Bacteriophages, gut bacteria, and microbial pathways interplay in cardiometabolic health

Cardiometabolic diseases are leading causes of mortality in Western countries. Well-established risk factors include host genetics, lifestyle, diet, and the gut microbiome. Moreover, gut bacterial communities and their activities can be altered by bacteriophages (also known simply as phages), bacteria-infecting viruses, making these biological entities key regulators of human cardiometabolic health. The manipulation of bacterial populations by phages enables the possibility of using phages in the treatment of cardiometabolic diseases through phage therapy and fecal viral transplants. First, however, a deeper understanding of the role of the phageome in cardiometabolic diseases is required. In this review, we first introduce the phageome as a component of the gut microbiome and discuss fecal viral transplants and phage therapy in relation to cardiometabolic diseases. We then summarize the current state of phageome research in cardiometabolic diseases and propose how the phageome might indirectly influence cardiometabolic health through gut bacteria and their metabolites.

Magnetically localized and wash-free fluorescent immuno-assay: From a research platform (MLFIA) to a multiplexed POC system (MagIA)

Sexually transmitted infections (STI) remain one of the world's public health priorities: Nearly 400 million people are infected not only in emerging, but also in western countries. HIV, HBV and HCV share common infection pathways; thus these 3 diseases are recommended to be tested at the same time. However, this combined approach is currently mainly available in laboratories, and seldomly at the Point-of-care (POC). Consequently, there is a need for a STI screening POC platform with laboratory-like performance. Such a platform should be autonomous and portable and enable multiplexed screening from capillary blood. The previously developed and introduced MLFIA (Magnetically Localized and wash-free Fluorescent Immuno-Assay) technology has the potential to address these needs, as the MLFIA 18-chamber microfluidic cartridge and the MLFIA Analyzer were previously characterized and evaluated with plasma and serum from patients infected with HIV, Hepatitis B (Hep B) or C (Hep C). Here, we present the efforts to transfer this research platform (MLFIA) to a fully integrated multi-analysis solution (MagIA). First, we present the design changes of the consumable enabling to perform multiple assays in parallel, a fast filling of the cartridge with patient samples, and a homogeneous reagent/sample incubation. Second, we describe the development a piezoelectric actuator integrated into the Analyzer: this mixing module allows for an automated, fully integrated and portable workflow, with homogeneous in-situ mixing capabilities. The obtained MagIA platform was further characterized and validated for immunoassays (LOD, cartridge stability over time), using various biological models including OVA and IgG. We discuss the performances of the MLFIA and MagIA platforms for the detection of HIV / Hep B / Hep C using results from 102 patient plasma samples. Lastly, we assessed the compatibility of the MagIA platform with veinous and capillary blood samples as a final step towards its POC validation.

Comparison of Answers between ChatGPT and Human Dieticians to Common Nutrition Questions

Background

More people than ever seek nutrition information from online sources. The chatbot ChatGPT has seen staggering popularity since its inception and may become a resource for information in nutrition. However, the adequacy of ChatGPT to answer questions in the field of nutrition has not been investigated. Thus, the aim of this research was to investigate the competency of ChatGPT in answering common nutrition questions.

Methods

Dieticians were asked to provide their most commonly asked nutrition questions and their own answers to them. We then asked the same questions to ChatGPT and sent both sets of answers to other dieticians (N = 18) or nutritionists and experts in the domain of each question (N = 9) to be graded based on scientific correctness, actionability, and comprehensibility. The grades were also averaged to give an overall score, and group means of the answers to each question were compared using permutation tests.

Results

The overall grades for ChatGPT were higher than those from the dieticians for the overall scores in five of the eight questions we received. ChatGPT also had higher grades on five occasions for scientific correctness, four for actionability, and five for comprehensibility. In contrast, none of the answers from the dieticians had a higher average score than ChatGPT for any of the questions, both overall and for each of the grading components.

Conclusions

Our results suggest that ChatGPT can be used to answer nutrition questions that are frequently asked to dieticians and provide encouraging support for the role of chatbots in offering nutrition support.

Magnetically localized and wash-free fluorescence immunoassay (MLFIA): proof of concept and clinical applications

Immunoassays are used for many applications in various markets, from clinical diagnostics to the food industry, generally relying on gold-standard ELISAs that are sensitive, robust, and cheap but also time-consuming and labour intensive. As an alternative, we propose here the magnetically localized and wash-free fluorescence immunoassay (MLFIA): a no-wash assay to directly measure a biomolecule concentration, without mixing nor washing steps. To do so, a fluorescence no-wash measurement is performed to generate a detectable signal. It consists of a differential measurement between the fluorescence of fluorophores bound to magnetic nanoparticles specifically captured by micro-magnets against the residual background fluorescence of unbound fluorophores. Targeted biomolecules (antibodies or antigens) are locally concentrated on micro-magnet lines, with the number of captured biomolecules quantitatively measured without any washing step. The performance of the MLFIA platform is assessed and its use is demonstrated with several biological models as well as clinical blood samples for HIV, HCV and HBV detection, with benchmarking to standard analyzers of healthcare laboratories. Thus, we demonstrated for the first time the versatility of the innovative MLFIA platform. We highlighted promising performances with the successful quantitative detection of various targets (antigens and antibodies), in different biological samples (serum and plasma), for different clinical tests (HCV, HBV, HIV).

Machine Learning in Nutrition Research

Data currently generated in the field of nutrition are becoming increasingly complex and high-dimensional, bringing with them new methods of data analysis. The characteristics of machine learning (ML) make it suitable for such analysis and thus lend itself as an alternative tool to deal with data of this nature. ML has already been applied in important problem areas in nutrition, such as obesity, metabolic health, and malnutrition. Despite this, experts in nutrition are often without an understanding of ML, which limits its application and therefore potential to solve currently open questions. The current article aims to bridge this knowledge gap by supplying nutrition researchers with a resource to facilitate the use of ML in their research. ML is first explained and distinguished from existing solutions, with key examples of applications in the nutrition literature provided. Two case studies of domains in which ML is particularly applicable, precision nutrition and metabolomics, are then presented. Finally, a framework is outlined to guide interested researchers in integrating ML into their work. By acting as a resource to which researchers can refer, we hope to support the integration of ML in the field of nutrition to facilitate modern research.

Precision nutrition: A systematic literature review

Precision Nutrition research aims to use personal information about individuals or groups of individuals to deliver nutritional advice that, theoretically, would be more suitable than generic advice. Machine learning, a subbranch of Artificial Intelligence, has promise to aid in the development of predictive models that are suitable for Precision Nutrition. As such, recent research has applied machine learning algorithms, tools, and techniques in precision nutrition for different purposes. However, a systematic overview of the state-of-the-art on the use of machine learning in Precision Nutrition is lacking. Therefore, we carried out a Systematic Literature Review (SLR) to provide an overview of where and how machine learning has been used in Precision Nutrition from various aspects, what such machine learning models use as input features, what the availability status of the data used in the literature is, and how the models are evaluated. Nine research questions were defined in this study. We retrieved 4930 papers from electronic databases and 60 primary studies were selected to respond to the research questions. All of the selected primary studies were also briefly discussed in this article. Our results show that fifteen problems spread across seven domains of nutrition and health are present. Four machine learning tasks are seen in the form of regression, classification, recommendation and clustering, with most of these utilizing a supervised approach. In total, 30 algorithms were used, with 19 appearing more than once. Models were through the use of four groups of approaches and 23 evaluation metrics. Personalized approaches are promising to reduce the burden of these current problems in nutrition research, and the current review shows Machine Learning can be incorporated into Precision Nutrition research with high performance. Precision Nutrition researchers should consider incorporating Machine Learning into their methods to facilitate the integration of many complex features, allowing for the development of high-performance Precision Nutrition approaches.

Who Should have a Prostatectomy? a Survey of the Management of Patients Presenting with Bladder Outflow Obstruction

A postal questionnaire was sent to 33 urologists and to 15 general surgeons who perform prostatic surgery in Scotland. Forty-six out of 48 surgeons replied. The waiting time for outpatient consultations and waiting list statistics of the respondents were compared. Differences in access to and use of imaging, laboratory and urodynamic facilities are reported. Waiting times were affected by the individual surgeon's policy. In busy units, the desire to achieve acceptable waiting times may lead to rationing of treatment to only the most severe cases. Better provision and use of modern investigational facilities might better select those patients who will benefit most from surgical management, leading to more effective use of resources. Medical audit of surgical patients must start from the time of their referral and not confine itself to patients undergoing treatment.

Retroperitoneal Fibrosis Complicating Intravesical Formalin Therapy

Two cases are reported of ureteric obstruction due to retroperitoneal fibrosis following the use of intravesical formalin. This particular complication of this treatment has not previously been described.

A Method for Investigating "Instructional Familiarity" and Discerning Authentic Learning

BACKGROUND

Presently, most medical educators rely exclusively on item difficulty and discrimination indices to investigate an item's psychometric quality and functioning. We argue "instructional familiarity" effects should also be of primary concern for persons attempting to discern the quality and meaning of a set of test scores.

AIM

There were four primary objectives of this study: (1) Revisit Haladyna and Roid's conceptualization of "instructional sensitivity" within the context of criterion-referenced assessments, (2) provide an overview of "instructional familiarity" and its importance, (3) reframe the concept for a modern audience concerned with medical school assessments, and (4) conduct an empirical evaluation of a medical school examination in which we attempt to investigate the instructional effects on person and item measures.

SUBJECTS AND METHODS

This study involved a medical school course instructor providing ratings of instructional familiarity (IF) for each mid-term examination item, and a series of psychometric analyses to investigate the effects of IF on students' scores and item statistics. The methodology used in this study is based primarily on a mixed-method, "action research" design for a medical school course focusing on endocrinology. Rasch measurement model; correlation analysis.

RESULTS

The methodology presented in this article was evidenced to better discern authentic learning than traditional approaches that ignore valuable contextual information about students' familiarity with exam items.

CONCLUSIONS

The authors encourage other medical educators to adopt this straightforward methodology so as to increase the likelihood of making valid inferences about learning.

Amnioreduction in the management of polyhydramnios complicating singleton pregnancies

OBJECTIVE

The purpose of this study was to evaluate the contribution of amnioreduction to the management of singleton pregnancies that are complicated by symptomatic polyhydramnios.

STUDY DESIGN

Retrospective review of all singleton pregnancies that received at least 1 amnioreduction for polyhydramnios from 2000-2012 at a single obstetric unit that provides a statewide service. The indications, procedural techniques, and pregnancy outcomes were evaluated.

RESULTS

One hundred thirty-eight women with polyhydramnios (maximal vertical pocket [MVP], ≥8 cm) had 271 amnioreduction procedures during the study period. The median gestation at the first drain was 31.4 weeks (interquartile range, 28.4-34 weeks) and a median of 1 procedure (interquartile range, 1-2 procedures) was performed per pregnancy. Sixty-three women (45.6%) required >1 amnioreduction. The median volume removed per pregnancy was 2100 mL (interquartile range, 1500-4260 mL). The median duration from the first amnioreduction until delivery was 26 days (interquartile range, 15-52.5 days). There was no significant association between gestation at delivery and the volume per procedure or total volume that was removed. Earlier gestation at first drain was associated positively with earlier gestations at delivery. In 4.1% of amnioreduction procedures (11/271 procedures), there was an unplanned preterm birth within 48 hours. The median gestation at delivery was 36.4 weeks (interquartile range, 34-38 weeks). The final diagnoses were gastrointestinal malformations (21%), idiopathic polyhydramnios (20.3%), chromosomal anomaly (15.2%), syndromic condition (13.7%), and neurologic condition (8%).

CONCLUSION

Amnioreduction has a useful role in the management of polyhydramnios in singleton pregnancies. Complications are uncommon, and delivery typically occurs near term.

Brain activation during autobiographical relationship episode narratives: a core conflictual relationship theme approach

The authors combined the core conflictual relationship theme (CCRT) method and functional magnetic resonance imaging (fMRI) to identify brain regions involved in recall of autobiographical relationship episodes, a key process in psychotherapy. Relationship narratives were obtained from healthy subjects and scored for CCRT relationship themes and emotion. Autobiographical personal and nonautobiographical control narratives were presented in a block-design fMRI experiment. Personal versus control narratives showed activations in anterior cingulate, precuneus, inferior and middle frontal gyri, and inferior parietal lobule. These are regions involved in autobiographical memory, theory of mind, self-referential processing, and emotion. In an exploratory analysis, higher CCRT scores correlated with increased brain activation in the left hippocampus, parahippocampal gyrus, and middle occipital gyrus. This suggests that brain systems subserving memory processes are more active when recalling relationship episodes with greater CCRT content.

Metabolic changes in rat brain following intracerebroventricular injections of streptozotocin: a model of sporadic Alzheimer's disease

A decrease in cerebral glucose metabolic uptake is an early and characteristic sign of Alzheimer's disease (AD). Streptozotocin (STZ) is a bacterial toxin which damages insulin-producing cells and insulin receptors. Intracerebroventricular (icv) application of STZ in rats has been found to chronically decrease cerebral glucose uptake and produce other effects that bear a resemblance to several other molecular and pathological features of AD. In the present experiments in vivo (1)H MR Spectroscopy with short echo time (3 ms) was used to non-invasively obtain a neurochemical profile of rat brains, 3 weeks and 2 months after double icv injections of STZ or vehicle. Seventeen metabolites were quantified from 27 microL tissue volume which included hippocampus and a part of cerebral cortex, using the LCModel and unsuppressed water signal as an internal reference. Three weeks after icv STZ several metabolites were significantly decreased, the most prominent changes noted in glycerophosphocholine and phosphocholine (-38 +/- 5%), glutathione (-37 +/- 4%), taurine (-30 +/- 19%), glutamate (-26 +/- 14%), phosphocreatine (-23 +/- 15%) and N-acetylaspartate (-16 +/- 6%). On the contrary, the concentration of N-acetylaspartylglutamate was found significantly increased (+38 +/- 18%). After 2 months some of these changes were even more pronounced. We conclude that in vivo (1)H MRS of rat brain following icv STZ injections provides a new input into a better understanding of the critical dependency of neural function and structure on brain glucose consumption, and may be of relevance in further studies of AD pathomechanism.

Simultaneous functional magnetic resonance imaging in the rat spinal cord and brain

Functional magnetic resonance imaging (fMRI) method was developed to investigate the pattern and temporal relationship in neuronal pathways of brain and spinal cord. Signal intensity changes correlating with stimulation patterns were observed simultaneously in the rat spinal cord and brain using fMRI at 9.4 T. Electrical stimulation of the forepaw was used to elicit activity. A quadrature volume RF coil covering both brain and the cervical spinal cord was used. Sets of fast spin echo (FSE) images were acquire simultaneously for both brain and spinal cord fMRI. Experiments were repeated in single animal and across animals. Activities within the dorsal horn of the spinal cord and within the somatosensory cortex were observed consistently within each animal as well as across animals.

Coat proteins of Rice tungro bacilliform virus and Mungbean yellow mosaic virus contain multiple nuclear-localization signals and interact with importin alpha

Transport of the viral genome into the nucleus is an obligatory step in the replication cycle of plant pararetro- and geminiviruses. In both these virus types, the multifunctional coat protein (CP) is thought to be involved in this process. Here, a green fluorescent protein tagging approach was used to demonstrate nuclear import of the CPs of Rice tungro bacilliform virus (RTBV) and Mungbean yellow mosaic virus--Vigna (MYMV) in Nicotiana plumbaginifolia protoplasts. In both cases, at least two nuclear localization signals (NLSs) were identified and characterized. The NLSs of RTBV CP are located within both N- and C-terminal regions (residues 479KRPK/497KRK and 744KRK/758RRK), and those of MYMV CP within the N-terminal part (residues 3KR and 41KRRR). The MYMV and RTBV CP NLSs resemble classic mono- and bipartite NLSs, respectively. However, the N-terminal MYMV CP NLS and both RTBV CP NLSs show peculiarities in the number and position of basic residues. In vitro pull-down assays revealed interaction of RTBV and MYMV CPs with the nuclear import factor importin alpha, suggesting that both CPs are imported into the nucleus via an importin alpha-dependent pathway. The possibility that this pathway could serve for docking of virions to the nucleus is discussed.

Recurrent severe hyperandrogenism during pregnancy: a case report

This report describes the case of a 28 year old woman with virilisation occurring in two successive pregnancies. Recurrent maternal virilisation is rare (seven previous reports) and this case is unique in its severity. Differential diagnoses include ovarian disease and fetal aromatase deficiency. New techniques to exclude a fetal cause were used in this case. This patient presented during the third trimester of her first pregnancy with rapid onset of hirsuitism, increased musculature, and deepening voice. A blood hormone profile revealed significant hyperandrogenism (testosterone, 72.4 nmol/litre; normal range, 0.5-3.0). She delivered a normal boy and maternal androgen concentrations returned rapidly to normal (testosterone, 0.8 nmol/litre). She presented two years later, during her second pregnancy, with similar symptoms and biochemistry (testosterone, 47.5 nmol/litre). Again, she delivered a healthy normal boy and androgens returned immediately to normal (serum testosterone, 2.0 nmol/litre). Ultrasonography revealed no evidence of ovarian (or adrenal) masses in either pregnancy. Umbilical cord venous blood sampling and placental assays revealed no evidence of fetal aromatase deficiency. Recurrent hyperandrogenism during pregnancy is rare. Ovarian luteoma rarely recurs and hyperreactio luteinalis does not lead to such pronounced androgen concentrations. Therefore, this patient has a unique ovarian condition that could be harmful to offspring and mother.

Timing and choice of androgen ablation

Hormone therapy remains central to the management of advanced prostate cancer. Evidence has accrued to suggest benefits from earlier treatment. Trials which demonstrate significant improvements in disease-specific survival may be underpowered to show overall survival benefits, due to the effect of mortality from unrelated causes. Toxicity, particularly the risk of osteoporosis, causes increasing concern, particularly where many years of use may be contemplated as in early relapse after curative treatment. Strategies to reduce toxicity include use different drugs, notably antiandrogens and with renewed interest in oestrogens in low dose or administered parenterally, and deferred and intermittent treatment. Further improvements in drug development, reducing toxicity, and identification of the cause of hormone refractory disease and its prevention would revolutionise the use of hormone therapy. Currently, deferred treatment, used selectively and with careful follow-up, remains an option for selected patients.

Combining a targeted radiotherapy and gene therapy approach for adenocarcinoma of prostate

A targeted radiotherapy/gene therapy approach for prostate cancer, using the radiopharmaceutical [(131)I]meta-iodobenzylguanidine ([(131)I]MIBG), would restrict the effects of radiotherapy to malignant cells, thereby increasing efficacy and decreasing morbidity of radiotherapy. Prostate cancer cells were transfected with a transgene encoding the noradrenaline transporter (NAT) under the control of tumour-specific telomerase promoters, enabling them to actively take up [(131)I]MIBG. This led to tumour-specific cell kill. This strategy has the advantage of generating a radiological bystander effect, leading to the destruction of neighbouring tumour cells that have escaped transfection. This targeted approach could be a promising tumour-specific treatment option for prostate cancer.

Is Psychotherapy Good for Your Health?

This is a dedicated review of the evidence for the relation of having a period of psychotherapy and then comparing it with a measure of improved physical health. We aimed to make it the first intended-to-be-complete review of this type. Three inter-related types of studies were examined: Type 1: reduction in physical illnesses through psychotherapy, especially for the patient's survival time during the interval between diagnosis and an end point, Type 2: reduction in pain in relation to receiving psychotherapy, and Type 3: reduction in costs of treatment in relation to receiving psychotherapy. To find the relevant studies on these topics, we performed a literature search using both Psychinfo and Medline databases. An average of the effect sizes under each type was taken to calculate the mean effect size along with its confidence interval. Our results (1) on survival time for the combined severe patients, did not reach even the lowest significant level of effect size, although the low severity patients seemed to fit the hypothesis better, but the other two reduction topics, (2) and (3), clearly did achieve it.

Chronic testicular pain: an overview

Chronic testicular pain (orchialgia, orchidynia or chronic scrotal pain) is common and well recognized but its pathophysiology is poorly understood. Currently treatment is largely empirical. This article aims to present an overview of its prevalence, possible aetiology and the available treatment options. The contribution of psychological factors is unclear, although some of these patients undoubtedly are depressed. Post vasectomy chronic testicular pain may be due to functional obstruction of the vas, or to spermatic granuloma. The surgical technique used may be relevant and the application of intraoperative local anaesthetic may have a role in reducing the risk. The importance of the sympathetic nervous system and the role of a possible alteration of the adrenergic receptors of the vas deferens in patients with chronic testicular pain are discussed. For patients failing to respond to conservative treatment, microsurgical denervation of the spermatic cord, epididymectomy and vasovasostomy have all shown a degree of relief. Unfortunately a small number of patients fail to respond to both conservative and more invasive treatment methods and for them the only available therapeutic option is inguinal orchiectomy.

Improved prognosis of patients with intermediate- and poor-risk nonseminomatous germ cell tumours by optimizing combined treatment

OBJECTIVE

To assess whether the optimal use of combined treatment with chemotherapy and appropriately timed surgical intervention by a specialized team might improve the outcome for patients with poor- and intermediate-prognosis (International Germ Cell Consensus Classification, IGCCC) nonseminomatous germ cell tumours (NSGCTs).

PATIENTS AND METHODS

Between 1984 and 1998, 47 patients with intermediate (16) and poor prognosis (31) NSGCT were treated; 43 had a testicular and four a retroperitoneal primary.

RESULTS

Of the 47 patients only seven (15%) had a complete radiological response after primary chemotherapy; 36 (77%) required surgery after chemotherapy (29 para-aortic lymphadenectomy, 13 resection of pulmonary metastases, two each excision of supraclavicular and retrocrural lymph nodes and one resection of brain metastases; 13 required surgery at more than one site). There was no surgical mortality, with postoperative wound pain the commonest morbidity. On pathology, the resected masses were mature teratoma in 13, necrosis in 12 and malignant disease in 11 patients, the resection being complete in 30. There were microscopically positive margins in the other six patients, all but one having viable residual cancer. Of the 47 patients, 18 needed treatment for relapse, with four having surgery for growing mature teratoma, six chemotherapy plus surgery and eight salvage chemotherapy alone. Of 31 patients, 22 (71%) with a poor and 13 of 16 with an intermediate prognosis were alive at a median (range) follow-up of 94 (41-171) months; of all 47, 34 (72%) remain in complete remission. Ten patients died from disease progression. The presence of residual malignant disease at the resection margin was significantly associated with poorer survival (hazard ratio 7.21, P = 0.0016). Prognostic factors, e.g. number of involved sites, IGCCC group and viable tumour in resected masses, were not significant. The 5-year overall and relapse-free survival (95% confidence interval) was 81 (69-93)% and 57 (43-71)%, respectively.

CONCLUSION

The optimal delivery and timing of chemotherapy and surgical resection by a specialist team of oncologists, urological and cardiothoracic surgeons is critical in treating poor-risk NSGCT and might be responsible for improving the outcome of these patients. The detection of residual malignant disease after chemotherapy by positron emission tomography should be investigated to identify those who might benefit from further systemic treatment before complete surgical resection.

Bilateral testicular cancer: a preventable problem? Experience from a large cancer centre

OBJECTIVE

To report a retrospective review of patients with a testicular germ cell tumour treated in a large cancer centre who developed a second tumour, as 1.8-5% of such patients will subsequently develop a new primary tumour in the contralateral testis.

PATIENTS AND METHODS

From a database of 570 men treated for testicular cancer in the West of Scotland between 1989 and 1998, all those who developed bilateral testicular tumours were identified.

RESULTS

Nineteen men (3.3%) developed a second primary testicular malignancy; the mean age at diagnosis of the first tumour was 29.5 years, with the mean (range) interval to diagnosis of the second tumour of 76 (11-181) months (except for one man with synchronous tumours). The first tumour was teratoma in 11 and seminoma in seven; one patient had synchronous bilateral teratoma. The second primary was teratoma in 10 and seminoma in eight. Known risk factors for carcinoma in situ were present in nine patients, i.e. a small atrophic contralateral testis in five, a family history of testicular cancer in two, a history of infertility in two and unilateral undescended testis in one. Two patients had had contralateral testicular biopsies at the first diagnosis; both were negative for intratubular germ cell neoplasia (IGCN). Eight patients had chemotherapy to treat the first tumour and 14 for the second. All underwent bilateral orchidectomy. Overall, 18 of 19 men are alive and disease-free, with a median follow-up of 51 months. Pathology for 12 of the second testicular tumours was available for review; there was no IGCN in any of the slides from three patients, it was only present focally around the tumour in seven, and was diffuse in two patients.

CONCLUSIONS

Chemotherapy for the first testicular tumour does not eliminate the risk of developing a contralateral tumour. Despite careful follow-up, in most patients the second primary tumour was not diagnosed early enough to avoid chemotherapy. The focal nature of IGCN in the second testis in most patients questions the value of biopsy of the contralateral testis. Improved methods of detecting patients at risk of second testicular tumours are needed.

A non-circadian role for cAMP signaling and CREB activity in Drosophila rest homeostasis

In the fruit fly, Drosophila melanogaster, rest shares features with mammalian sleep, including prolonged immobility, decreased sensory responsiveness and a homeostatic rebound after deprivation. To understand the molecular regulation of sleep-like rest, we investigated the involvement of a candidate gene, cAMP response-element binding protein (CREB). The duration of rest was inversely related to cAMP signaling and CREB activity. Acutely blocking CREB activity in transgenic flies did not affect the clock, but increased rest rebound. CREB mutants also had a prolonged and increased homeostatic rebound. In wild types, in vivo CREB activity increased after rest deprivation and remained elevated for a 72-hour recovery period. These data indicate that cAMP signaling has a non-circadian role in waking and rest homeostasis in Drosophila.

Shunting is a translation strategy used by plant pararetroviruses (Caulimoviridae)

In eukaryotes standard initiation of translation involved 40S ribosome scanning to bridge the distance from the cap to the initiation codon. Recently deviations from that rule had been described, including "internal initiation", "poly-A dependent translation", and "ribosome shunting". In ribosome shunting, ribosomes start scanning at the cap but large portions of the leader are skipped. Thereby the secondary structure of the shunted region is preserved. Scanning in plant caulimoviruses involve a small open reading frame properly spaced in front of a strong stem structure, and, in order to function, the small open reading frome has to be translated and the peptide released. This arrangement can be mimicked by artificial small open reading frames and stem structures. Shunting with viral and synthetic leaders occurs not only in plant-, but also in mammalian and yeast systems. Thus it responds to an intrinsic property of the eukaryotic translational machinery and probably acts in many cases where coding regions are preceded by complex leaders.

Improving the outcome of salvage treatment for non-seminomatous germ cell tumours (NSGCT)

Between 1991-96, 41 patients were treated in this unit for relapsed non-seminomatous germ cell tumours (NSGCT). Twenty-eight patients had raised markers at relapse: 17 required salvage chemotherapy and post-chemotherapy surgery, 11 only chemotherapy. In addition 9 patients received high dose chemotherapy. Overall 16/28 patients (57%) requiring chemotherapy remain alive, 14 (50%) disease free. Of the 17 patients treated with chemotherapy and surgery: 12 remain alive, 10 (59%) with no evaluable disease. Only 4/11 (36%) patients treated with chemotherapy alone remain alive, all in complete remission (CR). For relapse with raised markers, univariate analysis suggests that less than CR to induction therapy, resulting in the presence of residual disease is the most important predictor of poor outcome (P<0.001). All of the 13 patients relapsing with normal markers remain alive, having been primarily treated surgically. Overall these results indicate an improving outlook for relapsed NSGCT.

Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial

BACKGROUND

Many patients with upper gastrointestinal (GI) bleeding have a benign outcome and could receive less intensive and costly care if accurately identified. We sought to determine whether early endoscopy performed shortly after admission in the emergency department could significantly reduce the health care use and costs of caring for patients with nonvariceal upper GI bleeding without adversely affecting the clinical outcome.

METHODS

All eligible patients with upper GI bleeding and stable vital signs were randomized after admission to undergo endoscopy in 1 to 2 days (control) or early endoscopy in the emergency department. Patients with low-risk findings on early endoscopy were discharged directly from the emergency department. Clinical outcomes and costs were prospectively assessed for 30 days.

RESULTS

We randomized 110 consecutive stable patients with nonvariceal upper GI bleeding during the 12-month study period. The baseline demographic features, endoscopic findings, and the clinical outcomes were no different between the two groups. However the findings of the early endoscopy allowed us to immediately discharge 26 of 56 (46%) patients randomized to that group. No patient discharged from the emergency department suffered an adverse outcome. The hospital stay (median of 1 day [interquartile range of 0 to 3 days] vs. 2 days [interquartile range of 2 to 3 days], p = 0.0001) and the cost of care ($2068 [interquartile range of $928 to $3960] versus $3662 [interquartile range of $2473 to $7280], p = 0.00006) were significantly less for the early endoscopy group.

CONCLUSIONS

Early endoscopy performed shortly after admission in the emergency department safely triaged 46% of patients with nonvariceal upper GI bleeding to outpatient care, which significantly reduced hospital stay and costs.