The Role of Spinal Cord Stimulation in Reducing Opioid Use in the Setting of Chronic Neuropathic Pain: A Systematic Review

OBJECTIVE

The aim was to examine research on the impact of spinal cord stimulation (SCS) on the reduction of preimplantation opioid dose and what preimplantation opioid dose is associated with a reduction or discontinuation of opioid use postimplantation.

METHODS

Systematic review of literature from PubMed, Web of Science, and Ovid Medline search of "opioid" and "pain" and "spinal cord stimulator." Inclusion criteria included original research providing data on SCS preimplantation opioid dosing and 12 months postimplantation opioid dosing or that correlated specific preimplantation opioid dose or opioid dose cutoff with significantly increased likelihood of opioid use discontinuation at 12 months postimplantation.

RESULTS

Systematic review of the literature yielded 17 studies providing data on pre-SCS and post-SCS implantation dose and 4 providing data on the preimplantation opioid dose that significantly increased likelihood of opioid use discontinuation at 12 months postimplantation. Data from included studies indicated that SCS is an effective tool in reducing opioid dose from preimplantation levels at 12 months postimplantation. Data preliminarily supports the assertion that initiation of SCS at a preimplantation opioid dose of ≤20 to ≤42.5 morphine milligram equivalents increases the likelihood of postimplantation elimination of opioid use.

DISCUSSION

SCS is an effective treatment for many types of chronic pain and can reduce or eliminate chronic opioid use. Preimplantation opioid dose may impact discontinuation of opioid use postimplantation and the effectiveness of SCS in the relief of chronic pain. More research is needed to support and strengthen clinical recommendations for initiation of SCS use at lower daily opioid dose.

Women neurosurgeons around the world: a systematic review

OBJECTIVE

Gender disparities in neurosurgery have persisted even as the number of female medical students in many countries has risen. An understanding of the current gender distribution of neurosurgeons around the world and the possible factors contributing to country-specific gender disparities is an important step in improving gender equity in the field.

METHODS

The authors performed a systematic review of studies pertaining to women in neurosurgery. Papers listed in PubMed in the English language were collected. A modified grounded theory approach was utilized to systematically identify and code factors noted to contribute to gender disparities in neurosurgery. Statistical analysis was performed with IBM SPSS Statistics for Windows.

RESULTS

The authors identified 39 studies describing the density of women neurosurgeons in particular regions, 18 of which documented the proportion of practicing female neurosurgeons in a single or in multiple countries. The majority of these studies were published within the last 5 years. Eight factors contributing to gender disparity were identified, including conference representation, the proverbial glass ceiling, lifestyle, mentoring, discrimination, interest, salary, and physical burden.

CONCLUSIONS

The topic of women in neurosurgery has received considerable global scholarly attention. The worldwide proportion of female neurosurgeons varies by region and country. Mentorship was the most frequently cited factor contributing to noted gender differences, with lifestyle, the glass ceiling, and discrimination also frequently mentioned. Future studies are necessary to assess the influence of country-specific sociopolitical factors that push and pull individuals of all backgrounds to enter this field.

Molecular mechanisms of trigeminal neuralgia: A systematic review

OBJECTIVE

To conduct a systematic review of the available literature for primary research articles identifying potential gene mutations, polymorphisms and other molecular regulatory mechanisms related to trigeminal neuralgia in order to identify the genetic and molecular models of primary trigeminal neuralgia currently being investigated.

METHODS

PubMed and Web of Science were systematically searched to identify primary research articles discussing genetic predictors of trigeminal neuralgia and neuropathic pain that were published prior to July 2020. This review was conducted according to PRISMA guidelines.

RESULTS

Out of the 333 articles originally identified, a total of 14 papers were selected for study inclusion. These articles included 5 human studies, 6 mouse studies and 3 rat studies. Four articles investigated sodium channels, 1 investigated a sodium channel and nerve growth factor receptor, 2 investigated potassium channels, 1 investigated calcium channels, 1 investigated the downstream regulatory element antagonist modulator protein, 1 investigated the dynorphin-kappa opioid receptor system, 1 investigated TRPA1, 1 investigated the Nrg1/ErbB3/ErbB2 signaling complex, 1 investigated a serotonin transporter and 1 investigated potassium channels, sodium channels, calcium channels, chloride channels, TRP channels and gap junctions.

CONCLUSION

Researchers have identified multiple genetic and molecular targets involved with potential pathophysiologies that have a relationship to the creation of trigeminal neuralgia. At this time, there does not seem to be clear causal frontrunner, demonstrating the possibility that genetic predisposition to trigeminal neuralgia may involve multiple genes and/or downstream products, such as ion channels.

Vulnerable Immigrant Populations in the New York Metropolitan Area and COVID-19: Lessons Learned in the Epicenter of the Crisis

The epicenter of the COVID-19 crisis since March 17, 2020-the New York metropolitan area-is home to some of the largest Latino immigrant communities in the nation. These communities have long faced barriers to health care access, challenges due to immigration status, and financial and labor instability. The COVID-19 pandemic has aggravated these existing issues in a vulnerable, often forgotten, immigrant community. It has been challenging for this population to access public information regarding COVID-19 testing, treatment, and assistance programs because this information has seldom been disseminated in Spanish and even less frequently in Portuguese. While long-term solutions will require time and changes to policy, some short-term measures can mitigate the current situation. The authors share their experience from Newark, New Jersey, where partnerships of public and private community-based organizations (CBOs) have been successful in establishing trust between the health care system and a fearful Latino community. The Ironbound Initiative, a student group at Rutgers New Jersey Medical School in Newark, New Jersey, has partnered with Mantena Global Care, a Brazilian CBO in Newark, to facilitate dissemination of COVID-19-relevant information. Medical student volunteers, removed from their clinical duties, serve as virtual patient navigators, using social media to reach community members with the goals of improving awareness of precautions to take during the pandemic and of increasing access to needed medical care. These students have collaborated with colleagues in other disciplines to provide necessary legal guidance to community members fearful of seeking care because of their immigration status. The authors urge other academic institutions across the country to recruit multidisciplinary teams of medical, health professions, and law students invested in their local communities and to empower students to partner with CBOs, immigrant community leaders, faith-based organizations, hospitals, and local authorities to support these vulnerable communities during this crisis.

Pent-up demand for care among dual-eligible victims of elder financial exploitation in Maine

Elder financial exploitation (EFE), the misuse of a vulnerable adult's property or resources for personal gain, is a form of elder abuse. This study addresses whether dual-eligible EFE victims were experiencing pent-up demand for health services alleviated through investigation by Adult Protective Services (APS). A quasi-experimental design addressed health service utilization and costs for 131 dual-eligible Maine APS clients over age 60 with substantiated allegations of EFE relative to comparable non-APS controls. APS case files spanning 2007-2012 were linked to 2006-2014 Medicare and Medicaid claims data. Service utilization and costs were analyzed 1 year prior, during, and 2 years after the initial APS investigation. Difference in differences logistic regression and generalized linear models addressed the likelihood of incurring costs and expenditure levels relative to matched controls, respectively. Victims of EFE had higher overall odds of using inpatient and long-term services and supports (LTSS) and higher odds of using LTSS post-investigation than controls. Higher overall levels of outpatient and prescriptions expenditures and higher inpatient expenditures during the APS event year contributed toward APS clients incurring $1,142 higher PMPM total costs than controls. Victims of EFE were experiencing significant pent-up demand for health services post-APS involvement.

Evaluation of reproducible and transparent research practices in pulmonology

BACKGROUND

Study reproducibility is valuable for validating or refuting results. Provision of reproducibility indicators, such as materials, protocols, and raw data in a study improve its potential for reproduction. Efforts to reproduce noteworthy studies in the biomedical sciences have resulted in an overwhelming majority of them being found to be unreplicable, causing concern for the integrity of research in other fields, including medical specialties. Here, we analyzed the reproducibility of studies in the field of pulmonology.

METHODS

500 pulmonology articles were randomly selected from an initial PubMed search for data extraction. Two authors scoured these articles for reproducibility indicators including materials, protocols, raw data, analysis scripts, inclusion in systematic reviews, and citations by replication studies as well as other factors of research transparency including open accessibility, funding source and competing interest disclosures, and study preregistration.

FINDINGS

Few publications included statements regarding materials (10%), protocols (1%), data (15%), and analysis script (0%) availability. Less than 10% indicated preregistration. More than half of the publications analyzed failed to provide a funding statement. Conversely, 63% of the publications were open access and 73% included a conflict of interest statement.

INTERPRETATION

Overall, our study indicates pulmonology research is currently lacking in efforts to increase replicability. Future studies should focus on providing sufficient information regarding materials, protocols, raw data, and analysis scripts, among other indicators, for the sake of clinical decisions that depend on replicable or refutable results from the primary literature.

The safety and effectiveness of mind body interventions for women with pregnancy induced hypertension and or preeclampsia: A systematic review and meta-analysis

OBJECTIVES

To undertake a systematic review of the safety and effectiveness of mind body approaches for women with hypertensive disorders in pregnancy (HDP).

DESIGN

A search was undertaken of databases from inception to 2019 for randomised and quasi randomised controlled trials.

MAIN OUTCOME MEASURES

The primary outcome was a reduction in systolic and / or diastolic blood pressure for women with hypertension and or preeclampsia in pregnancy.

RESULTS

121 studies were identified and eight studies were included in this review. These included mind body interventions examining yoga, guided imagery, relaxation, music, and acupuncture for HDP. Two studies of relaxation found a reduction in systolic (MD -11.3, 95%CI -13.23 to -9.39) and diastolic blood pressure (MD -6.59, 95%CI -9.43 to -3.75) and reduced stress (MD -11.4, 95%CI -16.5 to -6.3). In one study of yoga, the risk of developing HDP was reduced (RR 0.28, 95% CI 0.09 to 0.91, 59 women) and a second study found a reduction in stress at the end of the intervention of yoga. One trial of guided imagery found a reduction in mean arterial blood pressure compared to the control (4.35, 95% -8.04 to -0.66, p=0.02). Overall there was no effect on the development of preeclampsia, use of anti-hypertensive medication and any neonatal outcomes from the interventions evaluated. Few trials reported on safety outcomes, one trial of acupuncture reported one case of placental abruption and three cases of acupuncture related side effects.

CONCLUSION

Few high quality trials have examined the effectiveness and safety of mind body interventions to manage HDP. Relaxation, yoga, guided imagery and music may have some potential benefit. Safety issues are completely unclear and thus the risk-benefit ratio of all interventions could not be determined. Further research is recommended.

X-ray diffraction at the National Ignition Facility

We report details of an experimental platform implemented at the National Ignition Facility to obtain in situ powder diffraction data from solids dynamically compressed to extreme pressures. Thin samples are sandwiched between tamper layers and ramp compressed using a gradual increase in the drive-laser irradiance. Pressure history in the sample is determined using high-precision velocimetry measurements. Up to two independently timed pulses of x rays are produced at or near the time of peak pressure by laser illumination of thin metal foils. The quasi-monochromatic x-ray pulses have a mean wavelength selectable between 0.6 Å and 1.9 Å depending on the foil material. The diffracted signal is recorded on image plates with a typical 2θ x-ray scattering angle uncertainty of about 0.2° and resolution of about 1°. Analytic expressions are reported for systematic corrections to 2θ due to finite pinhole size and sample offset. A new variant of a nonlinear background subtraction algorithm is described, which has been used to observe diffraction lines at signal-to-background ratios as low as a few percent. Variations in system response over the detector area are compensated in order to obtain accurate line intensities; this system response calculation includes a new analytic approximation for image-plate sensitivity as a function of photon energy and incident angle. This experimental platform has been used up to 2 TPa (20 Mbar) to determine the crystal structure, measure the density, and evaluate the strain-induced texturing of a variety of compressed samples spanning periods 2-7 on the periodic table.

Impact of Pharmacy Medication Reviews on the Prescribing of Potentially Inappropriate Medications for Older Veterans in Primary Care

OBJECTIVE: The primary objective was to evaluate prescribing of potentially inappropriate medications (PIMs) as defined by the Beers criteria in outpatient clinics with and without mandatory pharmacy medication reviews. DESIGN: Retrospective electronic medical chart review at a single academic Veterans Affairs (VA) medical center. SETTING: Home-based primary care (HBPC) and geriatric primary care. PATIENTS: Patients were included if they were 65 years of age or older at the time of enrollment and newly enrolled with an initial visit to HBPC or geriatric primary care between January 2015 and September 2015. Charts were included if patients received at least one follow-up visit with their primary care provider within 13 months of the initial visit. An additional inclusion criterion for HBPC patients was the documentation of at least one follow-up medication review by a clinical pharmacist within 13 months of the initial mandatory chart review. A total of 30 patients were included in both groups. INTERVENTIONS: Mandatory pharmacy medication reviews compared with usual care (no formal pharmacy review). MAIN OUTCOME MEASURE: Mean change in PIMs prescribed in both groups. RESULTS: The mean number of PIMs at initial and final visits was 0.4 unit per patient in HBPC. In geriatric primary care, the mean number of PIMs at the initial visit was 0.4 unit per patient, which increased at the final visit to 0.6 unit per patient. CONCLUSION: No change in PIMs was observed in the HBPC group, while an increase was observed in geriatric primary care.

Upgrade to the MAPS neutron time-of-flight chopper spectrometer

The MAPS direct geometry time-of-flight chopper spectrometer at the ISIS pulsed neutron and muon source has been in operation since 1999, and its novel use of a large array of position-sensitive neutron detectors paved the way for a later generations of chopper spectrometers around the world. Almost two decades of experience of user operations on MAPS, together with lessons learned from the operation of new generation instruments, led to a decision to perform three parallel upgrades to the instrument. These were to replace the primary beamline collimation with supermirror neutron guides, to install a disk chopper, and to modify the geometry of the poisoning in the water moderator viewed by MAPS. Together, these upgrades were expected to increase the neutron flux substantially, to allow more flexible use of repetition rate multiplication and to reduce some sources of background. Here, we report the details of these upgrades and compare the performance of the instrument before and after their installation as well as to Monte Carlo simulations. These illustrate that the instrument is performing in line with, and in some respects in excess of, expectations. It is anticipated that the improvement in performance will have a significant impact on the capabilities of the instrument. A few examples of scientific commissioning are presented to illustrate some of the possibilities.

CA 549 as a Marker in Breast Cancer

CA 549 is one of several carcinoma associated mucin antigens proposed as a breast cancer tumor marker. In this study, the performance characteristics of the CA 549 assay were validated and the clinical utility of the test was compared with that of other breast cancer markers including CA 15-3, CA M26, CA M29 and carcinoembryonic antigen. The upper limit of normal was established as 15.5 U/ml based on data for 250 control subjects apparently free of disease. Overall, CA 549 had a low negative predictive value (0.51) due to a low sensitivity in the detection of early breast cancer. However, the test had a high positive predictive value (0.93) reflecting a high specificity for the disease. In 56 patients with advanced breast cancer, the sensitivity was 0.71 for CA 549 alone and 0.79-0.84 for CA 549 combined with any of the other markers studied.

Image-based closed-loop feedback for highly mono-dispersed microdroplet production

Micron-scale droplets isolated by an immiscible liquid can provide miniaturised reaction vessels which can be manipulated in microfluidic networks, and has seen a rapid growth in development. In many experiments, the precise volume of these microdroplets is a critical parameter which can be influenced by many external factors. In this work, we demonstrate the combination of imaging-based feedback and pressure driven pumping to accurately control the size of microdroplets produced in a microfluidic device. The use of fast-response, pressure-driving pumps allows the microfluidic flow to be quickly and accurately changed, while directly measuring the droplet size allows the user to define the more meaningful parameters of droplet size and generation frequency rather than flow rates or pressures. The feedback loop enables the drift correction of pressure based pumps, and leads to a large increase in the mono-dispersity of the droplets produced over long periods. We also show how this can be extended to control multiple liquid flows, allowing the frequency of droplet formation or the average concentration of living cells per droplet to be controlled and kept constant.

Assessing retinal ganglion cell damage

Retinal ganglion cell (RGC) loss is the hallmark of optic neuropathies, including glaucoma, where damage to RGC axons occurs at the level of the optic nerve head. In experimental glaucoma, damage is assessed at the axon level (in the retinal nerve fibre layer and optic nerve head) or at the soma level (in the retina). In clinical glaucoma where measurements are generally limited to non-invasive techniques, structural measurements of the retinal nerve fibre layer and optic nerve head, or functional measurements with perimetry provide surrogate estimates of RGC integrity. These surrogate measurements, while clinically useful, are several levels removed from estimating actual RGC loss. Advances in imaging, labelling techniques, and transgenic medicine are making enormous strides in experimental glaucoma, providing knowledge on the pathophysiology of glaucoma, its progression and testing new therapeutic avenues. Advances are also being made in functional imaging of RGCs. Future efforts will now be directed towards translating these advances to clinical care.

Comparison of genome sequencing and clinical genotyping for pharmacogenes

We compared whole exome sequencing (WES, n = 176 patients) and whole genome sequencing (WGS, n = 68) and clinical genotyping (DMET array-based approach) for interrogating 13 genes with Clinical Pharmacogenetics Implementation Consortium (CPIC) guidelines. We focused on 127 CPIC important variants: 103 single nucleotide variations (SNV), 21 insertion/deletions (Indel), HLA-B alleles, and two CYP2D6 structural variations. WES and WGS provided interrogation of nonoverlapping sets of 115 SNV/Indels with call rate >98%. Among 68 loci interrogated by both WES and DMET, 64 loci (94.1%, confidence interval [CI]: 85.6-98.4%) showed no discrepant genotyping calls. Among 66 loci interrogated by both WGS and DMET, 63 loci (95.5%, CI: 87.2-99.0%) showed no discrepant genotyping calls. In conclusion, even without optimization to interrogate pharmacogenetic variants, WES and WGS displayed potential to provide reliable interrogation of most pharmacogenes and further validation of genome sequencing in a clinical lab setting is warranted.

Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour

OBJECTIVE

To evaluate the effect of an antenatal integrative medicine education programme in addition to usual care for nulliparous women on intrapartum epidural use.

DESIGN

Open-label, assessor blind, randomised controlled trial.

SETTING

2 public hospitals in Sydney, Australia.

POPULATION

176 nulliparous women with low-risk pregnancies, attending hospital-based antenatal clinics.

METHODS AND INTERVENTION

The Complementary Therapies for Labour and Birth protocol, based on the She Births and acupressure for labour and birth courses, incorporated 6 evidence-based complementary medicine techniques: acupressure, visualisation and relaxation, breathing, massage, yoga techniques, and facilitated partner support. Randomisation occurred at 24-36 weeks' gestation, and participants attended a 2-day antenatal education programme plus standard care, or standard care alone.

MAIN OUTCOME MEASURES

Rate of analgesic epidural use. Secondary: onset of labour, augmentation, mode of birth, newborn outcomes.

RESULTS

There was a significant difference in epidural use between the 2 groups: study group (23.9%) standard care (68.7%; risk ratio (RR) 0.37 (95% CI 0.25 to 0.55), p≤0.001). The study group participants reported a reduced rate of augmentation (RR=0.54 (95% CI 0.38 to 0.77), p<0.0001); caesarean section (RR=0.52 (95% CI 0.31 to 0.87), p=0.017); length of second stage (mean difference=-0.32 (95% CI -0.64 to 0.002), p=0.05); any perineal trauma (0.88 (95% CI 0.78 to 0.98), p=0.02) and resuscitation of the newborn (RR=0.47 (95% CI 0.25 to 0.87), p≤0.015). There were no statistically significant differences found in spontaneous onset of labour, pethidine use, rate of postpartum haemorrhage, major perineal trauma (third and fourth degree tears/episiotomy), or admission to special care nursery/neonatal intensive care unit (p=0.25).

CONCLUSIONS

The Complementary Therapies for Labour and Birth study protocol significantly reduced epidural use and caesarean section. This study provides evidence for integrative medicine as an effective adjunct to antenatal education, and contributes to the body of best practice evidence.

TRIAL REGISTRATION NUMBER

ACTRN12611001126909.

The Complementary Therapies for Labour and Birth Study making sense of labour and birth - Experiences of women, partners and midwives of a complementary medicine antenatal education course

OBJECTIVE

to gain insight into the experiences of women, partners and midwives who participated in the Complementary Therapies for Labour and Birth Study, an evidence based complementary medicine (CM) antenatal education course.

DESIGN

qualitative in-depth interviews and a focus group as part of the Complementary Therapies for Labour and Birth Study.

SETTING AND PARTICIPANTS

thirteen low risk primiparous women and seven partners who had participated in the study group of a randomised controlled trial of the complementary therapies for labour and birth study, and 12 midwives caring for these women. The trial was conducted at two public hospitals, and through the Western Sydney University in Sydney, Australia.

INTERVENTIONS

the Complementary Therapies for Labour and Birth (CTLB) protocol, based on the She Births® course and the Acupressure for labour and birth protocol, incorporated six evidence-based complementary medicine (CM) techniques; acupressure, relaxation, visualisation, breathing, massage, yoga techniques and incorporated facilitated partner support. Randomisation to the trial occurred at 24-36 weeks' gestation, and participants attended a two-day antenatal education programme, plus standard care, or standard care alone.

FINDINGS

the overarching theme identified in the qualitative data was making sense of labour and birth. Women used information about normal birth physiology from the course to make sense of labour, and to utilise the CM techniques to support normal birth and reduce interventions in labour. Women's, partners' and midwives' experience of the course and its use during birth gave rise to supporting themes such as: working for normal; having a toolkit; and finding what works.

KEY CONCLUSIONS

the Complementary Therapies for Labour and Birth Study provided women and their partners with knowledge to understand the physiology of normal labour and birth and enabled them to use evidence-based CM tools to support birth and reduce interventions.

IMPLICATIONS FOR PRACTICE

the Complementary Therapies for Labour and Birth Study introduces concepts of what constitutes normal birth and provides skills to support women, partners and midwives. It appears to be an effective form of antenatal education that supports normal birth, and maternity services need to consider how they can reform current antenatal education in line with this evidence.

Vascular smooth muscle desensitization in rabbit epigastric and mesenteric arteries during hemorrhagic shock

The decompensatory phase of hemorrhage (shock) is caused by a poorly defined phenomenon termed vascular hyporeactivity (VHR). VHR may reflect an acute in vivo imbalance in levels of contractile and relaxant stimuli favoring net vascular smooth muscle (VSM) relaxation. Alternatively, VHR may be caused by intrinsic VSM desensitization of contraction resulting from prior exposure to high levels of stimuli that temporarily adjusts cell signaling systems. Net relaxation, but not desensitization, would be expected to resolve rapidly in an artery segment removed from the in vivo shock environment and examined in vitro in a fresh solution. Our aim was to 1) induce shock in rabbits and apply an in vitro mechanical analysis on muscular arteries isolated pre- and postshock to determine whether VHR involves intrinsic VSM desensitization, and 2) identify whether net VSM relaxation induced by nitric oxide and cyclic nucleotide-dependent protein kinase activation in vitro can be sustained for some time after relaxant stimulus washout. The potencies of phenylephrine- and histamine-induced contractions in in vitro epigastric artery removed from rabbits posthemorrhage were decreased by ∼0.3 log units compared with the control contralateral epigastric artery removed prehemorrhage. Moreover, a decrease in KCl-induced tonic, relative to phasic, tension of in vitro mesenteric artery correlated with the degree of shock severity as assessed by rates of lactate and K(+) accumulation. VSM desensitization was also caused by tyramine in vivo and PE in vitro, but not by relaxant agents in vitro. Together, these results support the hypothesis that VHR during hemorrhagic decompensation involves contractile stimulus-induced long-lasting, intrinsic VSM desensitization.

High-throughput screening of antibiotic-resistant bacteria in picodroplets

The prevalence of clinically-relevant bacterial strains resistant to current antibiotic therapies is increasing and has been recognized as a major health threat. For example, multidrug-resistant tuberculosis and methicillin-resistant Staphylococcus aureus are of global concern. Novel methodologies are needed to identify new targets or novel compounds unaffected by pre-existing resistance mechanisms. Recently, water-in-oil picodroplets have been used as an alternative to conventional high-throughput methods, especially for phenotypic screening. Here we demonstrate a novel microfluidic-based picodroplet platform which enables high-throughput assessment and isolation of antibiotic-resistant bacteria in a label-free manner. As a proof-of-concept, the system was used to isolate fusidic acid-resistant mutants and estimate the frequency of resistance among a population of Escherichia coli (strain HS151). This approach can be used for rapid screening of rare antibiotic-resistant mutants to help identify novel compound/target pairs.

The use of a novel bone allograft wash process to generate a biocompatible, mechanically stable and osteoinductive biological scaffold for use in bone tissue engineering

Fresh-frozen biological allograft remains the most effective substitute for the 'gold standard' autograft, sharing many of its osteogenic properties but, conversely, lacking viable osteogenic cells. Tissue engineering offers the opportunity to improve the osseointegration of this material through the addition of mesenchymal stem cells (MSCs). However, the presence of dead, immunogenic and potentially harmful bone marrow could hinder cell adhesion and differentiation, graft augmentation and incorporation, and wash procedures are therefore being utilized to remove the marrow, thereby improving the material's safety. To this end, we assessed the efficiency of a novel wash technique to produce a biocompatible, biological scaffold void of cellular material that was mechanically stable and had osteoinductive potential. The outcomes of our investigations demonstrated the efficient removal of marrow components (~99.6%), resulting in a biocompatible material with conserved biomechanical stability. Additionally, the scaffold was able to induce osteogenic differentiation of MSCs, with increases in osteogenic gene expression observed following extended culture. This study demonstrates the efficiency of the novel wash process and the potential of the resultant biological material to serve as a scaffold in bone allograft tissue engineering.

Spatiotemporal expression patterns of doublesex and mab-3 related transcription factor 1 in the chicken developing gonads and Mullerian ducts

Sex of birds is genetically determined by the inheritance of sex chromosomes (ZZ for male and ZW for female), and the Z-linked gene named doublesex and mab-3 related transcription factor 1 (DMRT1) is a candidate sex-determining gene in avian species. However, the mechanisms underlying sex determination in birds are not yet understood, and the expression patterns of the DMRT1 protein in urogenital tissues have not been identified. In the current study, we used immunohistochemistry to investigate the detailed expression patterns of the DMRT1 protein in the urogenital systems (including Müllerian ducts) in male and female chicken embryos throughout embryonic development. Gonadal somatic cells in the male indifferent gonads showed stronger expressions of DMRT1 compared with those in the female indifferent gonads well before the presumptive period of the sex determination, and Sertoli cells forming testicular cords expressed DMRT1 in the testes after sex determination. Germ cells expressed DMRT1 equally in males and females after sex determination. The expression was continuous in males, but in females it gradually disappeared from the germ cells in the central part of the cortex of the left ovary toward both edges. The DMRT1 was also detected in the tubal ridge, which is a precursor of the Müllerian duct, and at the mesenchyme and outermost coelomic epithelium of the Müllerian duct in both sexes. Strong expression was observed in the males, but it was restricted to coelomic epithelium after the regression of the duct started. Thus, we observed the detailed spatiotemporal expression patterns of DMRT1 in the developing chicken urogenital systems throughout embryonic development, suggesting its various roles in the development of urogenital tissues in the chicken embryo.

Acupuncture and acupressure for pain management in labour and birth: a critical narrative review of current systematic review evidence

BACKGROUND

Reviews of maternity services highlight the need for a reduction of medical interventions for women with low risk pregnancies and births to prevent the potential cascade of interventions and their associated risks. Complementary medicines (CM) such as acupuncture and acupressure have claimed to be effective in reducing interventions in labour; however, systematic reviews of evidence to date are conflicting.

AIMS

To examine current evidence from systematic reviews on the topic of acupuncture and acupressure for pain management in labour and birth, and to evaluate the methodological and treatment frameworks applied to this evidence.

METHODS

A search limited to systematic reviews of the MEDLINE, CINAHL, PUBMED, EMBASE and Cochrane databases was performed in December 2013 using the keywords 'CAM', 'alternative medicine', 'complementary medicine', 'complementary therapies', 'traditional medicine', 'Chinese Medicine', 'Traditional Chinese Medicine', 'acupuncture', 'acupressure', cross-referenced with 'childbirth', 'birth', labo*r', and 'delivery'. The quality of the evidence is also evaluated in the context of study design.

RESULTS

The RCTs included in these systematic reviews differed in terms of study designs, research questions, treatment protocols and outcome measures, and yielded some conflicting results. It may be inappropriate to include these together in a systematic review, or pooled analysis, of acupuncture for labour with an expectation of an overall conclusion for efficacy. Trials of acupuncture and acupressure in labour show promise, but further studies are required.

CONCLUSION

The use of current systematic reviews of the evidence for acupuncture and acupressure for labour and birth may be misleading. Appropriate methods and outcome measures for investigation of acupuncture and acupressure treatment should more carefully reflect the research question being asked. The use of pragmatic trials designs with woman-centred outcomes may be appropriate for evaluating the effectiveness of these therapies.

The practice of acupuncture and moxibustion to promote cephalic version for women with a breech presentation: implications for clinical practice and research

OBJECTIVES

To examine what experienced acupuncture practitioners and researchers considered key aspects of treatment to promote cephalic version for women with a breech presentation, and to establish a treatment protocol through consensus to guide the self administration of moxa by pregnant women.

METHODS AND DESIGN

The Delphi method was used to seek the opinions of key informants. Sixteen English speaking international, Australian and New Zealand acupuncturists working in the area of pregnancy were invited to participate in the study. Participants were given a link to an online survey, and their views sought on treatment parameters guiding the treatment of breech presentation within a research setting.

RESULTS

Two rounds of the Delphi process were undertaken, 12 participants completed round one, and 10 completed round two. Eighty percent of participants agreed that moxa should commence between 34 and 35 weeks gestation. Ninety percent agreed to self administration of moxa by the woman, and use of smokeless and odourless sticks. Seventy percent agreed moxa should be applied for a minimum of 10 days, and be applied once a day for 30min. Monitoring safety was identified as an important outcome. Ninety percent agreed study clinical outcomes should assess side effects including burns, and maternal and foetal outcomes.

CONCLUSION

Findings from our study promote the clinical validity for a future research protocol, and highlight other areas for research to evaluate the role of acupuncture and moxibustion with normalising birth.

The molecular genetics of ovarian differentiation in the avian model

In birds as in mammals, sex is determined at fertilization by the inheritance of sex chromosomes. However, sexual differentiation - development of a male or female phenotype - occurs during embryonic development. Sex differentiation requires the induction of sex-specific developmental pathways in the gonads, resulting in the formation of ovaries or testes. Birds utilize a different sex chromosome system to that of mammals, where females are the heterogametic sex (carrying Z and W chromosomes), while males are homogametic (carrying 2 Z chromosomes). Therefore, while some genes essential for testis and ovarian development are conserved, important differences also exist. Namely, the key mammalian male-determining factor SRY does not exist in birds, and another transcription factor, DMRT1, plays a central role in testis development. In contrast to our understanding of testis development, ovarian differentiation is less well-characterized. Given the presence of a female-specific chromosome, studies in chicken will provide insight into the induction and function of female-specific gonadal pathways. In this review, we discuss sexual differentiation in chicken embryos, with emphasis on ovarian development. We highlight genes that may play a conserved role in this process, and discuss how interaction between ovarian pathways may be regulated.

Cognitive and EEG fluctuation in benign childhood epilepsy with central-temporal spikes: a case series

Aware of parental reports of academic variability, we investigated month-to-month fluctuations in cognitive abilities and EEG status by repeated measures testing in six children with benign epilepsy with central-temporal spikes (BECTS). All showed greater than normal test-retest variability. Daytime EEG abnormalities were also variable. Short-term fluctuations in cognitive function appear common in children with BECTS, potentially impacting academic performance.

Long-term follow-up of patients undergoing auto-SCT for advanced germ cell tumour: a multicentre cohort study

Failure of cisplatin-based chemotherapy in advanced germ cell tumour (GCT) is associated with a poor outcome. High-dose chemotherapy and auto-SCT is one therapeutic option, although the long-term outcome after this procedure is unclear. We conducted a multicentre cohort study of consecutive patients undergoing a single auto-SCT for GCT between January 1986 and December 2004. Of 71 subjects, median follow-up is 10.1 years. OS at 5 years is 44.7% (95% confidence interval (CI) 32.9-56.5%) and EFS is 43.5% (95% CI 31.4-55.1%). There were seven (10%) treatment-related deaths within 100 days of auto-SCT. Three (4.2%) patients developed secondary malignancies. Of 33 relapses, 31 occurred within 2 years of auto-SCT. Two very late relapses were noted 13 and 11 years after auto-SCT. In multivariate analysis, favourable outcome was associated with IGCCC (International Germ Cell Consensus Classification) good prognosis disease at diagnosis, primary gonadal disease and response to salvage chemotherapy. We conclude that auto-SCT results in successful outcome for a relatively large subgroup of patients with high-risk GCT. Late relapses may occur, a finding not previously reported.

Detection of herpes viruses in respiratory secretions of patients undergoing artificial ventilation

The significance of detection of herpes viruses in respiratory secretions of critically ill patients is controversial. The study aim was to determine the prevalence of herpes virus DNA in respiratory secretions in patients on artificial ventilation. Respiratory secretions taken thrice weekly from 174 patients in a tertiary center intensive therapy unit (ITU) were tested for herpes simplex virus (HSV) by nested PCR. Samples from 61 patients in ITU for 4 days or more were also tested for Epstein Barr Virus (EBV) and cytomegalovirus (CMV) using real-time PCR. HSV positivity increased with ITU stay with 18.6% admission samples positive, 32.5% day 2-5 samples, and 65.9% day 6-39 samples. Being HSV positive on admission did not influence mortality (9/27, 33.3% vs. 38/118, 32.2%) however, subsequently, mortality of those negative but becoming positive was higher than in those remaining negative (10/35, 29% vs. 5/24 21%). At least one sample was EBV positive in 61% and CMV positive in 19% of patients tested. Of 63 patients tested for all three viruses, 4 were positive for three viruses, 23 patients for two viruses, 24 for one virus and 12 were negative for all the above viruses. Detection of HSV, EBV and CMV is common in ITU patients. Becoming HSV positive while in ITU may increase mortality.

Association between the CYP1A1 gene polymorphism and susceptibility to emphysema and lung cancer

Aim-To investigate cytochrome P4501A1 (CYP1A1) polymorphism and susceptibility to emphysema and lung cancer.Methods-A novel polymerase chain reaction (PCR) for genotyping the CYP1A1 polymorphism, corresponding to putative low or high enzyme activity, was developed to genotype lung cancer resection samples which had been assessed macroscopically for the presence of centriacinar and panacinar emphysema. Samples were collected and genotyped from a group of patients with chronic obstructive airways disease. A control group of anonymous blood donations was genotyped to determine the basal levels of the polymorphism in the Scottish population.Results-The high activity allele of the CYP1A1 gene is associated with susceptibility to centriacinar emphysema and lung cancer but not panacinar emphysema. CYP1A1 polymorphism is not linked to lung cancer in the absence of emphysema, nor to chronic obstructive airways disease which is the clinical manifestation of emphysema, particularly of the panacinar type.Conclusions-Susceptibility to emphysema and lung cancer is associated with polymorphism of the P4501A1 gene. A trend towards damage of centriacinar pattern has been detected, which supports the theory that centriacinar emphysema results from local, direct damage to the respiratory bronchioles from exposure to cigarette smoke.

The SFRP family of WNT inhibitors function as novel tumor suppressor genes epigenetically silenced in medulloblastoma

Medulloblastoma (MB) is the most common malignant pediatric brain tumor. Dysregulation of WNT signaling occurs in up to 20% of cases. Using a genome-wide approach, we identified the secreted frizzled-related protein 1, 2 and 3 (SFRP1, SFRP2 and SFRP3) family of WNT inhibitors as putative tumor suppressor genes silenced by promoter region methylation in MB. SFRP1, SFRP2 and SFRP3 expression increased after 5-aza-2'-deoxycytidine treatment. SFRP1, SFRP2 and SFRP3 methylation was identified in 23.5, 3.9 and 15.7% of primary MB specimens, respectively, by methylation-specific PCR. Stable SFRP1, SFRP2 and SFRP3 expression reduced phospho-DVL2 levels and hindered MB cell proliferation and colony formation in soft agar in vitro. In 60% of primary tumors, SFRP1 was expressed at levels twofold lower than that in normal cerebellum. SFRP1 expression impaired tumor formation in vivo in flank and orthotopic intracerebellar xenograft models and conferred a significant survival advantage (P<0.0001). We identify for the first time tumor suppressor gene function of SFRP genes in MB, and suggest that loss of WNT pathway inhibition due to SFRP gene silencing is an additional mechanism that may contribute to excessive WNT signaling in this disease.

Contributions of central and peripheral chemoreceptors to the ventilatory response to CO2/H+

The major objective of this review is to evaluate existing information and reach conclusions regarding whether there is interaction between P(CO(2))/H(+) stimulation of carotid (peripheral) and intracranial (central) chemoreceptors. Interaction is defined as a ventilatory response to simultaneous changes in the degree of Pco2/H(+) stimulation of both chemoreceptors that is greater (hyperadditive) or less (hypoadditive) than the sum of the responses when stimulation of each set of chemoreceptors is individually altered. Simple summation of the simultaneous changes in stimuli results in no interaction (i.e., additive interaction). Knowledge of the nature of central/peripheral interaction is crucial for determining the physiological significance of newer models of ventilatory control based on recent neuroanatomic observations of the circuitry of key elements of the ventilatory control system. In this review, we will propose that these two sets of receptors are not functionally separate but rather that they are dependent on one another such that the sensitivity of the medullary chemoreceptors is critically determined by input from the peripheral chemoreceptors and possibly other breathing-related reflex afferents as well. The short format of this minireview demands that we be somewhat selective in developing our ideas. We will briefly discuss the limitations of experiments used to study CO(2)/H(+) sensitivity and interaction to date, traditional views of the relative contributions of peripheral and central chemoreceptors to CO(2)/H(+) sensitivity, the evidence for and against different types of interaction, and the effect of tonic carotid chemoreceptor afferent activity on central control mechanisms.

Host races in Chaetostomella cylindrica (Diptera: Tephritidae): genetic and behavioural evidence

The highly oligophagous tephritid Chaetostomella cylindrica infests the flower heads of six genera and ten species of thistles in Lebanon. It predominantly utilizes two hosts occurring in sympatry, Notobasis syriaca and Onopordum illyricum. Previous work showed that adult flies emerging from N. syriaca fit more closely the description of the species, particularly with respect to the colour and pattern on the mesonotum; furthermore, significant differences were observed between the aculeus shape and length. This study investigates the biology of the immatures and compares adults from the two host races behaviourally and genetically. Larvae of both races fed in a similar way, with each larva destroying 3-10 achenes; however, the oviposition behaviour of females differed. Females of the Onopordum-associated flies laid an average of three eggs per head, and deposited the eggs glued to each others in a cluster, while females of the Notobasis-associated flies deposited their eggs unattached, usually with one egg per head. Subtle differences were also observed in the post-mating behaviour of adult males. DNA sequencing of an amplified fragment of the mitochondrial NADH-dehydrogenase subunit 1 gene revealed 44 single nucleotide polymorphisms in 622 base pairs. A PCR-RFLP method was developed to distinguish the two host-associated populations. Together with previously published morphometric studies, our data show that C. cylindrica consists of distinct host races, which seem to be reproductively isolated as two separate genetic lineages were observed.

Long-term outcome after allo-SCT: close follow-up on a large cohort treated with myeloablative regimens

We analyzed the late outcomes of 429 long-term survivors post allogeneic hematopoietic SCT (allo-HSCT) who received transplant in our center between 1981 and 2002, and were free of their primary disease for > or =2 years after allo-HSCT. Late recurrent primary malignancy was found in 58 (13.5%) patients and was the primary cause of late death. A total of 37 (8.6%) patients died of non-relapse causes at a median of 5.5 years (range, 2-15.6 years) post allo-HSCT. The major non-relapse causes of death were chronic GVHD (cGVHD), secondary malignancy and infection. The probabilities of OS and EFS were 85% (95% cumulative incidence (CI) (81-89%)) and 79% (95% CI (74-83%)) at 10 years, respectively. Long-term allo-HSCT survivors were evaluated for late complications (median follow-up, 8.6 years (range, 2.3-22.8 years)). cGVHD was diagnosed in 196 (53.1%) survivors. The endocrine and metabolic complications were hypogonadism in 134 (36.3%) patients, osteopenia/osteoporosis in 90 (24.4%), dyslipidemia in 33 (8.9%), hypothyroidism in 28 (7.6%) and diabetes in 28 (7.6%). Hypertension was diagnosed in 79 (21.4%), renal impairment in 70 (19.0%), depression in 40 (10.8%) and sexual dysfunction in 33 (8.9%) survivors. We conclude that in patients who receive allo-HSCT as treatment for hematological malignancy and who are free of their original disease 2 years post transplant, mortality is low and the probability of durable remission is high. Lifelong surveillance is recommended.

Chinese herbal medicine for primary dysmenorrhoea

BACKGROUND

Conventional treatment for primary dysmenorrhoea has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine may be a suitable alternative.

OBJECTIVES

To determine the efficacy and safety of Chinese herbal medicine for primary dysmenorrhoea when compared with placebo, no treatment, and other treatment.

SEARCH STRATEGY

The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to December 2006), and the Chinese BioMedicine Database (CBM, 1990 to December 2006) were searched. Citation lists of included trials were also reviewed.

SELECTION CRITERIA

Any randomised controlled trials involving Chinese herbal medicine versus placebo, no treatment, conventional therapy, heat compression, another type of Chinese herbal medicine, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra-uterine contraceptive device.

DATA COLLECTION AND ANALYSIS

Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta-analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed-effect statistical model was used, where suitable. If data were not suitable for meta-analysis, any available data from the trial were extracted and presented as descriptive data.

MAIN RESULTS

Thirty-nine randomised controlled trials involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for Chinese herbal medicine compared to placebo were unclear as data could not be combined (3 RCTs). Chinese herbal medicine resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self-designed Chinese herbal formulae resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months of follow-up when compared to commonly used Chinese herbal health products. Chinese herbal medicine also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18).

AUTHORS' CONCLUSIONS

The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials.

Structure of the MDM2/MDMX RING domain heterodimer reveals dimerization is required for their ubiquitylation in trans

MDM2, a ubiquitin E3-ligase of the RING family, has a key role in regulating p53 abundance. During normal non-stress conditions p53 is targeted for degradation by MDM2. MDM2 can also target itself and MDMX for degradation. MDMX is closely related to MDM2 but the RING domain of MDMX does not possess intrinsic E3-ligase activity. Instead, MDMX regulates p53 abundance by modulating the levels and activity of MDM2. Dimerization, mediated by the conserved C-terminal RING domains of both MDM2 and MDMX, is critical to this activity. Here we report the crystal structure of the MDM2/MDMX RING domain heterodimer and map residues required for functional interaction with the E2 (UbcH5b). In both MDM2 and MDMX residues C-terminal to the RING domain have a key role in dimer formation. In addition we show that these residues are part of an extended surface that is essential for ubiquitylation in trans. This study provides a molecular basis for understanding how heterodimer formation leads to stabilization of MDM2, yet degradation of p53, and suggests novel targets for therapeutic intervention.

Chinese herbal medicine for primary dysmenorrhoea

BACKGROUND

Conventional treatment for primary dysmenorrhoea (PD) has a failure rate of 20% to 25% and may be contraindicated or not tolerated by some women. Chinese herbal medicine (CHM) may be a suitable alternative.

OBJECTIVES

To determine the efficacy and safety of CHM for PD when compared with placebo, no treatment, and other treatment.

SEARCH STRATEGY

The Cochrane Menstrual Disorders and Subfertility Group Trials Register (to 2006), MEDLINE (1950 to January 2007), EMBASE (1980 to January 2007), CINAHL (1982 to January 2007), AMED (1985 to January 2007), CENTRAL (The Cochrane Library issue 4, 2006), China National Knowledge Infrastructure (CNKI, 1990 to January 2007), Traditional Chinese Medicine Database System (TCMDS, 1990 to Dec 2006), and the Chinese BioMedicine Database (CBM, 1990 to Dec 2006) were searched. Citation lists of included trials were also reviewed.

SELECTION CRITERIA

Any randomised controlled trials (RCTs) involving CHM versus placebo, no treatment, conventional therapy, heat compression, another type of CHM, acupuncture or massage. Exclusion criteria were identifiable pelvic pathology and dysmenorrhoea resulting from the use of an intra-uterine contraceptive device (IUD).

DATA COLLECTION AND ANALYSIS

Quality assessment, data extraction and data translation were performed independently by two review authors. Attempts were made to contact study authors for additional information and data. Data were combined for meta-analysis using either Peto odds ratios or relative risk (RR) for dichotomous data or weighted mean difference for continuous data. A fixed-effect statistical model was used, where suitable. If data were not suitable for meta-analysis, any available data from the trial were extracted and presented as descriptive data.

MAIN RESULTS

Thirty-nine RCTs involving a total of 3475 women were included in the review. A number of the trials were of small sample size and poor methodological quality. Results for CHM compared to placebo were unclear as data could not be combined (3 RCTs). CHM resulted in significant improvements in pain relief (14 RCTs; RR 1.99, 95% CI 1.52 to 2.60), overall symptoms (6 RCTs; RR 2.17, 95% CI 1.73 to 2.73) and use of additional medication (2 RCTs; RR 1.58, 95% CI 1.30 to 1.93) when compared to use of pharmaceutical drugs. Self-designed CHM resulted in significant improvements in pain relief (18 RCTs; RR 2.06, 95% CI 1.80 to 2.36), overall symptoms (14 RCTs; RR 1.99, 95% CI 1.65 to 2.40) and use of additional medication (5 RCTs; RR 1.58, 95% CI 1.34 to 1.87) after up to three months follow up when compared to commonly used Chinese herbal health products. CHM also resulted in better pain relief than acupuncture (2 RCTs; RR 1.75, 95% CI 1.09 to 2.82) and heat compression (1 RCT; RR 2.08, 95% CI 2.06 to 499.18).

AUTHORS' CONCLUSIONS

The review found promising evidence supporting the use of CHM for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials.

Avian sex determination: what, when and where?

Sex is determined genetically in all birds, but the underlying mechanism remains unknown. All species have a ZZ/ZW sex chromosome system characterised by female (ZW) heterogamety, but the chromosomes themselves can be heteromorphic (in most birds) or homomorphic (in the flightless ratites). Sex in birds might be determined by the dosage of a Z-linked gene (two in males, one in females) or by a dominant ovary-determining gene carried on the W sex chromosome, or both. Sex chromosome aneuploidy has not been conclusively documented in birds to differentiate between these possibilities. By definition, the sex chromosomes of birds must carry one or more sex-determining genes. In this review of avian sex determination, we ask what, when and where? What is the nature of the avian sex determinant? When should it be expressed in the developing embryo, and where is it expressed? The last two questions arise due to evidence suggesting that sex-determining genes in birds might be operating prior to overt sexual differentiation of the gonads into testes or ovaries, and in tissues other than the urogenital system.

The apneic threshold during non-REM sleep in dogs: sensitivity of carotid body vs. central chemoreceptors

The relative importance of peripheral vs. central chemoreceptors in causing apnea/unstable breathing during sleep is unresolved. This has never been tested in an unanesthetized preparation with intact carotid bodies. We studied three unanesthetized dogs during normal sleep in a preparation in which intact carotid body chemoreceptors could be reversibly isolated from the systemic circulation and perfused. Apneic thresholds and the CO2 reserve (end-tidal Pco2 eupneic − end-tidal Pco2 apneic threshold) were determined using a pressure support ventilation technique. Dogs were studied when both central and peripheral chemoreceptors sensed transient hypocapnia induced by the pressure support ventilation and again with carotid body isolation such that only the central chemoreceptors sensed the hypocapnia. We observed that the CO2 reserve was ≅4.5 Torr when the carotid chemoreceptors sensed the transient hypocapnia but more than doubled (>9 Torr) when only the central chemoreceptors sensed hypocapnia. Furthermore, the expiratory time prolongations observed when only central chemoreceptors were exposed to hypocapnia differed from those obtained when both the central and peripheral chemoreceptors sensed the hypocapnia in that they 1) were substantially shorter for a given reduction in end-tidal Pco2, 2) showed no stimulus: response relationship with increasing hypocapnia, and 3) often occurred at a time (>45 s) beyond the latency expected for the central chemoreceptors. These findings agree with those previously obtained using an identical pressure support ventilation protocol in carotid body-denervated sleeping dogs (Nakayama H, Smith CA, Rodman JR, Skatrud JB, Dempsey JA. J Appl Physiol 94: 155–164, 2003). We conclude that hypocapnia sensed at the carotid body chemoreceptor is required for the initiation of apnea following a transient ventilatory overshoot in non-rapid eye movement sleep.

Translation efficiencies of the 5'-untranslated region of genotypes 1a and 3a in hepatitis C infected patients

Differences between the translation efficiencies mediated by the 5'-untranslated regions (5'-UTR) of genotypes (gt) 1 and 3 of hepatitis C virus (HCV) have been reported but it is unknown if such differences are biologically significant. The 5'-UTR was sequenced from paired serum and liver samples from 26 patients with chronic HCV hepatitis (11 gt 1a, 15 gt 3a). To determine whether there is a consistent difference between gts 1a and 3a translation efficiency, 5'-UTR (nt 1-356) and 5'-UTR plus core (nt 1-914) sequences were cloned into bicistronic, luciferase-encoding constructs and relative translation efficiencies (RTE) measured in Huh7 cells and BHK cells. The relationships between viral load, liver biopsy Ishak scores, degree of steatosis and translational activity of the patient-derived nucleotide sequence were examined. There were no differences in 5'-UTR sequence between serum and corresponding liver samples. The mean RTE of 5'-UTR sequences from gt 3a isolates was not significantly different from gt 1a whether or not the core encoding sequence was included, although inclusion of core led to a reduction in RTE by 93-97% for both genotypes. No correlation was found between RTE and serum HCV RNA levels, liver steatosis, inflammation, or fibrosis. However, a significant correlation was found between the presence of steatosis and infection with HCV gt 3a. It is concluded that there was no difference in translation efficiencies of 5'-UTRs from patients infected with gts 1a and 3a, and translation activity measured in vitro does not correlate with viral load or severity of liver disease.

Positive impact of selective outpatient management of high-risk acute myelogenous leukemia on the incidence of septicemia

BACKGROUND

Curative intent chemotherapy for acute myelogenous leukemia (AML) leads to prolonged severe neutropenia, during which patients are highly susceptible to infection. Traditionally these high-risk patients were treated as inpatients. Our center recently implemented a selective ambulatory management policy for AML patients undergoing chemotherapy.

MATERIALS AND METHODS

A retrospective analysis was conducted to assess the occurrence of septicemia in AML patients treated over a 5 years period with curative intent chemotherapy. This review encompasses a change in policy from primarily inpatient care to selective outpatient management coupled with prophylactic antibiotic therapy.

RESULTS

A total of 294 patients, receiving 623 cycles of chemotherapy were identified. A significant decrease in septicemia was observed from the inpatient to outpatient cohort (22% to 13% P < 0.05), which correlated with the shift towards outpatient treatment of consolidation cycles. A shift from Gram-negative to Gram-positive organisms as the cause of septicemia was also detected in the outpatient cohort, likely due to the introduction of ciprofloxacin prophylaxis. No significant emerging resistance and no septicemia-related mortality were noted in the outpatient cohort.

CONCLUSION

The observed decrease in the incidence of septicemia in the ambulatory cohort adds supportive evidence to the feasibility of selective outpatient management of AML patients with respect to infectious complications.

Primary therapy for adults with T-cell lymphoblastic lymphoma with hematopoietic stem-cell transplantation results in favorable outcomes

BACKGROUND

Controversy exists regarding the role of high-dose therapy followed by stem-cell transplant (SCT) in the treatment of T-cell lymphoblastic lymphoma (T-LBL). We conducted an intention-to-treat analysis of the strategy of SCT as definitive treatment of T-LBL.

PATIENTS AND METHODS

From July 1987 to March 2005, 34 adults with T-LBL were diagnosed and treated in British Columbia. Treatment, before planned SCT, consisted of a non-Hodgkin's lymphoma (NHL)/acute lymphoblastic leukemia hybrid chemotherapy protocol (28 patients) or a standard NHL chemotherapy regimen (six patients).

RESULTS

Median follow-up of the 23 surviving patients is 51 months (range 13-142 months). Twenty-nine proceeded to SCT (four allogeneic, 25 autologous). For all 34 patients, 4-year overall survival (OS) and event-free survival (EFS) are 72% and 68%, respectively. For patients proceeding to SCT, the 4-year OS and EFS are 79% and 73%, respectively. All patients who received allografts are alive without disease at 38-141 months since diagnosis. For patients who received autografts, the 4-year EFS is 69%. Bone marrow involvement was a significant prognostic factor predicting for a worse survival (P = 0.02).

CONCLUSION

A treatment strategy for adults with chemosensitive T-LBL that includes planned consolidation with SCT in first response produces favorable long-term outcome.

Complementary and alternative therapies for pain management in labour

BACKGROUND

Many women would like to avoid pharmacological or invasive methods of pain management in labour and this may contribute towards the popularity of complementary methods of pain management. This review examined currently available evidence supporting the use of alternative and complementary therapies for pain management in labour.

OBJECTIVES

To examine the effects of complementary and alternative therapies for pain management in labour on maternal and perinatal morbidity.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (February 2006), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to February 2006), EMBASE (1980 to February 2006) and CINAHL (1980 to February 2006).

SELECTION CRITERIA

The inclusion criteria included published and unpublished randomised controlled trials comparing complementary and alternative therapies (but not biofeedback) with placebo, no treatment or pharmacological forms of pain management in labour. All women whether primiparous or multiparous, and in spontaneous or induced labour, in the first and second stage of labour were included.

DATA COLLECTION AND ANALYSIS

Meta-analysis was performed using relative risks for dichotomous outcomes and mean differences for continuous outcomes. The outcome measures were maternal satisfaction, use of pharmacological pain relief and maternal and neonatal adverse outcomes.

MAIN RESULTS

Fourteen trials were included in the review with data reporting on 1537 women using different modalities of pain management; 1448 women were included in the meta-analysis. Three trials involved acupuncture (n = 496), one audio-analgesia (n = 24), two trials acupressure (n = 172), one aromatherapy (n = 22), five trials hypnosis (n = 729), one trial of massage (n = 60), and relaxation (n = 34). The trials of acupuncture showed a decreased need for pain relief (relative risk (RR) 0.70, 95% confidence interval (CI) 0.49 to 1.00, two trials 288 women). Women taught self-hypnosis had decreased requirements for pharmacological analgesia (RR 0.53, 95% CI 0.36 to 0.79, five trials 749 women) including epidural analgesia (RR 0.30, 95% CI 0.22 to 0.40) and were more satisfied with their pain management in labour compared with controls (RR 2.33, 95% CI 1.15 to 4.71, one trial). No differences were seen for women receiving aromatherapy, or audio analgesia.

AUTHORS' CONCLUSIONS

Acupuncture and hypnosis may be beneficial for the management of pain during labour; however, the number of women studied has been small. Few other complementary therapies have been subjected to proper scientific study.

HER2 expression as a potential marker for response to therapy targeted to the EGFR

Since human epidermal growth factor receptor 2 (HER2) is known to participate with the epidermal growth factor receptor (EGFR) in mitogenic signalling, we hypothesised that HER2 overexpression might indicate responsiveness to EGFR targeted therapies. MCF7 breast cancer cells transfected with the HER2 gene were subcloned to establish a set of genetically related cell lines expressing graded levels of HER2 by immunoblot analysis. The subcloned cell lines and parental MCF7 cells were characterised by their growth characteristics, and cell by cell patterns of EGFR, HER2 and HER3 expression as well as levels of phosphorylated mitogen-activated protein kinase (MAPK) and AKT by laser scanning cytometry (LSC). Growth inhibition assays were used to characterise response to EGFR targeted therapy, and to determine the relationship between therapeutic response and levels of tyrosine kinase expression. The levels of growth inhibition of AG1478 and of the AG1478-trastuzumab combinations were correlated with levels of HER2 expression among the different cell lines. Among EGFR, HER2 and HER3, HER2 overexpression was the best single predictive marker, but combinations of two markers provided additional predictive information.

Purification, crystallization and preliminary X-ray analysis of Mycobacterium tuberculosisfolylpolyglutamate synthase (MtbFPGS)

The gene encoding Mycobacterium tuberculosis FPGS (MtbFPGS; Rv2447c) has been cloned and the protein (51 kDa) expressed in Escherichia coli. The purified protein was crystallized either by the batch method in the presence of adenosine diphosphate (ADP) and CoCl2 or by vapour diffusion in the presence of ADP, dihydrofolate and CaCl2. X-ray diffraction data to approximately 2.0 and 2.6 A resolution were collected at the Stanford Synchrotron Radiation Laboratory (SSRL) for crystals grown under the respective conditions. Both crystals belong to the cubic space group P2(1)3, with a unit-cell parameter of 112.6 and 111.8 A, respectively. Structure determination is proceeding.