Genetic and microbial factors modulating the ubiquitin proteasome system in inflammatory bowel disease

OBJECTIVE

Altered microbiota composition, changes in immune responses and impaired intestinal barrier functions are observed in IBD. Most of these features are controlled by proteases and their inhibitors to maintain gut homeostasis. Unrestrained or excessive proteolysis can lead to pathological gastrointestinal conditions. The aim was to validate the identified protease IBD candidates from a previously performed systematic review through a genetic association study and functional follow-up.

DESIGN

We performed a genetic association study in a large multicentre cohort of patients with Crohn's disease (CD) and UC from five European IBD referral centres in a total of 2320 CD patients, 2112 UC patients and 1796 healthy controls. Subsequently, we did an extensive functional assessment of the candidate genes to explore their causality in IBD pathogenesis.

RESULTS

Ten single nucleotide polymorphisms (SNPs) in four genes were significantly associated with CD: CYLD, USP40, APEH and USP3. CYLD was the most significant gene with the intronically located rs12324931 the strongest associated SNP (p(FDR)=1.74e-17, OR=2.24 (1.83 to 2.74)). Five SNPs in four genes were significantly associated with UC: USP40, APEH, DAG1 and USP3. CYLD, as well as some of the other associated genes, is part of the ubiquitin proteasome system (UPS). We therefore determined if the IBD-associated adherent-invasive Escherichia coli (AIEC) can modulate the UPS functioning. Infection of intestinal epithelial cells with the AIEC LF82 reference strain modulated the UPS turnover by reducing poly-ubiquitin conjugate accumulation, increasing 26S proteasome activities and decreasing protein levels of the NF-κB regulator CYLD. This resulted in IκB-α degradation and NF-κB activation. This activity was very important for the pathogenicity of AIEC since decreased CYLD resulted in increased ability of AIEC LF82 to replicate intracellularly.

CONCLUSIONS

Our results reveal the UPS, and CYLD specifically, as an important contributor to IBD pathogenesis, which is favoured by both genetic and microbial factors.

Diabetes-oriented learning family intervention (DOLFIN): a feasibility study evaluating an intervention for carers of young persons with Type 1 diabetes

AIMS

To describe the development of an intervention for parents and carers of young people with Type 1 diabetes and assess the feasibility, acceptability and emerging clinical themes.

METHODS

Participants were carers of young persons aged 10-18 years with a diagnosis of Type 1 diabetes of more than 12 months' duration in two inner-city South London hospitals. Carers were invited to attend six sessions of a group workshop where they received emotional support, diabetes education and were taught motivational interviewing techniques to support their child.

RESULTS

Out of 106 eligible participants, carers of 31 young people with Type 1 diabetes were recruited, 17 of whom 'completed' the intervention (attending four or more sessions). Participants discussed a variety of themes in session, including the increasing difficulty of diabetes management as children grow older, parenting techniques for managing diabetes in the home and the emotional challenges of having a child with a chronic illness.

CONCLUSIONS

Engaging parents in a carer intervention for Type 1 diabetes was a challenge, but parents who participated appeared to value the programme. Future interventions for carers need to take account of carers' wishes and expectations in order to maximize user uptake.

Support matters: a mixed methods scoping study on the use of assistant staff in the delivery of community nursing services in England

Background

Community nursing (and health) services are faced with the growing challenge of caring for increasingly dependent patients with chronic conditions and complex care needs. Over the past decade there have been changes in the composition of the community nursing workforce with increasing numbers of assistants yet there is a lack of published literature on the roles, contribution and impacts of community nursing assistants to the delivery of care and services.

Design

We adopted a three-stage approach for the scoping study using mixed quantitative and qualitative methods. First, we established contact with senior managers in provider organisations where we had research governance approval (n = 76; 75% of total provider organisations) to determine whether or not (a) they employ assistants within community nursing teams and (b) they would be interested in participating in the study. Second, we carried out a short telephone interview with all senior managers who indicated a willingness to participate (census approach). We also analysed secondary data (using the NHS iView data source, from the Electronic Staff Record Data Warehouse) to scope the national use of community nursing assistant roles. Finally, we conducted telephone interviews with a purposive sample of managers from 10 organisations that participated in stage two to gain an in-depth understanding of assistant roles in community nursing teams

Setting

Community nursing provider organisations in England, UK.

Participants

Thirty-seven senior managers were interviewed for stage two (49% of all contacted). Thirty managers (20 service-level managers and 10 senior managers) were interviewed for stage three.

Results

Assistants promote flexibility in the community nursing workforce so as to respond to the changing demands on these services. However, the lack of consensus in defining the role of community nursing assistants has created inconsistency in the national deployment and development of these roles. These roles have tended to develop ad hoc, creating variations in numbers of assistants, the roles that they play and preparation for practice across different provider organisations and nursing teams. There is general enthusiasm among managers about the contribution of assistants. Their employment is regarded as fundamental to the ability of community nursing teams to deliver acceptable and appropriate services. However, the role may not always support career progression and development for those assistants who require this. The maturity and life experience of assistants is greatly valued in the nursing team to support care delivery and to offer stability and support to other members of the nursing team. Line management, responsibility and accountability in managing the work of assistants were highlighted as important for managing risk associated with an unregulated role. These have to be balanced with promoting flexibility in use and innovation.

Conclusions

Our scoping study highlights the opportunities and challenges associated with the use of assistants to deliver care by the community nursing team. Further attention at national and local levels is required to support and mediate the development of these roles in the future so as to promote the delivery of quality, safe and acceptable care. As provider organisations plan for delivering an ambitious community services agenda in the future, the role of the assistant is likely to have increasing importance.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Audit on breast ultrasound in women under 25 years

BACKGROUND

Women younger than 30 years with a focal breast finding have a low incidence of malignancy. Targeted ultrasound is an accurate primary imaging test.

MATERIALS AND METHODS

All breast ultrasounds performed from July 1, 2011 to September 30, 2011 were reviewed. All ultrasounds in patients under 25 years were reviewed with regard to indication, imaging findings, and pathology results.

RESULTS

Over a 3-month period, 855 breast ultrasounds were performed; 4.1 % breast ultrasounds were performed in a patient under 25 years. Twenty patients had imaging features consistent with a fibroadenoma. Pathology confirmed the diagnosis of fibroadenomas in 15 of the patients. Five patients did not have biopsies performed due to young age or presence of bilateral fibroadenoma.

CONCLUSION

A breast nodule in a patient under the age of 25 years with benign clinical findings and imaging features consistent with a fibroadenoma does not require biopsy.

Can the radiologist accurately predict the adequacy of sampling when performing ultrasound-guided core biopsy of BI-RADS category 4 and 5 lesions detected on screening mammography?

AIM

To investigate in mammography screening the correlation between the confidence level of the radiologist, in sampling BI-RADS assessment category 4 and 5 lesions using a single ultrasound-guided 14-gauge needle core biopsy, and the final histological diagnosis.

METHODS

In a prospective study, 389 consecutive ultrasound-guided 14-gauge needle core biopsies were performed on 131 BI-RADS assessment category 4 and 5 breast lesions in 126 women. On average, 3 passes were made through each lesion; for each pass, the radiologist rated confidence in adequacy of sampling at <50%, 50% to 90% or >90%. This was compared with the final histological diagnosis.

RESULTS

The radiologist was >90% confident in 293 biopsies; diagnostic results were confirmed at histology in 283 (97%). In 70 biopsies the radiologist was 50% to 90% confident; diagnostic results were confirmed in 60 (86%). Of 26 samples where confidence was <50%, 13 were diagnostic (50%) (p<0.0001).

CONCLUSION

If, at the time of ultrasound-guided needle core biopsy of BI-RADS assessment category 4 and 5 breast lesions, the radiologist is >90% confident that the lesion has been adequately sampled, a single pass is usually sufficient for diagnosis.

Evaluation of the current status of operating and closed landfills in Russia, Finland and Ireland with regard to water pollution and methane emission

The annual production of municipal solid wastes (MSW) in Russia, Finland and Ireland in the late 1990s accounts for 37.5, 2.5 and 2.05 min. tonnes or 252, 488 and 566 kg per capita, respectively. 96.5, 64 and 91% of these wastes (for Russia, Finland and Ireland, correspondingly) are currently disposed of via landfilling. However, nowadays, MSW management in these countries is undergoing drastic changes (source separation, closure of old landfills, reduction of the number of landfills etc.) forced by recent legislation set by the European Union and Russian authorities. This paper evaluates the current status of MSW landfills, as well as information on current leachate and methane emissions in the three above mentioned countries. Landfill leachates are highly variable in each country and between different countries due to different rainfall and climatic conditions and also due to poor landfill top insulation/cover. Leachates in poorly structured landfills are very dilute, whereas leachates with total COD and nitrogen contents as high as 33,700 mg COD/l and 4,030 mg N/l, respectively, have been detected from state-of-the-art sites. Currently, on-site treatment of leachates exists at only a few landfills in Russia, Finland and Ireland but this situation will be considerably improved during the next years. The annual methane emissions from landfills are estimated as 500-900 and 77 ktonnes for Russia and Finland, respectively. Recent estimates from Ireland suggest an annual landfill methane emission of c. 2.1 Mt CO2 equivalent. Several systems of methane recovery have been developed in all three countries and these are currently in different stages of implementation.

Hepatic metastases from an unknown primary neoplasm (UPN): survival, prognostic indicators and value of extensive investigations

AIM

The objectives of this study were to identify prognostic features for patients with hepatic metastases and unknown primary neoplasms (UPN), determine the common primary tumours, assess the value of diagnostic tests in finding these tumours, and evaluate the impact of therapy and knowledge of the primary tumour on patient survival.

MATERIALS AND METHODS

Eighty-eight patients with UPN and liver biopsy proven hepatic metastases over a 10-year period were reviewed (M:F, 58:30; age range 27-91 years, median 64.5 years). Histopathology, diagnostic investigations and success at identifying the primary neoplasm were recorded. In addition, in 70 patients with adenocarcinoma histology (M:F, 48:22; age range 27-91 years, median 65 years), treatment and survival data from the date of biopsy were recorded.

RESULTS

The histological spectrum included adenocarcinoma in 70, neuroendocrine in four, squamous cell carcinoma in four, small cell carcinoma in four, carcinoid in two, hepatoma in one and three others. Extensive investigation identified a primary neoplasm in 16/88 patients (18%) including colorectal in six, gastric in two, lung in four, oesophageal in two, prostate in one and carcinoid in one. In the adenocarcinoma group survival data were available for 62/70 patients. Sixteen of 62 patients received active treatment with either surgery, chemotherapy, radiotherapy or a combination protocol. Forty-six of 62 patients received palliative care alone. Median survival for the adenocarcinoma group overall was 49 days. The median survival for treated patients (49 days) versus untreated patients (52 days) was not significantly different (P=0.128). Patients <65 years were more likely to receive active treatment than those >65 years (P=0.006). Age with a hazard ratio (HR) of 1.01 (P=0.178), active treatment (HR=0.65;P=0.194), knowledge of the primary neoplasm (HR=0.60;P=0.213) and male gender (HR=0.88;P=0.642) had no significant effect on survival.

CONCLUSION

Although hepatic metastases are associated with poor prognosis, it is essential that a liver biopsy be performed to obtain a histological diagnosis. Adenocarcinoma metastases carry a dismal prognosis, and no prognostic factors, including knowledge of the primary tumour, are significant for patient survival. Extensive investigation is not warranted in patients with adenocarcinoma liver metastases.

Mesophilic and thermophilic anaerobic digestion of sulphate-containing wastewaters

The effect of sulphate at an influent chemical oxygen demand (COD):sulphate ratio of 4 on the operational performance of anaerobic hybrid reactors treating molasses wastewater was investigated under mesophilic and thermophilic conditions in a long-term laboratory-scale study over a 1,081 day period. The presence of sulphate reduced the COD removal efficiency under both mesophilic and thermophilic conditions. At 55 degrees C, effluent acetate levels were consistently greater than 4000 mg l(-1) indicating that thermophilic acetate-utilising methane-producing bacteria (MPB) or sulphate-reducing bacteria (SRB) had not developed in the reactor under the conditions applied. At 37 degrees C, acetate was exclusively utilised by acetoclastic methanogens, whereas H2-utilising SRB predominated over H2-utilising MPB in the competition for hydrogen. By contrast, hydrogenotrophic MPB were shown to outcompete H2-utilising SRB during long-term thermophilic operation. 16SrDNA analysis of the seed sludge and reactor biomass on conclusion of the 37 degrees C and 55 degrees C trials illustrated that the dominant methanogen present on conclusion of the thermophilic trial in the absence of influent sulphate was related to Methanocorpusculum parvuum, and was capable of growth on both acetate and hydrogen. By contrast, an organism closely related to Methanobacterium thermoautotrophicum was the dominant methanogen present in the sulphate-fed reactor on completion of the thermophilic trial.

Evaluation of the role of magnetic resonance myelography in lumbar spine imaging

The purpose of our study was to evaluate the accuracy of MR myelography in depicting disc herniation in the lumbar spine when compared with conventional MRI in patients presenting with clinical evidence of disc herniation. One hundred patients referred for conventional MR imaging of the lumbar spine also had coronal MR (TR 9000 ms, TE 272 ms eff, NEX 3, echo train length 32) myelography performed. Three experienced observers compared magnetic resonance myelography (MRM) with conventional lumbar spine MR using the following variables: visibility of thecal sac and nerve roots, and the presence, location and severity of disc herniation. Disc protrusions were seen at 110 disc space levels on conventional MR images as opposed to 93 on MRM. However, only 72 % of lesions seen on conventional MR were diagnosed by MRM. Similarly, only 63.8 % of nerve root compression abnormalities seen at conventional MR were visualized when compared with conventional MRM. The sensitivity, specificity and accuracy of MRM when compared with conventional MR was 72, 93 and 85 %, respectively. The MRM technique yields images that resemble conventional myelography and may be used to help confirm abnormalities seen on conventional MR in selected cases; however, the large number of false-positive and false-negative examinations indicates that caution should be used in interpreting MRM images.

Full-scale and laboratory-scale anaerobic treatment of citric acid production wastewater

This paper reviews the operation of a full-scale, fixed-bed digester treating a citric acid production wastewater with a COD:sulphate ratio of 3-4:1. Support matrix pieces were removed from the digester at intervals during the first 5 years of operation in order to quantify the vertical distribution of biomass within the digester. Detailed analysis of the digester biomass after 5 years of operation indicated that H2 and propionate-utilising SRB had outcompeted hydrogenophilic methanogens and propionate syntrophs. Acetoclastic methanogens were shown to play the dominant role in acetate conversion. Butyrate and ethanol-degrading syntrophs also remained active in the digester after 5 years of operation. Laboratory-scale hybrid reactor treatment at 55 degrees C of a diluted molasses influent, with and without sulphate supplementation, showed that the reactors could be operated with high stability at volumetric loading rates of 24 kgCOD.m-3.d-1 (12 h HRT). In the presence of sulphate (2 g/l-1; COD/sulphate ratio of 6:1), acetate conversion was severely inhibited, resulting in effluent acetate concentrations of up to 4000 mg.l-1.

Treatment of medullary carcinoma of the thyroid by laryngo-pharyngo-oesophagectomy--a case report

We report the case of a 34 year old man, who presented with advanced medullary carcinoma of the thyroid gland. His initial presentation, with dysphagia, is unusual in this condition. Surgery is the treatment of choice, radiotherapy and chemotherapy being relatively ineffective. Our patient underwent pharyngo-laryngo-oesophagectomy which is rarely performed in these cases, as such extensive disease is not often amenable to surgery.