Plasma Galectin-9 relates to cognitive performance and inflammation among adolescents with vertically acquired HIV

OBJECTIVE

Adolescents with perinatally-acquired HIV (AWH) are at an increased risk of poor cognitive development but the underlying mechanisms remain unclear. Circulating galectin-9 (Gal-9) has been associated with increased inflammation and multi-morbidity in adults with HIV despite anti-retroviral therapy (ART), however, relationship between Gal-9 in AWH and cognition remain unexplored.

DESIGN

A cross-sectional study of two independent age-matched cohorts from India [AWH on ART (n = 15), ART-naïve (n = 15), and adolescents without HIV (AWOH; n = 10)] and Myanmar [AWH on ART (n = 54) and AWOH (n = 22)] were studied. Adolescents from Myanmar underwent standardized cognitive tests.

METHODS

Plasma Gal-9 and soluble mediators were measured by immunoassays and cellular immune markers by flow cytometry. We used Mann-Whitney U tests to determine group-wise differences, Spearman's correlation for associations and machine learning (ML) to identify a classifier of cognitive status (impaired vs. unimpaired) built from clinical (age, sex, HIV status) and immunological markers.

RESULTS

Gal-9 levels were elevated in ART-treated AWH compared to AWOH in both cohorts (all p < 0.05). Higher Gal-9 in AWH correlated with increased levels of inflammatory mediators (sCD14, TNFα, MCP-1, IP-10, IL-10) and activated CD8 T cells (all p < 0.05). Irrespective of HIV status, higher Gal-9 levels correlated with lower cognitive test scores in multiple domains (verbal learning, visuospatial learning, memory, motor skills (all p < 0.05). ML classification identified Gal-9, CTLA-4, HVEM, and TIM-3 as significant predictors of cognitive deficits in adolescents (mean AUC = 0.837).

CONCLUSION

Our results highlight a potential role of Gal-9 as a biomarker of inflammation and cognitive health among adolescents with perinatally acquired HIV.

Pulmonary Lymphangioleiomyomatosis originates in the pleural mesothelial cell population

Lymphangioleiomyomatosis (LAM) is a cystic lung disease mainly affecting women, in which degradation of the lung parenchyma is associated with a cell of unknown provenance, known as a LAM cell. LAM cells carry TSC2 mutations and can be identified in the lung parenchyma by their expression of both smooth muscle actin and antigens characteristic of melanocytes and melanocytic tumors. The nature of the cell-of-origin of LAM is controversial, and despite continued research effort remains elusive. Further, it has not been possible to culture pulmonary LAM cells in vitro, and current research relies on cells and animal models which may not recapitulate all features of the disease. We noted aberrant expression of melanoma antigens in pleural mesothelial cells in lung tissue from LAM patients, indicating that these cells could be the precursors of parenchymal LAM cells. We hypothesise that loss of tuberin function following TSC2 mutation in the mesothelial cell lineage gives rise to the cell-of-origin of pulmonary LAM (P-LAM), and of other associated conditions commonly noted in LAM patients. The unique properties of mesothelial cells provide a straightforward explanation of the diverse presentation of LAM.

In vivo and in vitro immunogenicity of novel MHC class I presented epitopes to confer protective immunity against chronic HTLV-1 infection

Human T-cell leukemia virus type 1 (HTLV-1) has infected as many as 10 million people worldwide. While 90% are asymptomatic, 5% develop severe diseases including adult T-cell leukemia/lymphoka (ATLL) and HTLV-1-associated myelopathy/tropical spastic paraparesis (HAM/TSP). No vaccine against HTLV-1 exists, and screening programs are not universal. However, patients with chronic HTLV-1 infection have high frequencies of HTLV-1-activated CD8+ T cells, and the two main HLA alleles (A2, A24) are present in 88% of infected individuals. We thus utilized an immunoproteomics approach to characterize MHC-I restricted epitopes presented by HLA-A2+, A24+ MT-2 and SLB-1 cell lines. Unlike traditional motif prediction algorithms, this approach identifies epitopes associated with cytotoxic T-cell responses in their naturally processed forms, minimizing differences in antigen processing and protein expression levels. Out of nine identified peptides, we confirmed six novel MHC-I restricted epitopes that were capable of binding HLA-A2 and HLA-A24 alleles and used in vitro and in vivo methods to generate CD8+ T cells specific for each of these peptides. MagPix MILLIPLEX data showed that in vitro generated epitope-specific CD8+ T cells secreted IFN-ɣ, granzyme B, MIP-1α, TNF-α, perforin and IL-10 when cultured in the presence of MT-2 cell line. Degranulation assay confirmed cytotoxic response through surface expression of CD107 on CD8+ T cells when cultured with MT-2 cells. A CD8+ T-cell killing assay indicated significant antiviral activity of CD8+ T cells specific against all identified peptides. In vivo generated CD8+ T cells similarly demonstrated immunogenicity on ELISpot, CD107 degranulation assay, and MagPix MILLIPLEX analysis. These epitopes are thus candidates for a therapeutic peptide-based vaccine against HTLV-1, and our results provide preclinical data for the advancement of such a vaccine.

Gemcitabine enhances the efficacy of reovirus-based oncotherapy through anti-tumour immunological mechanisms

BACKGROUND

Reovirus preferentially infects and kills cancer cells and is currently undergoing clinical trials internationally. While oncolysis is the primary mode of tumour elimination, increasing evidence illustrates that reovirus additionally stimulates anti-tumour immunity with a capacity to target existing and possibly relapsing cancer cells. These virus-induced anti-tumour immune activities largely determine the efficacy of oncotherapy. On the other hand, anti-viral immune responses can negatively affect oncotherapy. Hence, the strategic management of anti-tumour and anti-viral immune responses through complementary therapeutics is crucial to achieve the maximum anti-cancer benefits of oncotherapy.

METHODS

Intra-peritoneal injection of mouse ovarian surface epithelial cells (ID8 cells) into wild-type C57BL/6 mice was treated with a therapeutic regimen of reovirus and/or gemcitabine and then analysed for prolonged survival, disease pathology, and various immunological parameters. Furthermore, in vitro analyses were conducted to assess apoptosis, viral spread, and viral production during reovirus and/or gemcitabine treatment.

RESULTS

We demonstrate that reovirus and gemcitabine combination treatment postpones peritoneal carcinomatosis development and prolongs the survival of cancer-bearing hosts. Importantly, these anti-cancer benefits are generated through various immunological mechanisms, including: (1) inhibition of myeloid-derived suppressor cells recruitment to the tumour microenvironment, (2) downmodulation of pro-MDSC factors, and (3) accelerated development of anti-tumour T-cell responses.

CONCLUSION

The complementation of reovirus with gemcitabine further potentiates virus-initiated anti-cancer immunity and enhances the efficacy of oncotherapy. In the context of ongoing clinical trials, our findings represent clinically relevant information capable of enhancing cancer outcomes.

Antibody and T cell responses in reciprocal prime-boost studies with full-length and truncated merozoite surface protein 1-42 vaccines

The P. falciparum Merozoite Surface Protein 1-42 (MSP1-42) is one of the most studied malaria subunit vaccine candidates. The N-terminal fragment of MSP1-42, MSP1-33, is primarily composed of allelic sequences, and has been shown to possess T helper epitopes that influence protective antibody responses toward the C-terminal region, MSP1-19. A truncated MSP1-42 vaccine, Construct 33-I, consisting of exclusively conserved T epitope regions of MSP1-33 expressed in tandem with MSP1-19, was previously shown to be a more effective immunogen than the full-length MSP1-42 vaccine. Here, by way of reciprocal priming/boosting immunization regimens, we studied the immunogenicity of Construct 33-I in the context of recognition by immune responses induced by the full-length native MSP1-42 protein, in order to gauge the effects of pre- and post-exposures to MSP1-42 on vaccine induced responses. Judging by immune responsiveness, antibody and T cell responses, Construct 33-I was effective as the priming antigen followed by full-length MSP1-42 boosting, as well as the boosting antigen following full-length MSP1-42 priming. In particular, Construct 33-I priming elicited the broadest responsiveness in immunized animals subsequently exposed to MSP1-42. Moreover, Construct 33-I, with its conserved MSP1-33 specific T cell epitopes, was equally well recognized by homologous and heterologous allelic forms of MSP1-42. Serum antibodies raised against Construct 33-I efficiently inhibited the growth of parasites carrying the heterologous MSP1-42 allele. These results suggest that Construct 33-I maintains and/or enhances its immunogenicity in an allelic or strain transcending fashion when deployed in populations having prior or subsequent exposures to native MSP1-42s.

CCR3 induced-p42/44 MAPK activation protects against staurosporine induced-DNA fragmentation but not apoptosis in airway smooth muscle cells

BACKGROUND

Chemokine receptors (CCRs) are expressed on airway smooth muscle (ASM) cells. As their ligands are present in the airways in asthma, we hypothesized that ASM CCR activation could promote the increase in ASM mass seen in patients with chronic asthma.

OBJECTIVE

To determine which CCRs are expressed by ASM cells and their potential functional relevance to the chronic airway changes seen in asthma.

METHODS

CCR expression in primary ASM cell cultures and airway biopsies from patients with and without asthma was examined by RT-PCR, fluorescence-activated cell sorting and immunohistochemistry. ASM p42/44 MAPK activity, proliferation, migration and apoptosis were examined by western blotting, thymidine incorporation, transwell assay and TUNEL assay respectively.

RESULTS

CCR3 was the most frequently expressed CCR protein and was present on 79 ± 14% of cells. CX3CR1 and CXCR6 were present on 6% and 11% of cells respectively. CCR3 ligands CCL11 and CCL24 caused rapid activation of p42/44 MAPK but not Akt. CCR3 activation did not affect ASM proliferation, migration or VEGF secretion. DNA fragmentation detected by TUNEL staining could be induced by staurosporine and Fas activation although only Fas activation resulted in caspase 3 cleavage. CCL11 and CCL24 protected ASM cells against DNA fragmentation dependent upon p42/44 MAPK activity only via caspase 3 independent pathways. CCR3 was expressed in the smooth muscle and epithelium in the airways of patients with and without asthma. Smooth muscle cell DNA fragmentation in the airways of patients with stable asthma and controls was very uncommon.

CONCLUSIONS AND CLINICAL RELEVANCE

CCR3 is strongly expressed by ASM cells in vitro and in vivo. Protection against cell death by CCR3 activation is dependent on p42/44 MAPK but does not affect caspase 3 mediated apoptosis.

Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience

INTRODUCTION

Perineal wound breakdown with delayed wound healing represents a significant cause of morbidity following surgery and radiotherapy to the perineum. The rectus abdominis myocutaneous (RAM) flap has been used increasingly to reconstruct the perineum with good effect. We describe our six-year experience of reconstruction of the perineum with the RAM flap and share some surgical adjuncts we believe are useful.

METHODS

We conducted a retrospective case note review of all patients who underwent a reconstruction of the perineum using the RAM flap between August 2003 and October 2009. Indications for the flap, complication rates and outcomes were all observed.

RESULTS

We conducted 16 RAM flap procedures, 15 of which (94%) were primary repairs and 1 (6%) a secondary repair. Three (19%) developed donor site hernias, two (12.5%) developed minor perineal wound infections, eight (50%) developed minor perineal wound breakdown and in one (6%) flap failure was observed. No perineal hernias were observed. There were no surgical mortalities.

CONCLUSIONS

The RAM flap has a high success rate and an acceptable morbidity rate and is a useful tool in the reconstruction of complex perineal wounds. Modifications to the standard surgical technique may reduce complications and improve the versatility of this flap.

Short-term outcomes with intrathecal versus epidural analgesia in laparoscopic colorectal surgery

BACKGROUND

Epidural analgesia is the mainstay of perioperative pain management in enhanced recovery programmes. This study compared short-term outcomes following epidural or intrathecal analgesia in patients undergoing elective laparoscopic colorectal surgery.

METHODS

A single-centre observational study was carried out in 175 consecutive patients who had elective laparoscopic colorectal surgery for benign or malignant disease within an enhanced recovery programme. Seventy-six patients received epidural analgesia and 99 had a single injection of intrathecal analgesia to provide perioperative pain control.

RESULTS

Patients who had intrathecal analgesia had a reduced median postoperative pain score compared with those receiving epidural analgesia (0 versus 3.5; P < 0.001), an earlier return to mobility (1 versus 4 days; P < 0.001) and a shorter hospital stay (4 versus 5 days; P < 0.001). Return to normal gut function and postoperative nausea and vomiting were similar in the two groups.

CONCLUSION

Intrathecal analgesia may have advantages over epidural analgesia in patients undergoing laparoscopic colorectal surgery.

Management of the asymptomatic primary in the palliative treatment of metastatic colorectal cancer

OBJECTIVE

The management of the asymptomatic primary in stage IV colorectal cancer presents a dilemma. There is an increased morbidity and mortality from surgical resection. Nonresectional management of the primary is associated with the risks of obstruction, perforation or haemorrhage. Our practice in patients with stage IV disease is palliative chemotherapy and symptom control. We reviewed our nonoperatively managed patients with colorectal liver metastases in order to identify the percentage of patients requiring urgent operative interventions for symptoms related to the primary. SUBJECTS/PATIENTS AND METHOD: A retrospective review of all patients treated for stage IV disease at our institution from 2003-2006 was undertaken. Patients were identified from multidisciplinary team (MDT) records. Demographic detail, treatment, and follow-up data were extracted from hospital records. These were analysed with Microsoft Excel.

RESULTS

Thirty-seven patients were identified. 26 Male:11 Female. Median age 63 years (range 38-78). The median survival from diagnosis was 14 months. Three (8%) patients developed obstruction whilst having palliative chemotherapy. Two required a defunctioning stoma, and one was treated by means of a stent. There were no similarities between these three patients in terms of age, sex, site or stage of primary, volume of liver metastases, and alkaline phosphatase (ALP) or carcinoembryonic antigen (CEA) levels.

CONCLUSION

Of 37 patients initially treated palliatively for stage IV colorectal cancer, 92% required no surgical treatment of their primary. Therefore it is the experience of this MDT that it is acceptable to treat such patients in an expectant manner. It is not possible to predict those patients, likely to require surgical intervention.

Application of the BSG guidelines to a colonoscopy waiting list

Abstract Objective Currently priority for colonoscopy is given to diagnostic and therapeutic procedures. Surveillance colonoscopies place a significant demand on the service. These are held on a separate waiting list in our institution, which is currently several years behind. The purpose of this study was to apply the BSG guidelines to this waiting list in our institution in order to ascertain whether patients are appropriately listed. Method This was a retrospective review. The patients on the waiting list whose procedures were due in 2004 and 2005 formed the study group. Information on demographics, previous colonoscopies, and indication was taken from the case notes. Results were analysed using Microsoft Excel. Results A total of 172 patients were overdue their colonoscopies. If the BSG guidelines were strictly adhered to, 49% of these patients were inappropriately listed. If applied less rigidly, 42% of patients should not have been on the list. The reasons for removal from the list were as follows: Thirty-nine patients were older than the upper age limit, 23 had had clear colonoscopies after adenomatous polyp follow up, four were listed for diverticular disease follow up, four for metaplastic polyps, one for constipation and one for per rectum (PR) bleed follow up. Conclusion With strict application of the BSG guidelines to a surveillance colonoscopy waiting list, 49% of the patients on the list do not need the procedure. It is recommended that consultant led education and control of the waiting list be used to reduce unnecessary investigations.

Determining the spatial distribution of viable and nonviable bacteria in hydrated microcosm dental plaques by viability profiling

AIMS

The aim of this study was to use confocal laser scanning microscopy (CLSM) to examine the spatial distribution of both viable and nonviable bacteria within microcosm dental plaques grown in vitro. Previous in vivo studies have reported upon the distribution of viable bacteria only.

METHODS AND RESULTS

Oral biofilms were grown on hydroxyapatite (HA) discs in a constant-depth film fermenter (CDFF) from a saliva inoculum. The biofilms were stained with the BacLight LIVE/DEAD system and examined by CLSM. Fluorescence intensity profiles through the depth of the biofilm showed an offset between the maximum viable intensity and the maximum nonviable intensity. Topographical differences between the surface properties of the viable and nonviable biofilm virtual surfaces were also measured.

CONCLUSIONS

The profile of fluorescence intensity from viable and nonviable staining suggested that the upper layers of the biofilm contain proportionally more viable bacteria than the lower regions of the biofilm.

SIGNIFICANCE AND IMPACT OF STUDY

Viability profiling records the transition from predominantly viable to nonviable bacteria through biofilms suggesting that this technique may be of use for quantifying the effects of antimicrobial compounds upon biofilms. The distribution of viable bacteria was similar to that found in dental plaque in vivo suggesting that the CDFF produces in vitro biofilms which are comparable to their in vivo counterparts in terms of the spatial distribution of viable bacteria.

Delayed post-traumatic osteonecrosis of a vertebral body (Kummell's disease)

Kummell's disease is a rare spinal disorder characterized as avascular necrosis of a vertebral body occurring in a delayed fashion after minor trauma. The disease derives its name from the German surgeon Hermann Kummell, who described a series of patients with the disorder in 1895. Kummell's disease is distinguished from typical osteoporotic compression fractures, by virtue of the fact that patients with Kummell's disease develop symptoms in delayed fashion. In addition, Kummell's disease exhibits different signal characteristics on magnetic resonance imaging when compared to osteoporotic compression fractures. In this review we discuss the pathophysiology, histopathology and treatment of this interesting disorder.

Initiation and early patterning of the endoderm

We review the early stages of endoderm formation in the major animal models. In Amphibia maternal molecules are important in initiating endoderm formation. This is followed by successive signaling events that establish and then pattern the endoderm. In other organisms there are differences in endodermal development, particularly in the initial, prephylotypic stages. Later many of the same key families of transcription factors and signaling cassettes are used in all animals, but more work will be needed to establish exact evolutionary homologies.

Changes in embryonic cell fate produced by expression of an endodermal transcription factor, Xsox17

Many molecules induce the ectopic expression of tissue-specific genes in Xenopus embryos. Conversely, interfering with their activity disrupts patterns of gene expression, implicating them in normal development. Does this mean that they control cell fate (i.e. position, as well as differentiation)? Xsox17alpha and beta can induce ectopic expression of endodermal markers; inhibiting their function suppresses expression of endodermal marker genes in the developing gut (Cell 91 (1997) 397). Here we show the effect of these manipulations on cell lineage. Expressing Xsox17 in a cells normally fated to become ectoderm causes their descendants either to relocate into the embryonic gut or to die at a late developmental stage. Conversely, disrupting Xsox17 activity in cells normally fated to be endodermal causes them to enter mesodermal and ectodermal lineages.

Interference of antibody production to hepatitis B surface antigen in a combination hepatitis A/hepatitis B vaccine

A randomized trial comparing 3 manufacturing consistency lots of a combination hepatitis A/hepatitis B vaccine to each other and to hepatitis A vaccine and hepatitis B vaccine given separately and concurrently was done to evaluate safety, tolerability, and immunogenicity. Healthy volunteers >/=11 years of age were divided into 4 groups. Each of 3 groups received a separate consistency lot of the combination vaccine, and 1 group received separate but concurrent injections of hepatitis A and hepatitis B vaccines. Injections were given at weeks 0 and 24. The combination vaccine was generally well tolerated. The hepatitis A portion of the combination vaccine produced clinically acceptable high seropositivity rates 4 and 52 weeks after the first injection. The hepatitis B portion of the vaccine did not produce clinically acceptable seropositivity rates 4 weeks after the second injection. Lack of antibody production may be attributed, at least in part, to immunologic interference.

Mode of action of VegT in mesoderm and endoderm formation

mRNA encoding the T-box transcription factor VegT is located throughout the vegetal pole of the Xenopus egg and is believed to play an important part in endoderm and mesoderm formation. We find that VegT generates endoderm both by cell-autonomous action and by generating TGF-beta family signals, the latter being entirely responsible for its mesoderm-inducing activity. Signalling molecules induced cell-autonomously by VegT include derriere, Xnr4 and activin B. Xnr1 and Xnr2 are also induced, but primarily in a non-autonomous manner. All of these signalling molecules are found in the blastula and gastrula vegetal pole and induce both endoderm and mesoderm in the animal cap assay, and hence are good candidates both for the endogenous zygotic mesoderm-inducing signal and for reinforcing the vegetal expression of endoderm markers.

Biomarkers of oxidative stress are significantly elevated in Down syndrome

There is convincing epidemiological and in vitro evidence of chronic oxidative stress in individuals with Down syndrome (DS). These individuals develop Alzheimer like changes in the brain in their 30s and 40s. The incidence of autoimmune diseases and cataracts is significantly increased, and the overall ageing process is accelerated. In vitro studies show that impaired viability of DS neurons may be amended by simple chemical antioxidants, such as vitamin E, BHT and propyl gallate, clearly indicative of oxyl radical involvement. However, because of the lack of in vivo experiments, the role of oxidative stress in DS remains controversial. We report here on the results of the chemical analyses of urine samples of 166 individuals, where DS subjects were matched by their siblings. The levels of 8-hydroxy-2'-deoxyguanosine (2.35 +/- 1.69 in DS vs. 1.35 +/- 1.04 in controls, P = 0.00011), a biomarker of oxidative damage to DNA, and malondialdehyde (0.255 +/- 0.158 in DS vs. 0.204 +/- 0.128 in controls, P = 0.033), a biomarker of lipid peroxidation, are significantly elevated in individuals with DS. Dietary influences failed to show any significant correlation with the oxidative stress biomarkers. These results provide direct evidence for increased oxidative stress in individuals with DS.

Xsox17alpha and -beta mediate endoderm formation in Xenopus

We have isolated two Xenopus relatives of murine Sox17 expressed in gastrula presumptive endoderm. Xsox17alpha and -beta expression can be induced in animal caps by activin, but not by FGF. Ectopic expression of these genes in animal caps induces the expression of endoderm markers; this induction is blocked by overexpression of a fusion of the Xsox17beta HMG domain to the Drosophila Engrailed repressor domain, as is induction of endoderm markers by activin and the expression of endodermal markers in whole embryos and isolated vegetal poles. These experiments, as well as the effects of the mRNAs on embryo phenotypes, suggest that the Xsox17 genes mediate an activin-induced endoderm differentiation pathway in animal caps and are involved in normal endoderm differentiation in embryos.

Semirigid instrumentation in the management of lumbar spinal conditions combined with circumferential fusion. A multicenter study

STUDY DESIGN

Patients with the diagnosis of degenerative disc conditions or spondylolisthesis undergoing circumferential fusion with posterior pedicle screw fixation using a semirigid rod were reviewed.

OBJECTIVES

To determine the effectiveness of this approach in achieving a spinal fusion and satisfactory clinical outcome, and to determine the complications associated with the procedure.

SUMMARY OF BACKGROUND DATA

The use of instrumentation to stabilize the lumbar motion segments and thereby enhance the fusion rate has been proposed in a number of studies. Semirigid fixation was believed to be effective in achieving these objectives without concern for stress-shielding, which was suggested by some authors using rigid fixation systems.

METHODS

Patients who required spinal fusion with anterior and posterior approaches because of specific lumbar pathology or previous surgeries were selected. The surgery consisted of an anterior interbody fusion using allograft, followed by a posterolateral fusion and pedicle screw fixation. Fusion was determined by continuity of trabecular bridging, and outcomes were determined by pain reduction and return to previous levels of activity. Fusion was considered solid if the two posterolateral areas were fused (Zones one and two), if the anterior interbody area was fused (Zone three), or if all three zones were fused. Complications were documented during and after surgery.

RESULTS

Sixty-two percent of patients had previous surgery with 25% of these patients having a diagnosis of pseudarthrosis. Fifty-five percent of patients had two or more levels fused, and 43% were heavy smokers. Ninety-seven percent of patients had successful fusions. Pain was significantly reduced on a pain analogue scale from 7.1 to 2.1 in the back and from 5.8 to 1.5 in the leg (p < 0.006 and 0.0001, respectively). Fifty-nine percent of patients returned to their previous level of activity, and 18% returned to lighter work or job retraining, for a total of 77% returning to the same or lighter levels of activity. Complications included metal failure, 4.9%; neurologic deficit, 1.2%; deep infection, 1.2%; deep venous thrombosis, 4.9%; and vascular injury, 2.4%. Fatal pulmonary embolus occurred in one patient.

CONCLUSION

This technique produces a satisfactory fusion rate (97%) and a good clinical outcome based on pain reduction and return to a satisfactory level of activity (77%). It is associated with few, but significant, complications that compare well with other reported series in a difficult group of patients. This procedure should be reserved for patients who are considered to be at high risk for not achieving spinal fusion.

Distinct regulatory control of the Brachyury gene in axial and non-axial mesoderm suggests separation of mesoderm lineages early in mouse gastrulation

Brachyury is required for the normal extension of the anteroposterior axis during mouse embryogenesis. A transgene comprising sequences from -500 to +150 relative to the start of Brachyury transcription, and the reporter gene lacZ, recapitulates some, but not all elements of Brachyury expression. Beta-Galactosidase expression is seen in the primitive streak from 6.5 d.p.c. but there is no detectable reporter expression in the node or notochord. Thus, the regulatory sequences required for the expression of Brachyury in the cells traversing the primitive streak are distinct from those required for the initiation of expression in the node. This suggests that different or additional signals are involved in activation of Brachyury in the node and notochord than those inducing Brachyury in the primitive streak. Additionally, the data suggest the possibility that axial and non-axial mesoderm are distinct from the earliest stages of Brachyury expression.

Safety and cellular and humoral immune responses of a booster dose of varicella vaccine 6 years after primary immunization

Four hundred nineteen children and adolescents immunized with live varicella vaccine 4-6 years earlier were enrolled in a study to evaluate the safety and immune response to a booster dose containing approximately 3300 pfu of virus. Of the subjects, 99% (414/419) maintained antibody to varicella zoster virus (VZV) with a geometric mean titer of 25.7 and mean stimulation index (SI) for VZV-specific lymphoproliferation response of 40.3 +/- 5.3 (SE). Some 7-10 days after the booster immunization, seropositivity rates increased to 100% (302/302), and GMT was 143.6 (anamnestic response). At 6 weeks after the booster inoculation, a subset of subjects had 100% seropositivity (74/74) with a GMT of 218.8 and an SI of 58.6. After 3 months, seropositivity was 100% (358/358), GMT was 119.0, and SI was 61.4.

Audit of coding in gastrointestinal endoscopy

The accuracy of the coding of gastrointestinal endoscopic procedures at Llandough Hospital was audited over 12 months. Although the endoscopy unit kept its own records, none of the staff were initially aware of the coding system used for endoscopic procedures for subsequent hospital activity analysis. Conventional typed discharge summaries were usually inadequate for coding purposes, and there was considerable variation in the proportion of procedures coded. Changes made to improve the accuracy and completeness of coding for endoscopic procedures were seen to be effective in a follow-up study.

Bone loss in normal British women; a 5 year follow-up

To assess the rates of loss, forearm and spinal bone mineral were remeasured in 16 out of 18 peri- and post-menopausal women aged 45 to 60 years who had taken part in a previously reported cross-sectional study. The mean interval between measurements was 4.8 years (range 4.2-5.3 years). The mean (95% confidence interval (CI)) annual change in radial bone mineral density was -0.78%/year (-1.73 to +0.18%; not significant) and in spinal bone mineral -2.41%/year (-3.55 to 1.27%; p < 0.001). There was considerable variation in the rate of change in radius and spine, and between individuals. There was no significant correlation between rates of bone loss at either site, or between rates of loss and the initial bone density at either the radius or spine. There was no significant correlation between the rates of change and the age or number of years post-menopause of the women. There was no significant change in the Z score for the forearm (mean -0.20; 95% CI -0.65 to +0.25) or for the spine (mean -0.04; 95% CI -0.30 to +0.22). There have been no previous longitudinal studies of the changes of bone density in normal British women. These results show considerable variation between individuals, and rates of change at one site cannot be predicted from measurements at another site. Untreated, some normal individuals have high rates of loss that cannot be predicted from baseline values, age or number of years post-menopause.

Hormone replacement therapy prevents bone loss in patients with inflammatory bowel disease

Patients with inflammatory bowel disease have an increased prevalence of osteoporosis, and suffer high rates of spinal bone loss. Hormone replacement therapy (HRT) is effective in the treatment and prevention of osteoporosis but has not been studied in patients with inflammatory bowel disease. A two year prospective study of HRT in inflammatory bowel disease was performed in 47 postmenopausal women aged 44 to 67 years with ulcerative colitis (25) or Crohn's disease (22). Patients had radial and spinal bone density measured annually by single photon absorptiometry and quantitative computed tomography respectively. The mean (95% confidence intervals) annual change in radial bone density was +1.42%/yr (+0.58 to +2.26; P < 0.005) and for spinal bone +2.60%/yr (+1.06 to +4.15; p < 0.005). There was no significant correlation between rates of change of bone density at the two sites, or between the rates of change and the initial bone density either in the radius or spine. Twelve patients were given prednisolone during the study, and their rates of change for spinal bone density were lower, but values were not statistically significantly different from those who did not receive corticosteroids. Changes in bone density for patients with ulcerative colitis and Crohn's disease were not significantly different. The change in bone density did not correlate with the patients' age or number of years after the menopause. It is concluded that HRT is effective in prevention of bone loss in postmenopausal women with inflammatory bowel disease.

A four-year longitudinal study of bone loss in patients with inflammatory bowel disease

Serial measurements of spinal trabecular and radial cortical bone density were made over 4 years in 70 patients with inflammatory bowel disease. Mean rates of bone loss for the cohort differed little from rates reported in normal populations; however, some patients showed increased rates of loss, including patients whose bone density at entry to the study was already well below normal. There was a significant correlation between the amount of corticosteroid prescribed and spinal trabecular bone loss in males, but no significant correlation with other clinical parameters. Increased rates of bone loss emphasise the need for bone densitometry and prophylactic measures in patients with inflammatory bowel disease.

Hormone replacement therapy in chronic active hepatitis; a case report

There is an increased incidence of osteoporosis in patients with chronic liver disease. Because patients with chronic active hepatitis (CAH) usually require corticosteroids for their liver disease prevention and treatment of bone loss presents a difficult problem. This case report describes a 41 year old female patient with CAH who had a high rate of bone loss. After an early menopause with noticeable menopausal symptoms, she was given transdermal oestrogen replacement therapy. The menopausal symptoms resolved completely, and there was no deterioration in her liver function tests or corticosteroid requirement. In addition, follow up quantitative bone mineral measurements over two years have shown improvement. This case shows the value of measurements of bone density, and oestrogen replacement therapy in CAH, even in the presence of continued corticosteroids.

Longitudinal study of cortical bone loss in patients with inflammatory bowel disease

Bone mineral density of the radius was measured by single-photon absorptiometry in 50 patients with inflammatory bowel disease. Thirty-three had Crohn's disease and 17 ulcerative colitis; 25 were women. The mean age was 45 years (range, 18-70 years). Measurements were repeated in 39 of them after a mean follow-up period of 7.9 years (range, 7.1-8.2 years). In female patients the mean (95% confidence interval) annual change in radial bone mineral density was -0.74% (-1.34% to -0.14%) (P = 0.022), the greatest bone loss occurring in postmenopausal women (mean, -1.16% (-2.01% to -0.30%)). In male patients the mean annual rate of bone loss was -0.07% (-0.41% to 0.28%) (P = NS). Patients with abnormally low values at the first measurement remained osteopenic at the second measurement, whilst some others with normal values initially showed increased rates of bone loss and had a subnormal bone mineral density after the follow-up period. These results show increased rates of cortical bone loss in some patients with inflammatory bowel disease and emphasize the need to monitor bone mass in these patients so that prophylactic measures can be instituted.

An improved 'interim discharge letter' a successful outcome from audit

General practitioners were dissatisfied with this hospital's interim discharge letters. These were unstructured letters written by house officers shortly after the patient's discharge. A copy of the list of drugs prescribed on discharge was sent separately. After discussing the various needs with general practitioners a new form of discharge letter has been successfully introduced. The layout has been further modified in the light of feedback, and details of the new letter are presented. The new form has been well received by hospital staff and general practitioners. The paperwork for junior doctors has been reduced by the inclusion of the prescription in the discharge letter.