Upadacitinib Salvage Therapy for Infliximab-Experienced Patients with Acute Severe Ulcerative Colitis

BACKGROUND AND AIMS

Acute severe ulcerative colitis [ASUC] is a medical emergency treated with intravenous steroids followed by infliximab or cyclosporin in the case of steroid failure with emergent colectomy required in refractory or severe cases. Case series have reported on the effectiveness of tofacitinib for refractory disease, but data regarding the effectiveness of upadacitinib in this setting have not been previously reported. We describe the use of upadacitinib therapy for steroid-refractory ASUC in patients with prior loss of response to infliximab.

METHODS

Six patients who received upadacitinib for steroid-refractory ASUC were identified at two Australian tertiary inflammatory bowel disease centres. Patients were followed for up to 16 weeks after discharge with clinical, biochemical and intestinal ultrasound [IUS] outcomes.

RESULTS

All six patients demonstrated clinical response to upadacitinib induction during their inpatient admission. Four patients achieved corticosteroid-free clinical remission by week 8, including complete resolution of rectal bleeding and transmural healing assessed by IUS, and sustained clinical remission at week 16. One patient proceeded to colectomy at week 15 due to refractory disease. No adverse events directly attributable to upadacitinib were identified.

CONCLUSIONS

Upadacitinib may have a role as a safe and effective salvage therapy for steroid-refractory ASUC in patients who have previously failed to respond to infliximab therapy. Prospective studies are required to determine the safety and efficacy of upadacitinib use in this setting before routine use can be recommended.

Critical illness associated new onset atrial fibrillation: subsequent atrial fibrillation diagnoses and other adverse outcomes

AIMS

Amongst patients with critical illness associated new onset AF (CI-NOAF), the risk of subsequent atrial fibrillation (AF) diagnoses and other adverse outcomes is unknown, and the role for long-term anticoagulation is unclear. This study sought to determine the factors associated with subsequent AF diagnoses and other adverse outcomes in this cohort.

METHODS AND RESULTS

Admissions to a tertiary general intensive care unit (ICU) between December 2015 and September 2018 were screened for AF episodes through hourly analysis of continuous ECG monitoring. Patients with a prior history of AF were excluded. AF burden was defined as the percentage of monitored ICU hours in AF. The primary endpoint was subsequent AF diagnoses, as collated from the statewide electronic medical records. Secondary endpoints included mortality, embolic events, MACE and subsequent anticoagulation.

RESULTS

Of 7030 admissions with 509 303 h of monitoring data, 309 patients with CI-NOAF were identified, and 235 survived to discharge. Subsequent AF diagnoses were identified in 75 (31.9%) patients after a median of 413 days. Increased AF burden had the strongest independent association with AF recurrence (OR = 15.03, P = 0.002), followed by increased left atrial area (OR = 1.12, P = 0.01). Only 128 (54.5%) patients had their AF diagnosis acknowledged at ICU discharge, and 50 (21.3%) received anticoagulation at hospital discharge.

CONCLUSION

CI-NOAF is often under-recognized, and subsequent AF diagnoses are common post-discharge. AF burden during ICU admission has a strong independent association with subsequent AF diagnoses. Left atrial size is also independently associated with subsequent AF.

[Trajectories of body mass index Z-score and risk of high blood pressure in late adolescence in Suzhou children]

Objective: To identify age and gender standardized body mass index among children and adolescents and explore their associations with high blood pressure (HBP) in late adolescence. Methods: The current study was based on the Health Promotion Program for Children and Adolescents, school-based surveillance successively conducted from 2012 to 2019 in Suzhou, China. A total of 11 812 children and adolescents aged 16-18 years, who had ≥4 examination records during 2012-2018 and were also involved in a surveillance program in 2019, were included. Latent class growth mixture modeling was used to identify the BMI-Z trajectories in different genders, and multivariate logistic regression was used to analyze the associations between different BMI-Z trajectories and risk of HBP in late adolescence. Results: Six distinct BMI-Z trajectories were determined for both genders:thin, slightly thin,standard, declining, overweight, and obese. Compared with the regular group, the obesity group had 94.0% (OR=1.94, 95%CI: 1.43-2.63) and 107.0% (OR=2.07, 95%CI: 1.33-3.22) increased risk of developing HBP in late adolescence in boys and girls, respectively. However, a neutral association was found between the descending group and HBP in late adolescence. Conclusions: Persistent obesity in children may increase the risk of HBP in their late adolescence. If an obese child restores normal weight before late adolescence, the risk of HBP may reduce.

[Genetic characteristics of hantavirus from rodents in port area of Ningde , Fujian province in the summer of 2020]

Objective: To explore the genetic characteristics and evolution of hantavirus carried by rodents in port area of Ningde in Fujian province in the summer of 2020. Methods: Rodents were captured in the port area of Ningde, the RNA was extracted from rodent lung tissues and detected by using specific kit. The positive samples were used for whole-genome sequencing of the virus. Bioinformatics software was used for the analysis on the similarity and genetic variation of the sequences. Results: A total of 112 rodents were captured, including 5 Rattus norvegicus and 2 Rattus flavipectus, the positive rate of hantavirus was 6.25% (7/112). By virus gene sequencing, two hantavirus complete genome sequences were obtained (named as FJ35 and FJ36, GenBank accession numbers: MW449188-MW449193). The genetic analysis results showed that the hantavirus detected in positive samples were SEOV and shared 99% nucleotide similarity with hantavirus strains LZSF21 and JX20140581 isolated from Shandong province. Phylogenetic analysis using the maximum likelihood method showed that the hantavirus detected in positive samples belonged to S3 subtype, sharing the same subtype with hantavirus strains Z37 from Zhejiang province, LZSF21 from Shandong province, and zy27 and Gongzhuling 415 from northeastern China. Compared with FJ372, the amino acid variation of N259S was observed at sites 251-264 of nucleoprotein, which might be related to antigenicity. Another variation of Q81R was observed in glycoprotein compared with SEOV 80-39 segment of coded amino acid of international reference strain, which might also cause the change in antigenicity. Conclusion: The high positive rate of hantavirus in rodents in the port area of Ningde- would increase the risk of natural human infection and epidemic in local area. The hantavirus positive rodents in this focus might be from an endemic area in Shandong. It is necessary to strengthen the imported rodent control in the port area of Ningde. The virus detected in 2 positive samples belonged to SEOV subtype Ⅲ and shared high homologies of nucleotides and amino acid sequences with the hantavirus strains in surrounding area. However, some slight variations occurred in glycoprotein and nucleoprotein amino acid sequences, which might cause changes in its antigeniity.

Efficient Ground-State Cooling of Large Trapped-Ion Chains with an Electromagnetically-Induced-Transparency Tripod Scheme

We report the electromagnetically-induced-transparency (EIT) cooling of a large trapped ^{171}Yb^{+} ion chain to the quantum ground state. Unlike conventional EIT cooling, we engage a four-level tripod structure and achieve fast sub-Doppler cooling over all motional modes. We observe simultaneous ground-state cooling across the complete transverse mode spectrum of up to 40 ions, occupying a bandwidth of over 3 MHz. The cooling time is observed to be less than 300  μs, independent of the number of ions. Such efficient cooling across the entire spectrum is essential for high-fidelity quantum operations using trapped ion crystals for quantum simulators or quantum computers.

Non-thermalization in trapped atomic ion spin chains

Linear arrays of trapped and laser-cooled atomic ions are a versatile platform for studying strongly interacting many-body quantum systems. Effective spins are encoded in long-lived electronic levels of each ion and made to interact through laser-mediated optical dipole forces. The advantages of experiments with cold trapped ions, including high spatio-temporal resolution, decoupling from the external environment and control over the system Hamiltonian, are used to measure quantum effects not always accessible in natural condensed matter samples. In this review, we highlight recent work using trapped ions to explore a variety of non-ergodic phenomena in long-range interacting spin models, effects that are heralded by the memory of out-of-equilibrium initial conditions. We observe long-lived memory in static magnetizations for quenched many-body localization and prethermalization, while memory is preserved in the periodic oscillations of a driven discrete time crystal state.This article is part of the themed issue 'Breakdown of ergodicity in quantum systems: from solids to synthetic matter'.

Psychological Morbidity among Emergency Department Doctors and Nurses after the SARS Outbreak

Objective

To determine the psychological morbidity among emergency department (ED) doctors and nurses six months after the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak.

Methods

During the SARS outbreak from 13 March to 31 May 2003, the study ED was designated as Singapore's only screening centre for SARS and was closed to all other patients. A self-administered questionnaire survey was conducted in November 2003. Doctors and nurses of the study ED who had patient contact during the outbreak were included. Data collected were demographics and responses to (a) Impact of Event Scale (IES) and (b) General Health Questionnaire 28 (GHQ 28). Scores were assigned to the responses whereby an IES score ≥26/75 or a GHQ 28 score ≥5/28 was indicative of post-event and psychiatric morbidity respectively.

Results

Thirty-eight out of 41 (92.7%) doctors and 58 out of 83 (69.9%) nurses responded. Fewer doctors reported post-event and psychiatric morbidity compared to nurses, with 5 (13.2%) doctors and 12 (20.7%) nurses scoring ≥26 on IES, 6 (15.8%) doctors and 12 (20.7%) nurses scoring ≥5 on GHQ 28. The doctors reported a median of 9.5 (range 0–47) on IES and 0 (range 0–11) on GHQ 28. The nurses reported a median of 15 (range 0–61) on IES and 1 (range 0–25) on GHQ 28.

Conclusions

Six months after SARS, the rates of post-event and psychiatric morbidity were relatively low among the study ED doctors and nurses. The results might have underestimated actual morbidity as the study was conducted six months after the outbreak.

Jellyfish stings on Langkawi Island, Malaysia

INTRODUCTION

Jellyfish stings are the most frequently reported marine animal envenomation worldwide. However, data on jellyfish sting from Malaysia remains obscure due to inadequate research.

METHODS

We investigated the epidemiology, clinical features and treatment of patients presenting at the emergency department of Langkawi Hospital between January 2012 and December 2014. Secondary data on the nature of the incident, patient demographics, clinical presentation, and treatment were retrieved from the patients' medical records. Descriptive statistics were presented for all patient variables.

RESULTS

A total of 759 patients presented with jellyfish stings during the 3-year study period, with highest number of visits in July, October, November, and December. The mean patient age was 26.7 years (SD: 12.14), 59.4% were men, 68.1% were foreigners or international tourists, and 40.4% were stung between 12.00 p.m. and 6:59 p.m. At least 90 patients presented with mild Irukandji or Irukandji-like syndromes. Most of the jellyfish stings occurred at Chenang Beach (590 reported cases), followed by Tengah Beach and Kok Beach. Most patients were treated symptomatically, and no deaths following a jellyfish sting was reported during the study period.

CONCLUSION

There is a need for public health interventions for both local and international tourists who visit Langkawi Island. Preventive steps and education on initial treatment at the incident site could elevate public awareness and decrease the adverse effects of jellyfish stings.

Knowledge, attitude and practice of antibiotics prescribing among medical officers of public health care facilities in the state of Kedah, Malaysia

BACKGROUND

Antibiotic resistance is a rising problem in Malaysia. For instance, high antibiotic prescribing rate for upper respiratory tract infection and inappropriate choice of antibiotic is a significant healthcare concern in Malaysia. Our main objective was to study knowledge, attitude and practice of antibiotic prescribing among medical officers in Kedah, Malaysia.

METHODS

A cross sectional study was conducted in outpatient departments of health clinics and hospitals in Kedah from June 2013 until December 2013. Sample size was 118 and systematic sampling was conducted. Research tool used was a validated questionnaire from studies conducted in Congo and Peru.

RESULTS

Response rate was 84.8%. Majority of our respondents were female doctors (71.0%), local graduates (63.0%), and practiced for 4 years or less (61.0%). 52.0% of the respondents prescribed antibiotics more than once daily. Mean knowledge score on antibiotics was 5.31 ±1.19 (95% CI: 5.06; 5.54). More than half (62.0%) of our respondents were confident in antibiotic prescribing and there were merely 18.0% of them consulted any colleagues prior to prescription. There was a significant difference in frequency of antibiotic prescribing between junior doctors and senior doctors (P-value: 0.036). In addition, there was also a significant association between frequency of antibiotic prescribing and awareness of antibiotic resistance in their daily practice. (P-value: 0.002).

CONCLUSION

Knowledge on antibiotic was moderate among our medical officers and antibiotic prescribing was frequent. Training and courses on appropriate antibiotic prescribing should be emphasized to ensure the best practice in antibiotic prescription.

HOTAIR inhibited intracellular Ca2+ via regulation of Cav1.2 channel in human cardiomyocytes

HOTAIR, a long non—coding RNA (lncRNA), is reported to regulate chromatin organization and promote tumor progression. However, little is known about the roles of this gene in the modulation of calcium homeostasis in human cardiomyocytes. In the present study, we demonstrated that up—regulation of HOTAIR could suppress the expression of CaV1.2 in human cardiomyocytes. However, HOTAIR knockdown promoted CaV1.2 expression in human cardiomyocytes. In addition, we found that HOTAIR overexpression significantly reduced the intracellular Ca2+ contents; while knockdown of HOTAIR enhanced the Ca2+ contents in the cardiomyocytes. Moreover, enforced expression of CaV1.2 increased the calcium level in cardiomyocytes overexpressing HOTAIR. down—regulation of HOTAIR and up—regulation of CaV1.2 further enhanced the Ca2+ contents in the cardiomyocytes Taken together, these results for the first time demonstrate that HOTAIR inhibited the intracellular Ca2+ via regulation of CaV1.2 in human cardiomyocytes.

Using pictograms to assist caregivers in liquid medication administration: a systematic review

WHAT IS KNOWN AND OBJECTIVE

It has been reported that more than 80% of out-of-hospital medication errors among the young children involve liquid formulations. The usefulness of pictorial aids to improve communication of medication instructions has not been extensively investigated for child health. The objective of this study was to determine the effectiveness of pictorial aids used to assist caregivers in the administration of liquid medications.

METHODS

MEDLINE, CINAHL, PsycINFO, ScienceDirect, Scopus and the Cochrane Library were searched for articles published up to February 2015. Studies that used pictorial aids with liquid medications and measured at least one of the following outcomes were included: dosing accuracy, comprehension of medication instructions, recall of information and adherence of caregivers. Two authors independently selected studies, extracted data and assessed methodological quality of studies using the Cochrane Collaboration's tool.

RESULTS AND DISCUSSION

Five experimental studies (four hospital based and one community based) with a total of 962 participants were included. A wide range of liquid formulations were studied, including both prescription and over-the-counter medications. The existing findings suggest that pictographic interventions reduced dosing errors, enhanced comprehension and recall of medication instructions and improved adherence of caregivers. Incorporating pictorial aids into verbal medication counselling or text-based instructions was more beneficial than using the single approach alone. Mixed results were identified for the relationship between health literacy of caregivers and effectiveness of pictorial aids.

WHAT IS NEW AND CONCLUSION

The evidence remains limited due to the small number of studies found and variations in methodological quality. This review suggests that pictorial aids might be potential interventions, but more high-quality studies are needed to support the routine use of any pictogram-based materials with liquid medications in the clinical settings.

Silencing of stat4 gene inhibits cell proliferation and invasion of colorectal cancer cells

Signal transducers and activators of transcription (STAT) play critical roles in development, proliferation, and immune defense. However the consequences of STAT hyperactivity can predispose to diseases, including colorectal cancer. In the present study, we aimed to evaluate the function of STAT4 in human colorectal cancer (CRC). The expression of STAT4 was examined by immunohistochemical assay using a tissue microarray procedure. A loss-of-function experiment was carried out to investigate the effects of lentivirus-mediated STAT4 shRNA (Lv-shSTAT4) on cell proliferation and invasive potential indicated by MTT and Transwell assays in CRC cell lines (SW480 and Caco2). As a consequence, it was found that the expression of STAT4 protein was significantly increased in CRC tissues compared with that in adjacent non-cancerous tissues (ANCT) (71.1% vs 44.4%, P=0.015), and was related with the Duke’s staging and depth of invasion in CRC patients (P=0.022; P=0.001). Silencing of STAT4 gene suppressed cell proliferation and invasion of CRC cells. Taken together, these findings demonstrate that increased expression of STAT4 is positively correlated with the depth of invasion in CRC patients, and inhibition of STAT4 expression represses the growth and invasion of CRC cells, suggesting that STAT4 may be a promising therapeutic target for the treatment of CRC.

Can diffusion tensor imaging noninvasively detect IDH1 gene mutations in astrogliomas? A retrospective study of 112 cases

BACKGROUND AND PURPOSE

IDH1 mutational status probably plays an important role in the predictive response for patients with astroglioma. This study explores whether DTI metrics are able to noninvasively detect IDH1 status in astrogliomas.

MATERIALS AND METHODS

The DTI data of 112 patients with pathologically proven astroglioma (including 25, 12, and 10 cases with IDH1 mutation and 11, 11, and 43 cases without mutation in grades II, III, and IV, respectively) were retrospectively reviewed. The maximal fractional anisotropy, minimal ADC, ratio of maximal fractional anisotropy, and ratio of minimal ADC in the tumor body were measured. In the same World Health Organization grading, the imaging parameters of patients with and without IDH1 R132H mutation were compared by means of optimal metrics for detecting mutations. Receiver operating characteristic curve analysis was performed.

RESULTS

The maximal fractional anisotropy and ratio of maximal fractional anisotropy values had statistical significance between patients with IDH1 R132H mutation and those without mutation in astrogliomas of grades II and III. The areas under the curve for maximal fractional anisotropy and ratio of maximal fractional anisotropy were both 0.92 in grade II and 0.80 and 0.82 in grade III. The minimal ADC value and ratio of minimal ADC value also demonstrated statistical significance between patients with mutation and those without mutation in all astroglioma grades. The areas under the curve for minimal ADC were 0.94 (II), 0.76 (III), and 0.66 (IV), and the areas under the curve for ratio of minimal ADC were 0.93 (II), 0.83 (III), and 0.70 (IV).

CONCLUSIONS

Fractional anisotropy and ADC from DTI can noninvasively detect IDH1 R132H mutation in astrogliomas.

Validation of a semiquantitative food frequency questionnaire for estimation of intakes of energy, fats and cholesterol among Singaporeans

The aim of this study was to assess the relative validity of a 159-item semiquantitative food frequency questionnaire (FFQ) for use among adult Singaporeans. This FFQ should be able to classify intakes of energy, total fat, saturated fat, polyunsaturated fat, monounsaturated fat and cholesterol into quintiles of intakes for purposes of epidemiological studies. A total of 126 subjects (84 women and 42 men) took part in the study which included an interview using the newly developed FFQ (assess past month's intake) and three 24-h (24 h) recalls (reference method, collected over a period of 1 month). Subjects also collected two 24 h urinary samples for urea from which total nitrogen excretion was assessed to validate protein intake. When compared to the reference method, the FFQ slighty overestimated the intakes of energy, total fat and types of fat as reflected by the difference in means and the ratio of FFQ to 24 h intakes. The overestimation ranged from 1 to 11% of the reference method. Dietary cholesterol was underestimated by 17% by the FFQ. These differences were however, not statistically significant. Pearson's correlation coefficients (95% confidence intervals (CI)) between intakes assessed by FFQ and reference method varied from 0.58 (0.45, 0.69) for total fat to 0.39 (0.23, 0.53) for polyunsaturated fat. Cross-classification into quintiles resulted in correct classification into the same or adjacent quintiles in 70% of subjects, with only one or two subjects being grossly misclassified. Nitrogen (N) intake from the 24 h recalls did not differ significantly from that estimated from the urinary nitrogen excretion. The mean (± SD) difference was 0.0 ± 0.4 g and the Pearson correlation coefficient (95% CI) was 0.55 (0.31, 0.72). It is concluded that the newly developed FFQ is an adequate tool for classifying individuals' intakes into quintiles for epidemiological studies among Singaporean adults.

Prognostic significance of thymidylate synthase, dihydropyrimidine dehydrogenase and thymidine phosphorylase protein expression in colorectal cancer patients treated with or without 5-fluorouracil-based chemotherapy

BACKGROUND

Low tumour expression levels of thymidylate synthase (TS), dihydropyrimidine dehydrogenase (DPD) and thymidine phosphorylase (TP) have been linked with improved outcome for colorectal cancer (CRC) patients treated with 5-fluorouracil (5-FU). It is unclear whether this occurs because such tumours have better prognosis or they are more sensitive to 5-FU treatment.

PATIENTS AND METHODS

Associations between TS, DPD and TP levels, determined by tissue microarrays and immunohistochemistry, and survival was evaluated in 945 CRC patients according to treatment status.

RESULTS

Low TS and DPD expression associated with worse prognosis in stage II [hazard ratio (HR) = 1.69, 95% confidence interval (CI) (1.09-2.63) and HR = 1.92 (95% CI 1.23-2.94), respectively] and stage III CRC patients treated by surgery alone [HR = 1.39 (95% CI 0.92-2.13) and HR = 1.49 (95% CI 1.02-2.17), respectively]. Low TS, DPD and TP associated with trends for better outcome in stage III patients treated with 5-FU [HR = 0.81 (95% CI 0.49-1.33), HR = 0.70 (95% CI 0.42-1.15) and HR = 0.66 (95% CI 0.39-1.12), respectively].

CONCLUSION

Low TS and DPD expression are prognostic for worse outcome in CRC patients treated by surgery alone, whereas low TS, DPD and TP expression are prognostic for better outcome in patients treated with 5-FU chemotherapy. These results provide indirect evidence that low TS, DPD and TP protein expression are predictive of good response to 5-FU chemotherapy.

Modeling Caco-2 permeability of drugs using immobilized artificial membrane chromatography and physicochemical descriptors

This study evaluates the potential of immobilized artificial membrane (IAM) chromatography, in combination with other physicochemical descriptors for high-throughput absorption profiling during lead optimization. An IAM chromatographic method was developed and validated. Absorption profiles of 32 structurally diverse compounds (acidic, basic, neutral and amphoteric) were then evaluated based on their IAM retention factor (log k'IAM), molecular weight (MW), calculated log P (C log P), polar surface area (PSA), hydrogen bonding capacity (HBD and HBA) and calculated Caco-2 permeability (QPCaco). Using regression and stepwise regression analysis, experimental Caco-2 permeability was correlated against log k'IAM and a combination of various physicochemical variables for quantitative structural-permeability relationship (QSPR) study. For the 32 structurally diverse compounds, log k'IAM correlated poorly with Caco-2 permeability values (R2 = 0.227). Stepwise regression analysis confirmed that Clog, PSA, HBD and HBA parameters are not statistically significant and can be eliminated. Correlation between Caco-2 cell uptake and log k'IAM was enhanced when molecular size factor (MW) was included (R2 = 0.555). The exclusion of 11 compounds (paracellularly and actively transported, Pgp substrates and blocker, and molecules with MW lesser than 200 and greater than 800) improved the correlation between Caco-2 permeability, IAM and MW factors to R2 value of 0.84. The results showed that IAM chromatography can only profile the passive absorption of drug molecules. Finally, it was confirmed in this study that the IAM model can accurately identify the Caco-2 permeability of nontransported Pgp substrates, such as verapamil and ketoconazole, through passive permeation because of their high permeability. IAM chromatography, combined with molecular size factor (MW), is useful for elucidating biopartitioning mechanism of drugs.

Can dietary factors explain differences in serum cholesterol profiles among different ethnic groups (Chinese, Malays and Indians) in Singapore?

In Singapore. there exists differences in risk factors for coronary heart disease among the three main ethnic groups: Chinese, Malays and Indians. This study aimed to investigate if differences in dietary intakes of fat, types of fat, cholesterol, fruits, vegetables and grain foods could explain the differences in serum cholesterol levels between the ethnic groups. A total of 2408 adult subjects (61.0% Chinese, 21.4% Malays and 17.6% Indians) were selected systematically from the subjects who took part in the National Health Survey in 1998. The design of the study was based on a cross-sectional study. A food frequency questionnaire was used to assess intakes of energy, total fat, saturated fat, polyunsaturated fat, monounsaturated fat, cholesterol, fruits, vegetables and cereal-based foods. The Hegsted score was calculated. Serum total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol were analysed and the ratio of total cholesterol to high density lipoprotein cholesterol was computed. The results showed that on a group level (six sex-ethnic groups), Hegsted score, dietary intakes of fat, satutrated fat, cholesterol, vegetables and grain foods were found to be correlated to serum cholesterol levels. However, selected dietary factors did not explain the differences in serum cholesterol levels between ethnic groups when multivariate regression analysis was performed, with adjustment for age, body mass index, waist-hip ratio, cigarette smoking, occupation, education level and physical activity level. This cross-sectional study shows that while selected dietary factors are correlated to serum cholesterol at a group level, they do not explain the differences in serum cholesterol levels between ethnic groups independently of age, obesity, occupation, educational level and other lifestyle risk factors.

Isolation and characterization of mutants defective in seed coat mucilage secretory cell development in Arabidopsis

In Arabidopsis, fertilization induces the epidermal cells of the outer ovule integument to differentiate into a specialized seed coat cell type producing extracellular pectinaceous mucilage and a volcano-shaped secondary cell wall. Differentiation involves a regulated series of cytological events including growth, cytoplasmic rearrangement, mucilage synthesis, and secondary cell wall production. We have tested the potential of Arabidopsis seed coat epidermal cells as a model system for the genetic analysis of these processes. A screen for mutants defective in seed mucilage identified five novel genes (MUCILAGE-MODIFIED [MUM]1-5). The seed coat development of these mutants, and that of three previously identified ones (TRANSPARENT TESTA GLABRA1, GLABRA2, and APETALA2) were characterized. Our results show that the genes identified define several events in seed coat differentiation. Although APETALA2 is needed for differentiation of both outer layers of the seed coat, TRANSPARENT TESTA GLABRA1, GLABRA2, and MUM4 are required for complete mucilage synthesis and cytoplasmic rearrangement. MUM3 and MUM5 may be involved in the regulation of mucilage composition, whereas MUM1 and MUM2 appear to play novel roles in post-synthesis cell wall modifications necessary for mucilage extrusion.

Isolation and characterization of mutants defective in seed coat mucilage secretory cell development in Arabidopsis

In Arabidopsis, fertilization induces the epidermal cells of the outer ovule integument to differentiate into a specialized seed coat cell type producing extracellular pectinaceous mucilage and a volcano-shaped secondary cell wall. Differentiation involves a regulated series of cytological events including growth, cytoplasmic rearrangement, mucilage synthesis, and secondary cell wall production. We have tested the potential of Arabidopsis seed coat epidermal cells as a model system for the genetic analysis of these processes. A screen for mutants defective in seed mucilage identified five novel genes (MUCILAGE-MODIFIED [MUM]1-5). The seed coat development of these mutants, and that of three previously identified ones (TRANSPARENT TESTA GLABRA1, GLABRA2, and APETALA2) were characterized. Our results show that the genes identified define several events in seed coat differentiation. Although APETALA2 is needed for differentiation of both outer layers of the seed coat, TRANSPARENT TESTA GLABRA1, GLABRA2, and MUM4 are required for complete mucilage synthesis and cytoplasmic rearrangement. MUM3 and MUM5 may be involved in the regulation of mucilage composition, whereas MUM1 and MUM2 appear to play novel roles in post-synthesis cell wall modifications necessary for mucilage extrusion.

Malaria requiring intensive care

We studied 24 consecutive adult patients with malaria who required intensive care between 1 January 1994 and 31 December 1997. This was out of a total of 256 patients hospitalised at the Singapore General Hospital with malaria during these 4 years. Our aim was to characterise the type and severity, clinical features, complications, treatment and outcome of adult patients with malaria who required intensive care. In addition, we compared the actual and predicted mortality based on the Acute Physiology and Chronic Health Evaluation II (APACHE II) score. The travel history, prophylaxis, duration of fever before receiving treatment, type of malaria and severity, clinical data, complications, APACHE II score, treatment and outcome were analysed. Most cases were imported by locals travelling overseas or foreigners infected with the parasite elsewhere. Four patients had vivax malaria and 20 patients had severe falciparum malaria. All but 1 patient received transfusion with blood products and 6 patients with severe falciparum malaria had exchange transfusions. Complications were restricted to infection with P. falciparum: 9 patients required acute dialysis and 8 required mechanical ventilation. Three patients died giving a mortality of 15% for severe falciparum malaria. The overall mortality of patients with malaria was 1.2%. The mortality of patients with malaria requiring intensive care was 12.5% as compared with a predicted mortality of 18.7% based on the APACHE II prognostication system.

[Multiple pulmonary embolisms in nursing home patients recognizable by alertness to certain aspecific symptoms]

OBJECTIVE

To determine whether increased alertness regarding multiple pulmonary embolism in geriatric patients increases the number of cases diagnosed.

DESIGN

Retrospective descriptive study.

SETTING

Dutch nursing homes Mariënhaven (psychogeriatric) in Warmond and De Wilbert (somatic and psychogeriatric) in Katwijk aan den Rijn, the Netherlands.

METHOD

In the period 1989-1991, the diagnosis of multiple pulmonary embolism was suspected in 15 patients with an 'unclear' or 'aspecific' complex of symptoms, who subsequently underwent ventilation perfusion scintigraphy.

RESULTS

In 11/15 patients the diagnosis of multiple pulmonary embolism was confirmed. These patients were treated with anticoagulants resulting in complete recovery in 9 patients. Aspecific symptoms suggestive of pulmonary embolism include subfebrile temperature, respiratory and sensory disturbances and a clinical picture mimicking airway infection. If lung scintigraphy is only performed if a positive diagnosis will have the therapeutical consequences for the patients concerned, and assuming that refraining from treatment would lead to death, it was calculated that on a yearly basis mortality in subjects in nursing homes could be reduced by more than 2% when appropriate diagnosis is made and treatment given. Comparison of the data from SIG Health Information (Utrecht) with the present results suggests that the prevalence of (multiple) pulmonary embolism in the Dutch nursing homes is insufficiently recognized.

CONCLUSION

More alertness regarding multiple pulmonary embolism in nursing home patients will establish the diagnosis more frequently and proper treatment of this condition will lead to a decrease in mortality.

Distortion in TGF beta 1 peptide immunolocalization in biliary atresia: comparison with the normal pattern in the developing human intrahepatic bile duct system

Biliary atresia is an important cause of neonatal obstructive jaundice in which there is inflammation, sclerosis and eventual obliteration of the bile duct system. Its onset may be antenatal, affecting the normal development of the biliary system. The intrahepatic biliary system is derived from the ductal plate, a sheath of cuboidal epithelium that appears at the hepatocyte-mesenchymal junction around the portal vein branches at 6 weeks gestation. This epithelial structure is moulded into a network of tubular bile ducts by the proliferating mesenchyme. Certain portions of the ductal plate are selected to become definitive bile ducts, while redundant biliary epithelium is deleted. The molecular dynamics controlling the intra-uterine development of the biliary system in humans are not yet clearly understood. Transforming growth factor-beta 1 is a cytokine that stimulates mesenchymal proliferation and inhibits epithelial growth, and has been shown to be important in organogenesis. In the present study, the pattern of TGF beta 1 peptide immunolocalization was investigated with the aid of computerized image analysis, in normal human bile duct development and in biliary atresia. TGF beta 1 peptide was detected within hepatocytes and ductal plate epithelium from 7 weeks gestation; increased TGF beta 1 immunoreactivity was present within the epithelium of developing bile ducts at 13 weeks gestation, and apical polarization of the cytokine was observed from 16 weeks gestation. In biliary atresia, the TGF beta 1 immunoreactivity pattern within the bile duct structures at the porta hepatis and within intrahepatic portal tracts resembled that of the primitive ductal plate, and there was no significant apical polarization. This may indicate a developmental arrest in the normal ductal plate remodelling process in biliary atresia, and suggests an underlying epithelial-mesenchymal interactive disorder.

Factors associated with obesity in primary-school children in Singapore

An upward trend in obesity has been observed in Singapore school children over the 15 years prior to the study. A case-control study of 400 children (mean age 10 years) and their parents was conducted to determine some of the factors likely to be associated with obesity in primary-school children. It included dietary practices and intake, activity patterns, family history and social factors. It was found that obese children were more likely to consume foods that were deep-fried or sweet and were more likely to have at least one obese parent and sibling. A variety of intervention measures were taken to reduce the prevalence and severity of obesity in school children following the study.

The in vitro and in vivo antimalarial activity of some Mannich bases derived from 4-[7'-bromo (and chloro)-1',5'-naphthyridin-4'-ylamino]phenol and 4-(7'-trifluoromethylquinolin-4'-ylamino)phenol

A series of di-Mannich bases derived from 4-[7'-bromo (and chloro)-1',5'-naphthyridin-4'-ylamino]phenol and 4-(7'-trifluoromethylquinolin-4'-ylamino)phenol were assayed for activity against chloroquine-sensitive and chloroquine-resistant isolates of cultured Plasmodium falciparum using the inhibition of uptake of radiolabelled hypoxanthine. A number of the 4-(7'-trifluoromethylquinolinyl-amino)phenols showed statistically superior activity to chloroquine and amodiaquine against both isolates. Analysis of the antimalarial activity of some of these compounds against Plasmodium berghei in mice following oral administration again demonstrated activity equal or superior to that of the established antimalarials against a chloroquine-sensitive strain, and in some cases appreciably superior activity against a chloroquine-resistant strain.

Antimalarial activity of Mannich bases derived from 4-(7'-bromo-1',5'-naphthyridin-4'-ylamino)phenol and 4-(7'-trifluoromethylquinolin-4'-ylamino)phenol against Plasmodium falciparum in vitro

Mono- and di-Mannich bases derived from 4-(7'-bromo-1',5'-naphthyridin-4'-ylamino)phenol and 4-(7'-trifluoromethylquinolin-4'-ylamino)phenol were assayed for antimalarial activity (using an in vitro radioisotopic technique) against two isolates of Plasmodium falciparum. Many from these two series of compounds had an IC50 value (concentration of compound causing 50% inhibition of 3H-hypoxanthine incorporation) comparable to or better than those of mefloquine and amodiaquine, for both a chloroquine-sensitive isolate (FCQ-27) and the chloroquine-resistant isolate (K1). At least one compound, 2,6-bis (piperidin-1''-ylmethyl)-4-(7'-trifluoromethylquinolin -4'-ylamino)phenol (TN112), showed significant superior activity to the three antimalarials chloroquine, mefloquine and amodiaquine against both isolates. (Statistically superior activity compared to these three antimalarials was found for TN112, except that against the K1 isolate its activity was just outside the range of significance relative to mefloquine.) Some of the 7-bromo-1,5-naphthyridine Mannich bases were appreciably less toxic in mice than amodiaquine.

Potential Antimalarials. VI. Mannich-Bases Derived From 4-[7′-Bromo(and Chloro)-1′,5′-Naphthyridin-4′-Ylamino]Phenols and 4-(7′-Trifluoromethylquinolin-4′-Ylamino)Phenol

Eleven di-Mannich bases derived from 4-[7′-bromo(and chloro )-1′,5′-naphthyridin-4′-ylamino]phenols and 4-(7′-trifluoromethylquinolin-4′- ylamino )phenol have been prepared. Each of these compounds showed very good antimalarial activity w en injected intraperitoneally in a single dose of 50-100 mg/kg to mice infected with Plasmodium vinckei vinckei.

Potential Antimalarials. V. 4-(7′-Trifluoromethylquinolin-4′-Ylamino)Phenols, 4-[2′,7′ and 2',8′-Bis(Trifluoromethyl)Quinolin-4′-Ylamino]Phenols and N4-Substituted 2,7-(and 2,8-)Bis(Trifluoromethyl)-Quinolin-4-Amines

Mono- and di-Mannich bases of 4-(7′-trifluoromethylquinolin-4′- ylamino )phenol and its 2′,7′- and 2′,8′-bis( trifluoromethyl ) analogues, for example 2,6-bis(piperidin-1′-ylmethyl)-4-(7′-trifluoromethyl- quinolin-4′-ylamino)phenol, have been prepared. The Mannich bases from 4-(7′-trifluoromethyl-quinolin-4′-ylamino)phenol showed significant antimalarial activity when injected intraperitoneally in a single dose of 100 mg/kg to mice infected with Plasmodium vinckei vinckei ; those from its 2′,7′- and 2′,8′-bis( trifluoromethyl ) analogues did not show appreciable activity. Some N4-substituted 2,7(and 2,8)- bis ( trifluoromethyl )quinolin-4-amines with aliphatic side chains were also prepared but were inactive. The blood schizontocidal activity of mefloquine was not retained in the 2,8-bis( trifluoromethyl )-quinolin-4-amines prepared here.

24xi-Methylcholestane-3beta, 5alpha, 6beta, 12beta, 25-pentol 25-monoacetate, a novel polyoxygenated marine sterol

24xi--Methylcholestane-3beta, 5alpha, 6beta, 12beta, 25-pentol 25-monoacetate has been isolated from an Alyconarian and its structure was established in part through extensive high resolution mass spectral and nmr studies and partly through the nonidentity of one of its degradation products with 24xi-methylcholestane-3beta, 5alpha, 6beta, 12alpha-tetrol synthesized from deoxycholic acid.