CAnceR IN PreGnancy (CARING) - a retrospective study of cancer diagnosed during pregnancy in the United Kingdom

BACKGROUND

The incidence of cancer diagnosed during pregnancy is increasing. Data relating to investigation and management, as well as maternal and foetal outcomes is lacking in a United Kingdom (UK) population.

METHODS

In this retrospective study we report data from 119 patients diagnosed with cancer during pregnancy from 14 cancer centres in the UK across a five-year period (2016-2020).

RESULTS

Median age at diagnosis was 33 years, with breast, skin and haematological the most common primary sites. The majority of cases were new diagnoses (109 patients, 91.6%). Most patients were treated with radical intent (96 patients, 80.7%), however, gastrointestinal cancers were associated with a high rate of palliative intent treatment (63.6%). Intervention was commenced during pregnancy in 68 (57.1%) patients; 44 (37%) had surgery and 31 (26.1%) received chemotherapy. Live births occurred in 98 (81.7%) of the cases, with 54 (55.1%) of these delivered by caesarean section. Maternal mortality during the study period was 20.2%.

CONCLUSIONS

This is the first pan-tumour report of diagnosis, management and outcomes of cancer diagnosed during pregnancy in the UK. Our findings demonstrate proof of concept that data collection is feasible and highlight the need for further research in this cohort of patients.

Skp2-Cyclin A Interaction Is Necessary for Mitotic Entry and Maintenance of Diploidy

Skp2, the substrate recognition component of the SCFSkp2 ubiquitin ligase, has been implicated in the targeted destruction of a number of key cell cycle regulators and the promotion of S-phase. One of its critical targets is the Cyclin dependent kinase (Cdk) inhibitor p27, and indeed the overexpression of Skp2 in a number of cancers is directly correlated with the premature degradation of p27. Skp2 was first identified as a protein that interacts with Cyclin A in transformed cells, but its role in this complex has remained unclear. In this paper, we demonstrate that Skp2 interacts with Cyclin A in Drosophila and is required to maintain Cyclin A levels and permit mitotic entry. Failure of mitotic entry in Skp2 mutant cells results in polyploidy. If these cells enter mitosis again they are unable to properly segregate their chromosomes, leading to checkpoint dependent cell cycle arrest or apoptosis. Thus, Skp2 is required for mitosis and for maintaining diploidy and genome stability.

Including genomic information in the genetic evaluation of production and reproduction traits in South African Merino sheep

Genomic selection (GS) has become common in sheep breeding programmes in Australia, New Zealand, France and Ireland but requires validation in South Africa (SA). This study aimed to compare the predictive ability, bias and dispersion of pedigree BLUP (ABLUP) and single-step genomic BLUP (ssGBLUP) for production and reproduction traits in South African Merinos. Animals in this study originated from five research and five commercial Merino flocks and included between 54,072 and 79,100 production records for weaning weight (WW), yearling weight (YW), fibre diameter (FD), clean fleece weight (CFW) and staple length (SL). For reproduction traits, the dataset included 58,744 repeated records from 17,268 ewes for the number of lambs born (NLB), number of lambs weaned (NLW) and the total weight weaned (TWW). The single-step relationship matrix, H, was calculated using PreGS90 software combining 2811 animals with medium density (~50 K) genotypes and the pedigree of 88,600 animals. Assessment was based on single-trait analysis using ASREML V4.2 software. The accuracy of prediction was evaluated according to the 'LR-method' by a cross-validation design. Validation candidates were assigned according to Scenario I: born after a certain time point; and Scenario II: born in a particular flock. In Scenario I, the genotyping rate for the reference population between 2006 and the 2013 cut-off point approached 7% of animals with phenotypes and 20% of their sires. For reproduction traits, about 20% of ewes born between 2006 and 2011 cut-off were genotyped, along with 15% of their sires. Genotyping rates in the validation set of Scenario I were 3.7% (production) and 11.4% (reproduction) for candidates and 35% of their sires. Sires were allowed to have progeny in both the reference and validation set. In Scenario I, ssGBLUP increased the accuracy of prediction for all traits except NLB, ranging between +8% (0.62-0.67) for FD and +44% (0.36-0.52) for WW. This showed a promising gain in accuracy despite a modestly sized reference population. In the 'across flock validation' (Scenario II), overall accuracy was lower, but with greater differences between ABLUP and ssGBLUP ranging between +17% (0.12-0.14) for TWW and +117% (0.18-0.39) for WW. There was little indication of severe bias, but some traits were prone to over dispersion and the use of genomic information did not improve this. These results were the first to validate the benefit of genomic information in South African Merinos. However, because production traits are moderately heritable and easy to measure at an early age, future research should be aimed at best exploiting GS methods towards genetic prediction of sex-limited and/or lowly heritable traits such as NLW. GS methods should be combined with dedicated efforts to increase genetic links between sectors and improved phenotyping by commercial flocks.

Evaluation of Radiotherapy Dose and Survival Outcomes for Teenagers, and Young Adults with Nasopharyngeal Carcinoma in UK and Ireland

PURPOSE/OBJECTIVE(S)

Nasopharyngeal carcinoma (NPC) follows a bimodal distribution with a smaller incidence peak in teenagers and young adults (TYAs). In TYAs, an over-whelming proportion are associated with Epstein-Barr virus (EBV). We have evaluated the variation in TYA NPC practice patterns across the UK and Ireland, along with survival outcomes.

MATERIALS/METHODS

We performed a multicenter, observational cohort study, of patients aged 13-25 years, with histologically confirmed NPC, treated between the years 2002-2022. An initial expression of interest was sent to selected centers treating H&N patients in the UK and Ireland. For analysis, patients were assessed based on total prescribed dose, with a cut off for low dose (LD) (≤61.2Gy) versus a high dose (HD)(>61.2Gy).

RESULTS

Ninety-five patients, from 9 centers, were eligible for inclusion. Patient demographics are shown in table1. At a median follow up of 45 months (IQR 23-111), 3-year overall survival (OS) was 98% (95% CI 93%-100%) with LD versus 91% (95% CI 83%-99%) with HD (Hazard ratio (HR) = 3.0; 95% CI 0.3-27, p = 0.3). 3-year progression free survival (PFS) was 84% (95% CI 71%-97%) with LD versus 83% (95% CI 72%-94%) with HD (HR 1.3; 95% CI 0.4-4.0, p = 0.6), and 5-year PFS was 84% (95% CI 71%-97%) with LD versus 83% (95% CI 72%-94%) with HD (HR 1.3; 95% CI 0.4-4.0, p = 0.6). Incidence of distant metastasis (DM) was 9.9%. 2 patients (6%) with T3-T4 tumors, treated with LD, had locoregional failure (LRF) compared to 1 patient (3%) treated with HD.

CONCLUSION

We have demonstrated excellent survival outcomes for the UK & Ireland TYA NPC patients. As the majority of cases in this age group have EBV+ NPC, with survival similar between LD and HD protocols, we propose that pediatric protocols, with lower radiotherapy doses should be considered for all TYA NPC, with the aim of reducing late effects. Additional analysis to better understand the impact of heterogeneity between both groups, including choice of protocol, induction and adjuvant treatment will follow this study. Prospective evaluation, as part of an international collaboration, is required to optimize the management strategy for this rare cohort of patients.

A Multicenter Study of Clinician and Patient Reported Acute and Late Toxicity after Radical (Chemo)Radiotherapy for Non-Endemic Nasopharyngeal Cancer

PURPOSE/OBJECTIVE(S)

Curative (chemo)radiotherapy ((CT)RT) for Nasopharyngeal cancers (NPC) achieves excellent disease control but is associated with significant late toxicities despite modern treatment delivery. Contemporary late toxicity data, including patient reported outcomes (PROs), is limited in the non-endemic population; we present a large contemporary series of toxicity outcomes and late PROs following treatment of non-endemic NPC.

MATERIALS/METHODS

Adult patients completing radical (CT)RT for primary NPC between February 2016 and 2020 at 7 large UK cancer centers were identified on institutional databases. Patients were excluded if they had prior head and neck cancer or prior therapeutic head and neck surgery (except neck dissection). Patients with an active other cancer were excluded from PRO assessment. Demographic, treatment, acute toxicity and outcome data were collected retrospectively from patient records. Disease-free patients were invited to complete an M.D. Anderson Dysphagia Index (MDADI) and University of Washington (UoW) Quality of Life (QoL) PROs questionnaires.

RESULTS

A total of 180 eligible patients were identified: 68% male, median age 54 years, 11% ≥70 years. EBV status was positive in 61% (unknown 12%). Patients had stage I (5%), II (22%), III (37%), IV (36%) disease; 95% were performance status ≤1 at baseline. Median follow-up was 31.2 months (range 0-68). A total of 54% received 70Gy in 33-35# and 43% received 65-66 Gy in 30-33#. 66% received induction and 65% received concurrent chemotherapy. 9.5% had residual disease at the first follow-up scan. Subsequent locoregional or distant recurrence occurred in 5% and 12% respectively. At last assessment, 84% patients were alive, 16% had died (of which 70% had active disease). Acute treatment toxicity included: 63% of patients required enteral support (median duration 98 days) with 9% a feeding tube at 1 year post treatment. 18% G3 dermatitis, 53% G3 mucositis. 82% requiring opioids and 40% admitted for symptom management. 90 patients completed the PROs (76% response rate) at a median of 37.8 months post treatment (Table 1). These demonstrate significant QoL detriment: 28% report significant pain, 24% require regular analgesia, and 59% report significant impact on daily activity. This was found to persist at different timepoints (not shown).

CONCLUSION

Excellent cancer survival outcomes are seen in a non-selected, non-endemic NPC population. However significant acute and late toxicity following radical treatment is identified which can profoundly negatively impact QoL in a relatively young cohort. This highlights the importance of ongoing efforts to reduce toxicity and supports the prospective evaluation of potential toxicity sparing technologies, such as proton beam radiotherapy.

Biomarkers of systemic inflammation predict survival with first-line immune checkpoint inhibitors in non-small-cell lung cancer

INTRODUCTION

Pembrolizumab is an established first-line option for patients with advanced non-small-cell lung cancer (NSCLC) expressing programmed death-ligand 1 ≥50%. Durable responses are seen in a subset of patients; however, many derive little clinical benefit. Biomarkers of the systemic inflammatory response predict survival in NSCLC. We evaluated their prognostic significance in patients receiving first-line pembrolizumab for advanced NSCLC.

METHODS

Patients treated with first-line pembrolizumab for advanced NSCLC with programmed death-ligand 1 expression ≥50% at two regional Scottish cancer centres were identified. Pretreatment inflammatory biomarkers (white cell count, neutrophil count, neutrophil/lymphocyte ratio, platelet/lymphocyte ratio, albumin, prognostic nutritional index) were recorded. The relationship between these and progression-free survival (PFS) and overall survival (OS) were examined.

RESULTS

Data were available for 219 patients. On multivariate analysis, albumin and neutrophil count were independently associated with PFS (P < 0.001, P = 0.002, respectively) and OS (both P < 0.001). A simple score combining these biomarkers was explored. The Scottish Inflammatory Prognostic Score (SIPS) assigned 1 point each for albumin <35 g/l and neutrophil count >7.5 × 10⁹/l to give a three-tier categorical score. SIPS predicted PFS [hazard ratio 2.06, 95% confidence interval (CI) 1.68-2.52 (P < 0.001)] and OS [hazard ratio 2.33, 95% CI 1.86-2.92 (P < 0.001)]. It stratified PFS from 2.5 (SIPS2), to 8.7 (SIPS1) to 17.9 months (SIPS0) (P < 0.001) and OS from 5.1 (SIPS2), to 12.4 (SIPS1) to 28.7 months (SIPS0) (P < 0.001). The relative risk of death before 6 months was 2.96 (95% CI 1.98-4.42) in patients with SIPS2 compared with those with SIPS0-1 (P < 0.001).

CONCLUSIONS

SIPS, a simple score combining albumin and neutrophil count, predicts survival in patients with NSCLC receiving first-line pembrolizumab. Unlike many proposed prognostic scores, SIPS uses only routinely collected pretreatment test results and provides a categorical score. It stratifies survival across clinically meaningful time periods that may assist clinicians and patients with treatment decisions. We advocate validation of the prognostic utility of SIPS in this and other immune checkpoint inhibitor treatment settings.

The genomic structure of isolation across breed, country and strain for important South African and Australian sheep populations

Background

South Africa and Australia shares multiple important sheep breeds. For some of these breeds, genomic breeding values are provided to breeders in Australia, but not yet in South Africa. Combining genomic resources could facilitate development for across country selection, but the influence of population structures could be important to the compatability of genomic data from varying origins. The genetic structure within and across breeds, countries and strains was evaluated in this study by population genomic parameters derived from SNP-marker data. Populations were first analysed by breed and country of origin and then by subpopulations of South African and Australian Merinos.

Results

Mean estimated relatedness according to the genomic relationship matrix varied by breed (-0.11 to 0.16) and bloodline (-0.08 to 0.06) groups and depended on co-ancestry as well as recent genetic links. Measures of divergence across bloodlines (F_ST: 0.04–0.12) were sometimes more distant than across some breeds (F_ST: 0.05–0.24), but the divergence of common breeds from their across-country equivalents was weak (F_ST: 0.01–0.04). According to mean relatedness, F_ST, PCA and Admixture, the Australian Ultrafine line was better connected to the SA Cradock Fine Wool flock than with other AUS bloodlines. Levels of linkage disequilibrium (LD) between adjacent markers was generally low, but also varied across breeds (r²: 0.14–0.22) as well as bloodlines (r²: 0.15–0.19). Patterns of LD decay was also unique to breeds, but bloodlines differed only at the absolute level. Estimates of effective population size (N_e) showed genetic diversity to be high for the majority of breeds (N_e: 128–418) but also for bloodlines (N_e: 137–369).

Conclusions

This study reinforced the genetic complexity and diversity of important sheep breeds, especially the Merino breed. The results also showed that implications of isolation can be highly variable and extended beyond breed structures. However, knowledge of useful links across these population substructures allows for a fine-tuned approach in the combination of genomic resources. Isolation across country rarely proved restricting compared to other structures considered. Consequently, research into the accuracy of across-country genomic prediction is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12864-021-08020-3.

Collisions in a gas-rich white dwarf planetary debris disc

WD 0145+234 is a white dwarf that is accreting metals from a circumstellar disc of planetary material. It has exhibited a substantial and sustained increase in 3-5 [Formula: see text]m flux since 2018. Follow-up Spitzer photometry reveals that emission from the disc had begun to decrease by late 2019. Stochastic brightening events superimposed on the decline in brightness suggest the liberation of dust during collisional evolution of the circumstellar solids. A simple model is used to show that the observations are indeed consistent with ongoing collisions. Rare emission lines from circumstellar gas have been detected at this system, supporting the emerging picture of white dwarf debris discs as sites of collisional gas and dust production.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

The magnetorotational instability prefers three dimensions

The magnetorotational instability (MRI) occurs when a weak magnetic field destabilizes a rotating, electrically conducting fluid with inwardly increasing angular velocity. The MRI is essential to astrophysical disc theory where the shear is typically Keplerian. Internal shear layers in stars may also be MRI-unstable, and they take a wide range of profiles, including near-critical. We show that the fastest growing modes of an ideal magnetofluid are three-dimensional provided the shear rate, S, is near the two-dimensional onset value, S _c . For a Keplerian shear, three-dimensional modes are unstable above S ≈ 0.10S _c , and dominate the two-dimensional modes until S ≈ 2.05S _c . These three-dimensional modes dominate for shear profiles relevant to stars and at magnetic Prandtl numbers relevant to liquid-metal laboratory experiments. Significant numbers of rapidly growing three-dimensional modes remainy well past 2.05S _c . These finding are significant in three ways. First, weakly nonlinear theory suggests that the MRI saturates by pushing the shear rate to its critical value. This can happen for systems, such as stars and laboratory experiments, that can rearrange their angular velocity profiles. Second, the non-normal character and large transient growth of MRI modes should be important whenever three-dimensionality exists. Finally, three-dimensional growth suggests direct dynamo action driven from the linear instability.

PP2A-B55 promotes nuclear envelope reformation after mitosis in Drosophila

As a dividing cell exits mitosis and daughter cells enter interphase, many proteins must be dephosphorylated. The protein phosphatase 2A (PP2A) with its B55 regulatory subunit plays a crucial role in this transition, but the identity of its substrates and how their dephosphorylation promotes mitotic exit are largely unknown. We conducted a maternal-effect screen in Drosophila melanogaster to identify genes that function with PP2A-B55/Tws in the cell cycle. We found that eggs that receive reduced levels of Tws and of components of the nuclear envelope (NE) often fail development, concomitant with NE defects following meiosis and in syncytial mitoses. Our mechanistic studies using Drosophila cells indicate that PP2A-Tws promotes nuclear envelope reformation (NER) during mitotic exit by dephosphorylating BAF and suggests that PP2A-Tws targets additional NE components, including Lamin and Nup107. This work establishes Drosophila as a powerful model to further dissect the molecular mechanisms of NER and suggests additional roles of PP2A-Tws in the completion of meiosis and mitosis.

Estimates of genetic trend for single-step genomic evaluations

Background

A common measure employed to evaluate the efficacy of livestock improvement schemes is the genetic trend, which is calculated as the means of predicted breeding values for animals born in successive time periods. This implies that different cohorts refer to the same base population. For genetic evaluation schemes integrating genomic information with records for all animals, genotyped or not, this is often not the case: expected means for pedigree founders are zero whereas values for genotyped animals are expected to sum to zero at the (mean) time corresponding to the frequencies that are used to center marker allele counts when calculating genomic relationships.

Methods

The paper examines estimates of genetic trends from single-step genomic evaluations. After a review of methods which propose to align pedigree-based and genomic relationship matrices, simulation is used to illustrate the effects of alignments and choice of assumed gene frequencies on trajectories of genetic trends.

Results

The results show that methods available to alleviate differences between the founder populations implied by the two types of relationship matrices perform well; in particular, the meta-founder approach is advantageous. An application to data from routine genetic evaluation of Australian sheep is shown, confirming their effectiveness for practical data.

Conclusions

Aligning pedigree and genomic relationship matrices for single step genetic evaluation for populations under selection is essential. Fitting meta-founders is an effective and simple method to avoid distortion of estimates of genetic trends.

Role of Securin, Separase and Cohesins in female meiosis and polar body formation in Drosophila

Chromosome segregation in meiosis is controlled by a conserved pathway that culminates in Separase-mediated cleavage of the α-kleisin Rec8, leading to dissolution of cohesin rings. Drosophila has no gene encoding Rec8, and the absence of a known Separase target raises the question of whether Separase and its regulator Securin (Pim in Drosophila) are important in Drosophila meiosis. Here, we investigate the role of Securin, Separase and the cohesin complex in female meiosis using fluorescence in situ hybridization against centromeric and arm-specific sequences to monitor cohesion. We show that Securin destruction and Separase activity are required for timely release of arm cohesion in anaphase I and centromere-proximal cohesion in anaphase II. They are also required for release of arm cohesion on polar body chromosomes. Cohesion on polar body chromosomes depends on the cohesin components SMC3 and the mitotic α-kleisin Rad21 (also called Vtd in Drosophila). We provide cytological evidence that SMC3 is required for arm cohesion in female meiosis, whereas Rad21, in agreement with recent findings, is not. We conclude that in Drosophila meiosis, cohesion is regulated by a conserved Securin-Separase pathway that targets a diverged Separase target, possibly within the cohesin complex.

Technical note: Genetic principal component models for multitrait single-step genomic evaluation

A reparameterization of the multivariate linear mixed model in genetic evaluation to principal components is described. This yields an equivalent model with a sparser coefficient matrix in the mixed model equations and, thus, reduced computational requirements to solve them. It is especially advantageous for analyses incorporating genomic relationship information with many nonzero elements in the inverse of the relationship matrix. Moreover, the framework lends itself directly to dimension reduction and, thus, further computational savings by omitting genetic principal components with negligible eigenvalues. The potential impact on computational demands is illustrated for an application to single-step genomic evaluation of Australian sheep.

Evidence that the spindle assembly checkpoint does not regulate APC(Fzy) activity in Drosophila female meiosis

The spindle assembly checkpoint (SAC) plays an important role in mitotic cells to sense improper chromosome attachment to spindle microtubules and to inhibit APC(Fzy)-dependent destruction of cyclin B and Securin; consequent initiation of anaphase until correct attachments are made. In Drosophila , SAC genes have been found to play a role in ensuring proper chromosome segregation in meiosis, possibly reflecting a similar role for the SAC in APC(Fzy) inhibition during meiosis. We found that loss of function mutations in SAC genes, Mad2, zwilch, and mps1, do not lead to the predicted rise in APC(Fzy)-dependent degradation of cyclin B either globally throughout the egg or locally on the meiotic spindle. Further, the SAC is not responsible for the inability of APC(Fzy) to target cyclin B and promote anaphase in metaphase II arrested eggs from cort mutant females. Our findings support the argument that SAC proteins play checkpoint independent roles in Drosophila female meiosis and that other mechanisms must function to control APC activity.

Cks85A and Skp2 interact to maintain diploidy and promote growth in Drosophila

The Cks or Suc1 proteins are highly conserved small proteins that play remarkably diverse roles in the cell cycle. All Cks homologues have the ability to associate with Cyclin dependent kinases (Cdks) and in many cases this interaction has been shown to be important for function. Here we characterize the null and RNAi knockdown phenotype of the Drosophila Cks1 (Cks85A) gene. Cks85A is essential for viability in Drosophila. Cks85A null animals have reduced overall growth and this correlates with reduced ploidy and impaired DNA replication in endoreplicating cells. Interestingly, Cks85A is also required for the maintenance of diploidy in mitotically cycling cells. The requirement for Cks85A in growth is similar to that of the mammalian Cks1, which was found to interact with the SCF(Skp2) ubiquitin ligase. We identified the Drosophila Skp2 gene and generated null alleles. Comparison of these mutants to null mutants for Cks85A reveals a remarkably similar dual requirement in growth and in maintenance of diploidy. We find that Cks85A interacts directly with the SCF(Skp2) ubiquitin ligase and genetic evidence indicates that this is its major molecular function. The closely related Cks30A cannot interact with the SCF(Skp2) and cannot functionally compensate for loss of Cks85A. We also find that the critical growth promoting and diploidy maintaining functions of Cks85A and Skp2 are independent of known SCF(Skp2) substrates, p27 and Cdt1, indicating that other critical substrates remain to be identified.

Glucocorticoid corticosteroids for Duchenne muscular dystrophy

BACKGROUND

Duchenne muscular dystrophy (DMD) is the most common muscular dystrophy of childhood. This incurable disease is characterised by muscle wasting and loss of walking ability leading to complete wheelchair dependence by 13 years of age. Prolongation of walking is one of the major aims of treatment.

OBJECTIVES

The aim of this review was to assess whether glucocorticoid corticosteroids stabilize or improve muscle strength and walking in boys with DMD.

SEARCH STRATEGY

This is an update of the Cochrane systematic review first published in 2004 (Manzur 2004). We searched the Cochrane Neuromuscular Disease Group Trials Register (August 2006) using the term 'Duchenne muscular dystrophy'. We also searched MEDLINE (January 1966 to July 2007), EMBASE (January 1980 to August 2006), CINAHL and LILACS (January 1982 to August 2006). We wrote to authors of published studies and other experts in this disease to help identify other trials, checked the references in the identified trials and hand searched the abstracts of relevant journals.

SELECTION CRITERIA

Types of studies: randomised or quasi-randomised trials.

TYPES OF PARTICIPANTS

all patients with a definite diagnosis of Duchenne muscular dystrophy. Types of interventions: glucocorticoids such as prednisone, prednisolone, deflazacort or others, with a minimum treatment period of three months.

PRIMARY OUTCOME MEASURE

prolongation of walking (independent walking without long leg calipers).

SECONDARY OUTCOME MEASURES

strength outcome measures, manual muscle strength testing using Medical Research Council strength scores, functional outcome measures and adverse events.

DATA COLLECTION AND ANALYSIS

We identified six randomised controlled trials that met the inclusion criteria for our review, and one of these (Beenakker 2005) is a new addition to this update, as it was published subsequent to our first review (Manzur 2004). Two review authors independently selected the trials for the review and assessed methodological quality. Data extraction and inputting were double-checked.

PRIMARY OUTCOME MEASURE

data from one small study used prolongation of walking as an outcome measure and did not show significant benefit.

SECONDARY OUTCOME MEASURES

The meta-analysis of the results from four randomised controlled trials with altogether 249 participants showed that glucocorticoid corticosteroids improved muscle strength and function over six months. Improvements were seen in time taken to rise from the floor (Gowers' time), nine metres walking time, four-stair climbing time, ability to lift weights, leg function grade and forced vital capacity. One randomised controlled trial with altogether 28 participants showed that glucocorticoid corticosteroids stabilize muscle strength and function for up to two years. The most effective prednisolone regime appears to be 0.75 mg/kg/day, given in a daily dose regime. Not enough data were available to compare efficacy of prednisone with deflazacort. Adverse effects: Excessive weight gain, behavioural abnormalities, cushingoid appearance and excessive hair growth were all more common with glucocorticoid corticosteroids than placebo. Long-term adverse effects of glucocorticoid therapy could not be evaluated because of the short-term duration of the randomised studies.Non-randomised studies: A number of non-randomised studies with important efficacy and adverse effects data are tabulated and discussed.

AUTHORS' CONCLUSIONS

There is evidence from randomised controlled studies that glucocorticoid corticosteroid therapy in Duchenne muscular dystrophy improves muscle strength and function in the short-term (six months to two years). The most effective prednisolone regime appears to be 0.75 mg/kg/day, given daily. In the short term, adverse effects were significantly more common but not clinically severe. Long-term benefits and hazards of glucocorticoid treatment cannot be evaluated from the currently published randomised studies. Non-randomised studies support the conclusions of functional benefits but also identify clinically significant adverse effects of long-term treatment. These benefits and adverse effects have implications for future research studies and clinical practice.

The Cdc20 (Fzy)/Cdh1-related protein, Cort, cooperates with Fzy in cyclin destruction and anaphase progression in meiosis I and II in Drosophila

Meiosis is a highly specialized cell division that requires significant reorganization of the canonical cell-cycle machinery and the use of meiosis-specific cell-cycle regulators. The anaphase-promoting complex (APC) and a conserved APC adaptor, Cdc20 (also known as Fzy), are required for anaphase progression in mitotic cells. The APC has also been implicated in meiosis, although it is not yet understood how it mediates these non-canonical divisions. Cortex (Cort) is a diverged Fzy homologue that is expressed in the female germline of Drosophila, where it functions with the Cdk1-interacting protein Cks30A to drive anaphase in meiosis II. Here, we show that Cort functions together with the canonical mitotic APC adaptor Fzy to target the three mitotic cyclins (A, B and B3) for destruction in the egg and drive anaphase progression in both meiotic divisions. In addition to controlling cyclin destruction globally in the egg, Cort and Fzy appear to both be required for the local destruction of cyclin B on spindles. We find that cyclin B associates with spindle microtubules throughout meiosis I and meiosis II, and dissociates from the meiotic spindle in anaphase II. Fzy and Cort are required for this loss of cyclin B from the meiotic spindle. Our results lead to a model in which the germline-specific APC(Cort) cooperates with the more general APC(Fzy), both locally on the meiotic spindle and globally in the egg cytoplasm, to target cyclins for destruction and drive progression through the two meiotic divisions.

Deadlock, a novel protein of Drosophila, is required for germline maintenance, fusome morphogenesis and axial patterning in oogenesis and associates with centrosomes in the early embryo

The deadlock gene is required for a number of key developmental events in Drosophila oogenesis. Females homozygous for mutations in the deadlock gene lay few eggs and those exhibit severe patterning defects along both the anterior-posterior and dorsal-ventral axis. In this study, we analyzed eggs and ovaries from deadlock mutants and determined that deadlock is required for germline maintenance, stability of mitotic spindles, localization of patterning determinants, oocyte growth and fusome biogenesis in males and females. Deadlock encodes a novel protein which colocalizes with the oocyte nucleus at midstages of oogenesis and with the centrosomes of early embryos. Our genetic and immunohistological experiments point to a role for Deadlock in microtubule function during oogenesis.

Drosophila female meiosis and embryonic syncytial mitosis use specialized Cks and CDC20 proteins for cyclin destruction

Female meiosis and the rapid mitotic cycle of early embryos are two non-canonical cell cycles that occur sequentially in the same cell, the egg, and utilize the same pool of cell cycle proteins. Using a genetic approach to identify genes that are specifically required for these cell cycles in Drosophila, we found that a Drosophila Cks gene, Cks30A is required for spindle assembly and anaphase progression in both female meiosis and in the syncytial embryo. Cks30A interacts with Cdk1 to target cyclin A for destruction in the female germline, possibly through the activation of a novel germline specific CDC20 protein, Cortex. These results indicate that anaphase progression in female meiosis and the early embryo are under unique control in Drosophila.

Drosophila Cks30A interacts with Cdk1 to target Cyclin A for destruction in the female germline

Cks is a small highly conserved protein that plays an important role in cell cycle control in different eukaryotes. Cks proteins have been implicated in entry into and exit from mitosis, by promoting Cyclin-dependent kinase (Cdk) activity on mitotic substrates. In yeast, Cks can promote exit from mitosis by transcriptional regulation of cell cycle regulators. Cks proteins have also been found to promote S-phase via an interaction with the SCF(Skp2) Ubiquitination complex. We have characterized the Drosophila Cks gene, Cks30A and we find that it is required for progression through female meiosis and the mitotic divisions of the early embryo through an interaction with Cdk1. Cks30A mutants are compromised for Cyclin A destruction, resulting in an arrest or delay at the metaphase/anaphase transition, both in female meiosis and in the early syncytial embryo. Cks30A appears to regulate Cyclin A levels through the activity of a female germline-specific anaphase-promoting complex, CDC20-Cortex. We also find that a second closely related Cks gene, Cks85A, plays a distinct, non-overlapping role in Drosophila, and the two genes cannot functionally replace each other.

Glucocorticoid corticosteroids for Duchenne muscular dystrophy

BACKGROUND

Duchenne muscular dystrophy is the most common muscular dystrophy of childhood. This incurable disease is characterised by muscle wasting and loss of walking ability leading to complete wheelchair dependence by 13 years of age. Prolongation of walking is one of the major aims of treatment.

OBJECTIVES

The aim of this review was to assess whether glucocorticoid corticosteroids stabilize or improve muscle strength and walking in boys with DMD.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group specialised register (October 2003) using the term 'Duchenne muscular dystrophy'. We also searched MEDLINE (January 1966 to October 2003), EMBASE (January 1980 to October 2003), CINAHL and LILACS (January 1982 to October 2003). We wrote to authors of published studies and other experts in this disease to help identify other trials, checked the references in the identified trials and handsearched the abstracts of relevant journals.

SELECTION CRITERIA

Types of studies: randomised or quasi-randomised trials.

TYPES OF PARTICIPANTS

all patients with a definite diagnosis of Duchenne muscular dystrophy. Types of interventions: glucocorticoids such as prednisone, prednisolone, deflazacort or others, with a minimum treatment period of three months.

PRIMARY OUTCOME MEASURE

prolongation of walking (independent walking without long leg calipers).

SECONDARY OUTCOME MEASURES

strength outcome measures, manual muscle strength testing using Medical Research Council strength scores, functional outcome measures and adverse events.

DATA COLLECTION AND ANALYSIS

We identified five randomised controlled trials that met the inclusion criteria for our review. Two reviewers independently selected the trials for the review and assessed methodological quality. Data extraction and inputting were double-checked.

PRIMARY OUTCOME MEASURE

data from one small study used prolongation of walking as an outcome measure and did not show significant benefit.

SECONDARY OUTCOME MEASURES

The meta-analysis of the results from three randomised controlled trials showed that glucocorticoid corticosteroids improved muscle strength and function over six months. Improvements were seen in time taken to rise from the floor (Gowers' time), nine metres walking time, four-stair climbing time, ability to lift weights, leg function grade and forced vital capacity. One randomised controlled trial showed that glucocorticoid corticosteroids stabilize muscle strength and function for up to two years. The most effective prednisolone regime appears to be 0.75 mg/kg/day. Not enough data were available to compare efficacy of prednisone with deflazacort.Adverse effects: Excessive weight gain, behavioural abnormalities, cushingoid appearance and excessive hair growth were all more common with glucocorticoid corticosteroids than placebo. Long-term adverse effects of glucocorticoid therapy could not be evaluated because of the short-term duration of the randomised studies.Non-randomised studies: a number of non-randomised studies with important efficacy and adverse effects data are tabulated and discussed.

REVIEWERS' CONCLUSIONS

There is evidence from randomised controlled studies that glucocorticoid corticosteroid therapy in Duchenne muscular dystrophy improves muscle strength and function in the short-term (six months to two years). The most effective prednisolone regime appears to be 0.75 mg/kg/day. In the short term, adverse effects were significantly more common but not clinically severe. Long-term benefits and hazards of glucocorticoid treatment cannot be evaluated from the currently published randomised studies. Non-randomised studies support the conclusions of functional benefits but also indicate clinically significant adverse effects of long-term treatment. These benefits and adverse effects have implications for future research studies and clinical practice.

The value of synovial fluid assays in the diagnosis of joint disease: a literature survey

OBJECTIVE

To carry out a critical appraisal of the literature in an attempt to assess the current value of synovial fluid (SF) analysis in the diagnosis of joint disease.

METHODS

A literature search was undertaken using the Medline, Biomed, Bids, Pubmed, and Embase electronic databases using the keywords: synovial fluid (SF) analysis, SF crystals, joint sepsis, acute arthritis, and SF cell counts, cytology, biomarkers, and microbiology.

RESULTS

Publications fell into three main categories. Firstly, reports assessing the value of the three traditional assays (microbiology, white blood cell counts, and microscopy for pathogenic crystals). For these quality control evidence was found to be sparse, and tests for sensitivity, specificity, and reliability showed worrying variations. These poor standards in SF analysis may be due to lack of inclusion of some tests within routine pathology services. Secondly, claims for the usefulness of "new" assays (cytology and biochemical markers). For cytology, the supporting evidence was mainly anecdotal and there were no reports on specificity, sensitivity, and reliability. Interpretation difficulties are a major hindrance to the clinical use of biochemical assays, which remain primarily research tools. Finally, work on the diagnostic value of SF analysis in general. The appraisal confirmed that SF analysis remains of major diagnostic value in acute arthritis, where septic arthritis or crystal arthropathy is suspected, and in intercritical gout.

CONCLUSIONS

Given the importance of SF tests, rationalisation of their use, together with improved quality control, should be immediate priorities. Further investigation is recommended into the contribution of SF inspection and white cell counts to diagnosis, as well as of the specificity and sensitivity of SF microbiological assays, crystal identification, and cytology.

The molecular epidemiology of tuberculosis in inner London

The study used DNA fingerprint typing (spoligotyping and Heminested-lnverse-PCR) of Mycobacterium tuberculosis from all culture-confirmed inner London patients over a 12-month period to describe transmission. The methodology was evaluated by comparison with standard IS6110 typing and by examining its ability to identify known household clusters of cases. Isolates sharing indistinguishable typing patterns using both techniques were defined as clustered. Clusters were investigated to identify epidemiological links. The methodology showed good discriminatory power and identified known household clusters of cases. Of 694 culture-confirmed cases, 563 (81%) were typed. Eleven (2%) were due to laboratory cross-contamination and were excluded. Of the remaining 552 isolates 148 (27%) were clustered. Multivariate analysis indicated that clustering was more common in those with pulmonary smear positive disease (P < 0.02); those born in the United Kingdom (P < 0.0003) and in patients living in south London (P = 0.02). There was also a trend towards clustering being more common in those not known to have HIV infection (P = 0.051). The results suggest that in inner London, recent local transmission makes an important contribution to notification rates.

Bladder rupture after blunt trauma: guidelines for diagnostic imaging

PURPOSE

The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome.

METHODS

We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series.

RESULTS

Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates.

CONCLUSION

The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.

The utilization of synovial fluid analysis in the UK

OBJECTIVE

To ascertain what use is being made of synovial fluid analysis in the UK, who is carrying out polarized light microscopy (PLM), and what confidence clinicians have in the results. Subjects and methods. A postal survey was developed, piloted, adjusted and then posted to 535 people, 90% of whom were senior rheumatologists and 10% orthopaedic surgeons, whose names had been obtained from professional lists.

RESULTS

Three hundred and eleven replies (59%) were obtained after 1 month. Analysis of the replies showed that only microbiological tests and PLM are used regularly, that these are used mainly for the diagnosis of acute arthritis, and that the majority of respondents would like data from these assays to be available within 24 h. The majority of the respondents (95%) had access to PLM and 80% said that clinicians should be able to use it. However, PLM is currently being undertaken by a variety of people: non-specialist technicians (34% of respondents), specialist technicians (35%) and clinicians (31%). Respondents were confident in microbiological assays but not in cell counts or PLM, unless they were undertaking it themselves.

CONCLUSIONS

There is an urgent need for guidelines, standardization and education about the use of synovial fluid assays in the UK.

Randomized controlled trial of intravenous immunoglobulin versus oral prednisolone in chronic inflammatory demyelinating polyradiculoneuropathy

This multicenter, randomized, double-blind, crossover trial compared a six week course of oral prednisolone tapering from 60 mg to 10 mg daily with intravenous immunoglobulin (IVIg) 2.0 g/kg given over one to two days for treating chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Twenty-four of the thirty-two randomized patients completed both treatment periods. Both treatments produced significant improvements in the primary outcome measure, change in an 11-point disability scale two weeks after randomization. There was slightly, but not significantly, more improvement after IVIg than with prednisolone, the mean difference between the groups in change in disability grade being 0.16 (95% CI = -0.35 to 0.66). There were also slightly, but not significantly, greater improvements favoring IVIg in the secondary outcome measures: time to walk 10 meters after two weeks and improvement in disability grade after six weeks. Results may have been biased against IVIg by the eight patients who did not complete the second arm of the trial. A serious adverse event (psychosis) attributable to treatment occurred in one patient while on prednisolone and in none with IVIg.

Making vaccines more acceptable--methods to prevent and minimize pain and other common adverse events associated with vaccines

The growing abundance of highly immunogenic vaccines has arrived with a burden of pain, distress, and common adverse reactions that in turn may interfere with parental compliance and aggravate anti-vaccine sentiment. In a study of 150 children in each of 2 age-groups, we found that approximately 20% of the subjects suffered serious distress or worse. During the procedural phase, approximately 90% of the 15-to-18 month old children and 45% of the 4-to-6 year old children showed serious distress or worse. To address non-adherence with pediatric vaccine schedules, we must consider all of the possible issues that might prevent a parent from taking a child to a health care provider for vaccination. In that same study we identified useful predictors for both preparatory and procedural distress - predictors that might be used in identifying children who might benefit from preventive interventions. Vaccine providers might consider a variety of interventions. Attitude, empathy, instruction, and practice have all been shown to have a salutatory effect upon pain and anxiety with medical procedures in general and specifically with vaccinations. Distraction has also been found to be an effective method for distress and pain prevention in children. More formal methods of clinical hypnosis which combine a deep state of relaxation with focused imagery and suggestion have also been found to be effective in helping children and adolescents prepare for, cope with, and tolerate the pain and anxiety associated with medical procedures. So-called 'sugar nipples' delivering small amounts of sucrose orally at the time of a painful procedure in an infant has been not been shown to decrease vaccination pain and studies on refrigerant topical anesthetics are mixed. Studies have found a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine (EMLA) effective in providing adequate local anesthesia in children, but it suffers from problems in practical application. Studies with various injection techniques have not identified ready solutions, and although jet injection appears to provoke less anxiety and cause less immediate pain, studies also indicate a somewhat greater incidence of delayed local reactogenicity including soreness and edema. Other measures to prevent or rapidly treat other common adverse events have been shown effective and should be considered as well.

Identification of new X-chromosomal genes required for Drosophila oogenesis and novel roles for fs(1)Yb, brainiac and dunce

We performed a screen for female sterile mutations on the X chromosome of Drosophila melanogaster and identified new loci required for developmental events in oogenesis as well as new alleles of previously described genes. We present mapping and phenotypic characterization data for many of these genes and discuss their significance in understanding fundamental developmental and cell biological processes. Our screen has identified genes that are involved in cell cycle control, intracellular transport, cell migration, maintenance of cell membranes, epithelial monolayer integrity and cell survival or apoptosis. We also describe new roles for the genes dunce (dnc), brainiac (brn) and fs(1)Yb, and we identify new alleles of Sex lethal (Sxl), ovarian tumor (otu), sans filles (snf), fs(1)K10, singed (sn), and defective chorion-1 (dec-1).

A survey of the microbiological quality of private water supplies in England

Results from statutory testing of private water supplies in nine Public Health Laboratories in England were compiled, and the effects of supply class, source, treatment and location on water quality were examined. A total of 6551 samples from 2911 supplies was examined, over a 2-year period, of which 1342 (21%) samples, and 949 (33%) supplies on at least one occasion, failed current regulations for Escherichia coli. Total coliforms, including E. coli, were detected in 1751 (27%) samples from 1215 (42%) supplies. The percentage of samples positive for E. coli was highest in summer and autumn, and lowest in winter. Samples taken from larger supplies and from boreholes were less frequently contaminated than those from other sources. Chlorination, filtration or UV light treatment improved the bacteriological quality of supplies, but still resulted in a low level of compliance with the regulations. The public health implications of the study are discussed.

Drosophila Lissencephaly-1 functions with Bic-D and dynein in oocyte determination and nuclear positioning

Here we show that the Drosophila homologue of Lissencephaly-1, DLis-1, acts together with Bicaudal-D (Bic-D), Egalitarian (Egl), dynein and microtubules to determine oocyte identity. DLis-1 is further required for nurse-cell-to-oocyte transport during oocyte growth, and for the positioning of the nucleus in the oocyte. Immunostaining of DLis-1 protein reveals a cortical localization that is independent of microtubules. DLis-1 may function in this position as a cortical anchor for the other nuclear-localization factors. DLis-1 and Bic-D are further required for nuclear localization in the developing nervous system, indicating that homologues of Bic-D, dynein and Egl-like proteins may also be involved in vertebrate neural migration and that their absence may cause a Miller-Dieker-like lissencephaly.

Olanzapine in dementia with Lewy bodies: a clinical study

OBJECTIVES

Dementia with Lewy bodies (DLB) is now a well-recognized form of dementia in which psychosis and behavioural disturbance are common. Treatment with conventional neuroleptics is often very poorly tolerated. Olanzapine, a newly introduced atypical neuroleptic which binds to multiple receptor types with relatively low affinity for D2 receptors, may be a useful treatment option in DLB.

MAIN OUTCOME MEASURES

The Behavioural Pathology in Alzheimer's Disease Rating Scale, The Neuropsychiatric Inventory, Unified Parkinson's Disease Rating Scale and The Webster Disability Scale.

DESIGN

We present the results of eight DLB patients with associated psychotic and behavioural difficulties. All patients were given olanzapine 2.5-7.5 mg. Their psychotic phenomena and behavioural and extrapyramidal symptoms were monitored at 2-weekly intervals.

RESULTS

Three out of the eight patients could not tolerate olanzapine even at the lowest available dose. Two patients had clear improvement in psychotic and behavioural symptoms. Three patients were able to tolerate olanzapine but gained only minimal benefit.

CONCLUSIONS

Olanzapine at the doses used conferred little advantage over conventional neuroleptics and should only be given with great caution to patients with DLB. The utility of smaller doses deserves further evaluation.