndrome. Recently, HLXB9 has been identified as the major causative gene in Currarino syndrome allowing identification of asymptomatic heterozygotes. In this review, we have performed an analysis of medical publications, and our own additional cases, to identify the range of malformations and complications that occur. We have also estimated risks of malformation in heterozygotes by using Weinburg's proband method on families personally known to us in order to provide accurate genetic counselling information.

Helicopter in transit care of the critically ill--the Whangarei experience

AIMS

To describe our experience in transit care of the critically ill in Northland and to highlight the multidisciplinary co-operation which renders this an efficient model of transit care in suburban and rural areas.

METHODS

Since its inception in 1988, Northland's wholly community owned rescue helicopter has played an integral part in transit Intensive Care in Northland. This aids in transportation of medical and nursing intensive care staff to outlying primary hospitals for patient stabilisation, subsequent transfer of the patient to the intensive care unit (ICU) in Whangarei and, occasionally, for transfer to specialised critical care services in Auckland.

RESULTS

As of August 1999, over 3,900 helicopter missions have been accomplished. A doctor, vetting each request for Medevac, minimises over-triage, thus ensuring adequate levels of transit care and effective utilisation of expensive resources. More than 90% of non-obstetric adult patients were ventilated and the number of Medevac missions increased over the years. The Accident Compensation Corporation (ACC) funds 40% of all flights, another 40% of flights are funded by Northland Health and the Order of St John funds the remainder.

CONCLUSIONS

With a widespread geography, efficient transit care of the critically ill is imperative to quality hospital care and ensures equity of access to the rural populace. The Whangarei system of transit intensive care is an ideal template for suburban and rural areas.

Effect of pregnancy on exposure to malaria mosquitoes

Pregnant women attracted twice the number of Anopheles gambiae complex--the predominant African malaria-carrying mosquito--than did their non-pregnant counterparts. We postulate that physiological and behavioural changes that occur during pregnancy are responsible for increased attractiveness, which could be important in intervention strategies aimed at protecting this high-risk group against malaria.

The short stature homeobox gene SHOX is involved in skeletal abnormalities in Turner syndrome

Turner syndrome is characterized by short stature and is frequently associated with a variable spectrum of somatic features including ovarian failure, heart and renal abnormalities, micrognathia, cubitus valgus, high-arched palate, short metacarpals and Madelung deformity. Madelung deformity is also a key feature of Leri-Weill syndrome. Defects of the pseudoautosomal homeobox gene SHOX were previously shown to lead to short stature and Leri-Weill syndrome, and haploinsufficiency of SHOX was implicated to cause the short stature phenotype in Turner syndrome. Despite exhaustive searches, no direct murine orthologue of SHOX is evident. SHOX is, however, closely related to the SHOX2 homeobox gene on 3q, which has a murine counterpart, Og12x. We analysed SHOX and SHOX2 expression during human embryonic development, and referenced the expression patterns against those of Og12x. The SHOX expression pattern in the limb and first and second pharyngeal arches not only explains SHOX -related short stature phenotypes, but also for the first time provides evidence for the involvement of this gene in the development of additional Turner stigmata. This is strongly supported by the presence of Turner-characteristic dysmorphic skeletal features in patients with SHOX nonsense mutations.

SRY, SOX9, and DAX1 expression patterns during human sex determination and gonadal development

SRY, SOX9, and DAX1 are key genes in human sex determination, by virtue of their associated male-to-female sex reversal phenotypes when mutated (SRY, SOX9) or over-expressed (DAX1). During human sex determination, SRY is expressed in 46,XY gonads coincident with sex cord formation, but also persists as nuclear protein within Sertoli cells at 18 weeks gestation. High-level SOX9 expression in the sex cords of the testis parallels that seen during mouse development, however in humans, SOX9 transcripts also are detected in the developing ovary. Low-level DAX1 expression predates peak SRY expression by at least 10 days, and persists in Sertoli cells throughout the entire sex determination period. In Dosage Sensitive Sex reversal, the anti-testis properties of DAX1 over-expression could act prior to the peak effects of SRY and continue during the period of SOX9 expression. These findings highlight expression differences for the SRY, SOX9, and DAX1 genes during sex determination in humans and mice. These results provide a direct framework for future investigation into the mechanisms underlying normal and abnormal human sex determination.

Human-mouse differences in the embryonic expression patterns of developmental control genes and disease genes

Our understanding of early human development has been impeded by the general difficulty in obtaining suitable samples for study. As a result, and because of the extraordinarily high degree of evolutionary conservation of many developmentally important genes and developmental pathways, great reliance has been placed on extrapolation from animal models of development, principally the mouse. However, the strong evolutionary conservation of coding sequence for developmentally important genes does not necessarily mean that their expression patterns are as highly conserved. The very recent availability of human embryonic samples for gene expression studies has now permitted for the first time an assessment of the degree to which we can confidently extrapolate from studies of rodent gene expression patterns. We have found significant human-mouse differences in embryonic expression patterns for a variety of genes. We present detailed data for two illustrative examples. Wnt7a, a very highly conserved gene known to be important in early development, shows significant differences in spatial and temporal expression patterns in the developing brain (midbrain, telencephalon) of man and mice. CAPN3, the locus for LGMD2A limb girdle muscular dystrophy, and its mouse orthologue differ extensively in expression in embryonic heart, lens and smooth muscle. Our study also shows how molecular analyses, while providing explanations for the observed differences, can be important in providing insights into mammalian evolution.