A census of general surgery consultants in England and Wales: implications for the current and future surgical workforce

INTRODUCTION

This study aimed to describe the composition of the current general surgical consultant body in England and Wales and quantify levels of inequality within it as well as describe future workforce challenges.

METHODS

This is an observational study of all general surgical departments in England and Wales. Consultant general surgeons were identified and data regarding their gender, country of undergraduate medical education, subspecialty and private practice were recorded.

RESULTS

Of the 2,682 consultant general surgeons in England and Wales identified for this study, just 17% are women, with gender inequality most marked in university teaching hospitals and among certain subspecialties. Almost 40% of consultants did not obtain their primary undergraduate degree in the United Kingdom and there are considerably fewer surgeons who studied abroad in university teaching hospitals. Over 40% of current general surgical consultants have been qualified for more than three decades and there is no equivalent sized group of younger consultants.

CONCLUSIONS

There remains considerable gender and racial inequality in the consultant general surgical workforce, with pockets of a lack of diversity within university or teaching hospital surgical departments and some subspecialties. The proportion of surgeons in their fourth decade of clinical practice represents the largest group of current practising consultants, which points towards an impending workforce crisis should senior clinicians seek to reduce activity or consider taking early retirement.

Differences in molecular sensitization profiles between a Spanish and Latin American mite allergic patients

BACKGROUND AND OBJECTIVE

To analyze the sensitization pattern to Dermatophagoides pteronyssinus and to associate the diagnostic findings and clinical severity in 218 allergic patients from two different continents.

METHODS

Mite allergic patients were recruited by the Allergology departments from Latin America (n=88: Colombia, Costa Rica and Guatemala) and Spain (N=130). All patients had allergic rhinitis with or without asthma and positive skin prick test results to D. pteronyssinus. Specific IgE levels to D. pteronyssinus, D. farinae, Der p 1, Der p 2, and Der p 23 were quantified by ImmunoCAP system (ThermoFisher Scientific). Allergenic profile was also determined by western blot. Comparative Statistical analysis was performed by GraphPad software.

RESULTS

Patients recognized most frequently Der p 2 (79%) followed by Der p 1 (73%), and Der p 23 (69%) allergens. The percentage of asthmatic patients increases with the number of sensitizations however none statistically significant differences were found. Interestingly, asthmatic patients presented the highest median levels of total IgE and specific IgE levels of D. pteronyssinus and molecular allergens, mainly Der p 2. Analysing the two different populations, Spanish patients were predominantly sensitized to Der p 2 (88.46%) and Der p 1 (83.84%), whereas Latin American population were more sensitized to Der p 23.

CONCLUSION

Our data support the relevance of Der p 2 in mite allergy as the major allergen, with the high number of patients sensitized to it and its importance in the development of asthma. Sensitization to Der p 23 was more important in Latin America.

132 Improving the Long Term Follow Up of Bisphosphonates in the Community

Aim

Bisphosphonates are generally first line treatment for osteoporosis in primary care. However, long term bisphosphonate use has been associated with atypical femoral fractures. Therefore, it is recommended that bisphosphonates are reviewed every 3–5 years. This study set out to assess and improve the long term follow up of bisphosphonates in a GP practice in Leeds.

Method

System One was searched to identify patients prescribed alendronic acid or risedronate in January and February of 2021 from Aire Valley Surgery, a GP practice in Leeds. These patient’s notes were then used to see if they had planned bisphosphate follow up and if this was via a script note, scheduled task, or recall. In March of 2021 a teaching session on osteoporosis and bisphosphonates was delivered to GPs working at the practice. GPs were also asked to make sure that they planned follow up when prescribing bisphosphonates via a script note. System One was searched again to identify patients prescribed alendronic acid or risedronate in April and May of 2021.

Results

Prior to the teaching session 47.9% of patients had planned follow up with 56.4% via script note, 16.4% via scheduled task and 27.3% via recall. Following the teaching session 48.4% of patients had planned follow up with 73.1% via script note, 13.5% via scheduled task and 13.5% via recall.

Conclusions

This study has identified a group of patients who are taking oral bisphosphonates in the community without planned follow up and are therefore more likely to sustain an atypical femoral fracture.

149 Non-Pharmacological Treatment of Bone Health in Fallers

Introduction

1 in 2 women and 1 in 5 men will suffer a fragility fracture. Research into calcium and vitamin D supplements has found no consistent evidence to suggest that they reduce the risk of osteoporotic fractures. There has been little research to suggest that dietary calcium is effective at reducing the risk osteoporotic fractures, but supplements have been linked to increased risk of cardiovascular disease and urinary stones. Bisphosphonates have been shown to reduce the risk of osteoporotic fractures and are usually taken in combination with calcium and vitamin D supplements given that deficiencies must be corrected prior to starting. This study set out to assess the dietary calcium intake of patients who attend the falls clinic and explore their attitudes towards dietary change, as an alternative or adjunct to a calcium and vitamin D tablet.

Methods

Data was collected during private interviews conducted with patients who attended the falls clinic. The Edinburgh University Centre for Genomic and Experimental research (CGEM) food frequency calculator was used to calculate dietary calcium intake. Microsoft Excel was used to collate and analyse the data.

Results

No association was found between dietary calcium intake, age and sex. We did find that mean dietary calcium intake was significantly less than the recommended daily amount for adults with osteoporosis, with 80% not getting their recommended daily intake (p < 0.05). We identified patients who don’t receive a calcium and vitamin D supplement as an at-risk group who would benefit from advice on sources of dietary calcium and 83% of patients said that they would be interested in a leaflet on sources of dietary calcium.

Conclusion

This study has identified a group of patients who will hopefully benefit from a leaflet on sources of dietary calcium and as result improve their bone health.

1115 Sleep Misperception, Anxiety, And Sleep Quality

Introduction

Sleep misperception is a phenomenon often identified in insomnia literature, in which individuals subjective reporting does not match objective measurements of their own sleep. Research indicates that anxiety symptoms may play a role in sleep misperception. This study assessed the relationship between sleep misperception, sleep quality, and anxiety in a young adult population with sub-clinical insomnia and anxiety symptoms. Linear regression models examined the relationships between sleep quality, anxiety symptoms, and sleep misperception.

Methods

This sample consisted of 130 young adults recruited from a University in the Bronx, NY. Anxiety was assessed using the Beck Anxiety Inventory (BAI), and sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). Objective measures of sleep were collected via wrist-based actigraphy over a period of 7-14 days. Subjective sleep measures were collected via an online sleep diary. A misperception index was calculated to determine the discrepancy between subjective and objective sleep measures based on a formula established in previous research.

Results

Higher anxiety symptoms were associated with greater sleep disturbance. Higher sleep misperception was not associated with greater sleep disturbance. There was a significant, positive relationship between sleep misperception and anxiety symptoms (r=0.18, p=0.000). Gender emerged as an important covariate, with males exhibiting significantly higher sleep misperception and underestimating TST (M=-0.31, SD=0.22) compared to females (M=-0.18, SD=0.12).

Conclusion

Sleep misperception was not related to sleep quality, but was strongly related to anxiety symptoms in this population. In a sub-clinical young adult sample, sleep misperception is associated with anxiety but not sleep quality, and has significant gender differences. These findings contribute to sleep misperception literature with potential applications in diagnosis and treatment of insomnia and anxiety.

Support

n/a

Risk factors associated with the development of active tuberculosis among patients with advanced chronic kidney disease

OBJECTIVES

The risk of developing active TB is greater in those receiving haemodialysis. This study aimed to describe the incidence of active tuberculosis among patients referred for management of kidney disease and dialysis in a high incidence UK city, with the purpose of informing latent TB testing and treatment practice.

METHODS

Information from the tuberculosis register was cross-referenced with the Department of Renal Medicine patient information system. All patients seen between 1st January 2005 and 1st October 2016 were included in the analyses with the exception of those with prior TB.

RESULTS

68 cases of active TB were identified, an incidence of 126/100,000 patient-years (95% CI 97-169). Incidence was lowest in those with CKD 1 or 2 and rose as high as 256/100,000 patient-years (95% CI 183-374) in those receiving renal replacement therapy. 48% of cases were pulmonary and 87% of TB patients gave their ethnicity as either black/black British or Asian/Asian British, significantly more than in the non-TB renal group. Cases occurred steadily over the time period in which patients were in the cohort.

CONCLUSION

TB incidence was very high among those receiving renal replacement therapy or CKD 4 or 5. Most cases occurred in those of an Asian/Asian British or black/black British background. Testing and treating such patients for latent TB is justified and should include those who have been receiving renal replacement therapy for some years.

Sophisticated Clean Air Strategies Required to Mitigate Against Particulate Organic Pollution

Since the 1980's, measures mitigating the impact of transboundary air pollution have been implemented successfully as evidenced in the 1980-2014 record of atmospheric sulphur pollution over the NE-Atlantic, a key region for monitoring background northern-hemisphere pollution levels. The record reveals a 72-79% reduction in annual-average airborne sulphur pollution (SO4 and SO2, respectively) over the 35-year period. The NE-Atlantic, as observed from the Mace Head research station on the Irish coast, can be considered clean for 64% of the time during which sulphate dominates PM1 levels, contributing 42% of the mass, and for the remainder of the time, under polluted conditions, a carbonaceous (organic matter and Black Carbon) aerosol prevails, contributing 60% to 90% of the PM1 mass and exhibiting a trend whereby its contribution increases with increasing pollution levels. The carbonaceous aerosol is known to be diverse in source and nature and requires sophisticated air pollution policies underpinned by sophisticated characterisation and source apportionment capabilities to inform selective emissions-reduction strategies. Inauspiciously, however, this carbonaceous concoction is not measured in regulatory Air Quality networks.

Prolactin and hostility in hospitalised patients and healthy women: A systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to assess any difference in the self-ratings of hostility in mentally healthy women with different levels of prolactin (PRL). Electronic databases (PubMed, MEDLINE, EMBASE and the Cochrane Library) were searched up to 2nd July 2012 for published literature comparing hostility levels in women with different levels of PRL. Keyword pairs ('prolactin' and 'aggression', 'prolactin' and 'hostil*', 'prolactin' and 'anger', and 'prolactin' and 'angry') were entered simultaneously. From 1065 resulting titles, and one unpublished study, 214 articles underwent full-text review by authors JB and EM. Studies were selected based on clinical relevance. Eight comparative studies consisting of 242 female patients with high PRL levels, 207 female patients with normal PRL levels and 127 healthy controls with normal PRL levels were included. Data were analysed using the inverse variance method with a random-effects model. Analysis revealed significantly higher hostility in patients with high PRL compared with that in healthy control women (Z = 1.94, p < 0.05; Hedges' g = 0.72; 95% confidence interval [CI]: -0.01-1.45), significantly higher hostility in patient controls compared with that in healthy controls (Z = 1.94, p < 0.05; Hedges' g = 0.47; 95% CI: 0.00-0.94) and non-significantly higher hostility levels in patients with high PRL compared with that in patients with normal PRL levels (Z = 1.45, p < 0.15; Hedges' g = 0.38; 95% CI: -0.13-0.89). In this meta-analysis, hostility appears to be accounted for partly by PRL levels and also partly by patient status, perhaps due to the stress of being a patient. Methodological considerations and implications for patient care are discussed.

The changing face of multiple sclerosis: Prevalence and incidence in an aging population

Objective:

To assess multiple sclerosis (MS) incidence from 1998 to 2007, and MS prevalence on 31 December 2007, in the province of Genoa, Italy.

Methods:

We identified MS cases diagnosed before 31 December 2007 by analyzing archives of hospitals with neurological or rehabilitation wards, the local Italian MS society, family doctor records and requests for oligoclonal band analysis on cerebrospinal fluid (CSF).

Results:

A total of 1312 MS patients were residing in the province of Genoa on the prevalence day; 431 (32.85%) were men and 881 (67.15%) were women; mean age was 50.6 (± 13.9). The overall crude MS prevalence rate was 148.5/100,000; 103.1/100,000 in men and 189.1/100,000 in women. The crude mean annual MS incidence rate was 6.6 cases/100,000 (4.4/100,000 men; 8.6/100,000 women). Mean age at diagnosis was 39.5 ± 12.3 (men: 39.9 ± 13.0; women: 39.3 ± 11.9). A mean annual incidence of 4 MS patients ≥ 60 was observed.

Conclusions:

We observed an increased MS prevalence in the province of Genoa, compared to 1997. The mean age at diagnosis was relatively high (39 years old), 18% of our MS patients were over 65, and a notable incidence increase was seen in patients over 60. This has important implications, in terms of the need to organize the health system to better serve elderly MS patients, especially considering comorbidities and different medical needs of elderly MS patients; and to increase awareness within the medical community about the increasing risk of newly-presenting MS in the older population.

Prolactin and aggression in women with fertility problems

This study tested the hypothesis that women with higher prolactin feel more hostility, anger and aggression. A total of 66 women with moderate fertility problems were grouped into the 50% who had the highest and the 50% who had the lowest levels of prolactin. Levels of hostility, aggression and anger were compared. Women with higher prolactin levels did not report significantly increased hostility. After Bonferroni correction, women with lower prolactin showed non-significantly increased scores on two measures of state anger, and on a measure of trait temper. When comparing those with the highest and lowest 20% of prolactin levels, those with lower prolactin had non-significantly higher scores on trait temper and outward expression of anger, and non-significantly lower scores for control of anger. Although non-significant, these findings run counter to those of earlier studies on this topic. Implications for future research and patient care are discussed.

Endoscopic full-thickness biopsy of the gastric wall with defect closure by using an endoscopic suturing device: survival porcine study

BACKGROUND

The pathogenesis of several common gastric motility diseases and functional GI disorders remains essentially unexplained. Gastric wall biopsies that include the muscularis propria to evaluate the enteric nervous system, interstitial cells of Cajal, and immune cells can provide important insights for our understanding of the etiology of these disorders.

OBJECTIVES

To determine the technical feasibility, reproducibility, and safety of performing a full-thickness gastric biopsy (FTGB) by using a submucosal endoscopy with mucosal flap (SEMF) technique; the technical feasibility, reproducibility, and safety of tissue closure by using an endoscopic suturing device; the ability to identify myenteric ganglia in resected specimens; and the long-term safety.

DESIGN

Single center, preclinical survival study.

SETTING

Animal research laboratory, developmental endoscopy unit.

SUBJECTS

Twelve domestic pigs.

INTERVENTIONS

Animals underwent an SEMF procedure with gastric muscularis propria resection. The resultant offset mucosal entry site was closed by using an endoscopic suturing device. Animals were kept alive for 2 weeks.

MAIN OUTCOME MEASUREMENTS

The technical feasibility, reproducibility, and safety of the procedure; the clinical course of the animals; the histological and immunochemical evaluation of the resected specimen to determine whether myenteric ganglia were present in the sample.

RESULTS

FTGB was performed by using the SEMF technique in all 12 animals. The offset mucosal entry site was successfully closed by using the suturing device in all animals. The mean resected tissue specimen size was 11 mm. Mean total procedure time was 61 minutes with 2 to 4 interrupted sutures placed per animal. Histology showed muscularis propria and serosa, confirming full-thickness resections in all animals. Myenteric ganglia were visualized in 11 of 12 animals. The clinical course was uneventful. Repeat endoscopy and necropsy at 2 weeks showed absence of ulceration at both the mucosal entry sites and overlying the more distal muscularis propria resection sites. There was complete healing of the serosa in all animals with minimal single-band adhesions in 5 of 12 animals. Retained sutures were present in 10 of 12 animals.

LIMITATIONS

Animal experiment.

CONCLUSIONS

FTGB by using the SEMF technique and an endoscopic suturing device is technically feasible, reproducible, and safe. Larger tissue specimens will allow improved analysis of multiple cell types.

A microcarrier-based cell culture process for the production of a bovine respiratory syncytial virus vaccine

Veterinary viral vaccines generally comprise either attenuated or chemically inactivated viruses which have been propagated on mammalian cell substrates or specific pathogen free (SPF) eggs. New generation vaccines include chemically inactivated virally-infected whole cell vaccines. The NM57 cell line is a bovine nasal turbinate persistently infected (non-lytic infection) with a strain of the respiratory syncytial virus (RSV). The potential of microcarrier technology for the cultivation in bioreactors of this anchorage dependent cell line for RSV vaccine production has been investigated. Both Cytodex 3 and Cultispher S microcarriers proved most suitable from a selection of microcarriers as growth substrates for this NM57 cell line. Maximum cell densities of 4.12×105 cells ml-1and 5.52×105 cells ml-1 respectively were obtained using Cytodex 3 (3 g l-1) and and Cultispher S (1 g l-1) in 5 l bioreactor cultures. The fact that cell growth was less sensitive to agitation rate when cultured on Cultispher S microcarriers, and that cells were efficiently harvested from this microcarrier by an enzymatic method, suggested Cultispher S is suitable for further evaluation at larger bioreactor scales (>5 l) than that described here.

A multi-scale approach to colorectal cancer: from a biochemical- interaction signaling-network level, to multi-cellular dynamics of malignant transformation. Interplay with mutations and onco-protein inhibitor drugs

This review article is part of a special Current Cancer Drug Targets issue devoted to colorectal cancer and molecularly targeted treatments. In our paper we made an attempt to connect more basic aspects with preclinical, pharmacological / therapeutic and clinical aspects. Reconstruction of a Molecular Interaction Map (MIM) comprising an important part of the G0 - G1 - S cell cycle transition, was a major component of our review. Such a MIM serves also as a convenient / organized database of a large set of important molecular events. The frequency of mutated / altered signaling-proteins indicates the importance of this signaling-network region. We have considered problems at different scale levels. Our MIM works at a biochemical-interaction level. We have also touched the multi-cellular dynamics of normal and aberrant colon crypts. Until recently, dynamic simulations at a biochemical or multi-cellular scale level were considered as a sort of esoteric approach. We tried to convince the reader, also on the basis of a rapidly growing literature, mostly published in high quality journals, that suspicion towards simulations should dissipate, as the limitations and advantages of their application are better appreciated, opening the door to their permanent adoption in everyday research. What is really required is a more interdisciplinary mentality and an interdisciplinary approach. The prize is a level of understanding going beyond mere intuition.

Assessing the invasiveness of NOTES perforated viscus repair: a comparative study of NOTES and laparoscopy

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) repair of perforated peptic ulcers may decrease surgical invasiveness and improve patient outcomes.

METHODS

Full thickness gastrotomy was created laparoscopically in swine followed by soilage time. Repair proceeded with a laparoscopic (n = 14) or the NOTES (n = 14) approach. For NOTES repair, the omentum was endoscopically pulled into the gastric lumen and clipped. Intraoperative and postoperative parameters were recorded, including arterial blood gas (ABG) analysis and serum samples for white blood cell (WBC), TNF-α, IL-1, and IL-6 analysis.

RESULTS

Twenty-four of 28 animals thrived to study completion. NOTES repair could not be accomplished in one animal. At necropsy, all repairs were intact. Blood pressure was equivalent between groups. Pulse examined during the last 30 min of each procedure revealed a slightly higher mean pulse in the animals undergoing NOTES procedures (NOTES, 102 ± 28; laparoscopy, 83 ± 24). ABG obtained at the conclusion of the procedure revealed a pH of 7.47 in NOTES animals and 7.43 in the laparoscopy animals (p = 0.06), a change from baseline in both groups. The final pCO(2) was lower in the NOTES group (NOTES, 40.62; laparoscopy, 47.49, p = 0.03). WBC counts were comparable on postoperative day (POD) 1 (NOTES, 21.1; laparoscopy, 19.0; p = 0.49). Mean TNF-α serum levels were equivalent at all time points between groups; however, TNF-α varied significantly from baseline to POD 7 (p = 0.002).

CONCLUSION

NOTES omental repair appears comparable to that of laparoscopy. The lower arterial pCO(2) at the conclusion of the NOTES procedure may be advantageous in critically ill patients.

Current standards and future strategies in immunochemotherapy of non-Hodgkin's lymphoma

The therapeutic options for B-cell non-Hodgkin's lymphoma (NHL) have dramatically expanded with the advent of immune-based treatments. The monoclonal antibody anti- CD20 rituximab represents the best example of these advances and has quickly become incorporated into the therapeutic armamentarium for this hematological disease. In addition, other antibodies are eventually becoming part of treatment approaches to NHL. Furthermore, the role of therapeutic vaccines continues to be an important ongoing research question. Despite this success, several questions on how to optimize the use of monoclonal antibodies in NHL remain open since the best administration schedules, as well as the optimal duration of immunotherapy still have to be determined. Finally the development of resistance to treatment remains the main limit of this innovative approach, necessitating the development of strategies to circumvent resistance itself. This review will summarize the state of the art of antibody-based immunotherapy of NHL and discuss prospective approaches to improve the benefit of these treatments in patients.

The challenges with NOTES retroperitoneal access in humans

BACKGROUND

Animal studies have supported natural orifice transluminal endoscopic surgery (NOTES) retroperitoneal access. NOTES also may offer unique retroperitoneal access in humans.

OBJECTIVES

This study was designed to assess the feasibility of endoscopic transgastric and transrectal retroperitoneal access in a cadaver model using prone and supine positioning, and to compare NOTES retroperitoneal examination with endoscopic ultrasound.

METHODS

Using a multidisciplinary team, this institutional review board-approved study evaluated transgastric and transrectal retroperitoneal examination in six cadavers (3 male, 3 female; body mass index range, 25-37 kg/m(2)). Endoscopic ultrasound retroperitoneal examination preceded NOTES access. Transgastric Access: Using a prototype dual channel endoscope, a needle knife gastrotomy was created on the preantral posterior gastric wall. Retroperitoneal examination specifically targeted the pancreas and surrounding structures with the cadaver supine and prone. Transrectal Access: Using the same endoscope, a posterior needle knife rectotomy distal to the upper valve of Houston provided extraluminal access. Retroperitoneal examination proceeded with the cadaver prone and supine. Open dissection followed procedure completion.

RESULTS

Access into the retroperitoneum succeeded at all sites. Significant challenges locating identifiable landmarks were faced-mostly transrectal and improved transgastric prone. All cadavers, despite body mass index or sex, had significant retroperitoneal adipose tissue limiting the endoscopic view.

CONCLUSIONS

Although porcine studies have highlighted successful NOTES retroperitoneal procedures, the abundant human retroperitoneal adipose tissue challenged the translation of porcine research to humans. Additionally, although access to the retroperitoneal space and dissection within this space were accomplished easily, the appearance of cadaveric tissue and lack of blood flow made confident landmark identification impossible. Further study should continue in this area and focus on confident landmark identification for directed dissection. In a cadaveric model, this would best be improved by pre-NOTES anatomic marking or active perfusion of vasculature along with consideration of direct entry into the retroperitoneum from a targeted intraperitoneal site in clinical patients.

Peripheral blood vs. bone marrow for molecular monitoring of BCR-ABL1 levels in chronic myelogenous leukemia, a retrospective analysis in allogeneic bone marrow recipients

Molecular monitoring of the BCR-ABL1 transcript in chronic myelogenous leukemia (CML) using quantitative real-time PCR (RQ-PCR) can be performed using either bone marrow (BM) or peripheral blood (PB). However, a recent report by Stock et al. [International Journal of Oncology 28 (2006) 1099] questioned the reliability of PB samples for BCR-ABL1 detection as performed by RQ-PCR. We report a study on 114 CML patients who received allogeneic stem cell transplantation (ASCT), and who were monitored by RQ-PCR using paired samples of BM and PB: the total number of determinations was 428, with a median follow-up after transplant of 8 years. BCR-ABL1 transcript was undetectable or <0.1%, in 106 (49.57%) and 62 (29%) paired determinations, respectively. BCR-ABL1 was >0.1% in 36 (16.8%) paired determinations and was discordant in 10 (4.7%). Agreement between PB and BM results was quantified by the kappa test (k = 0.85; 95% CI 0.76-0.94). This study shows that BCR-ABL1 RQ-PCR monitoring of CML patients after ASCT with PB is concordant with BM in 95.3% of cases, and thus may be used to monitor the disease. This may be relevant when discussing both quality of life issues and the need for post-transplant monitoring with the patient.

Molecular diagnosis and monitoring of chronic myelogenous leukemia: BCR-Abl and more

The current treatment of chronic myelogenous leukemia (CML) is one of the most successful examples of molecularly targeted therapy in cancer. The identification of the fusion oncogene BCR-ABL allowed the discovery of small molecule inhibitors of its tyrosine kinase activity which, in turn, have literally revolutionized the treatment of this disease. However, large part of a successful clinical management of CML relies on appropriate diagnosis, molecular monitoring and identification of mutations potentially leading to drug resistance. These issues are discussed here together with an overview on how patients treated with tyrosine kinase inhibitors should be monitored.

Imaging amyloid deposition in Lewy body diseases

BACKGROUND

Extrapyramidal motor symptoms precede dementia in Parkinson disease (PDD) by many years, whereas dementia occurs early in dementia with Lewy bodies (DLB). Despite this clinical distinction, the neuropsychological and neuropathologic features of these conditions overlap. In addition to widespread distribution of Lewy bodies, both diseases have variable burdens of neuritic plaques and neurofibrillary tangles characteristic of Alzheimer disease (AD).

OBJECTIVES

To determine whether amyloid deposition, as assessed by PET imaging with the beta-amyloid-binding compound Pittsburgh Compound B (PiB), can distinguish DLB from PDD, and to assess whether regional patterns of amyloid deposition correlate with specific motor or cognitive features.

METHODS

Eight DLB, 7 PDD, 11 Parkinson disease (PD), 15 AD, and 37 normal control (NC) subjects underwent PiB-PET imaging and neuropsychological assessment. Amyloid burden was quantified using the PiB distribution volume ratio.

RESULTS

Cortical amyloid burden was higher in the DLB group than in the PDD group, comparable to the AD group. Amyloid deposition in the PDD group was low, comparable to the PD and NC groups. Relative to global cortical retention, occipital PiB retention was lower in the AD group than in the other groups. For the DLB, PDD, and PD groups, amyloid deposition in the parietal (lateral and precuneus)/posterior cingulate region was related to visuospatial impairment. Striatal PiB retention in the DLB and PDD groups was associated with less impaired motor function.

CONCLUSIONS

Global cortical amyloid burden is high in dementia with Lewy bodies (DLB) but low in Parkinson disease dementia. These data suggest that beta-amyloid may contribute selectively to the cognitive impairment of DLB and may contribute to the timing of dementia relative to the motor signs of parkinsonism.

Guiding empirical antibiotic therapy in orthopaedics: The microbiology of prosthetic joint infection managed by debridement, irrigation and prosthesis retention

OBJECTIVES

This study describes the microbiological spectrum of prosthetic joint infection (PJI) managed by debridement, washout and retention and so guides the choice of empirical antibiotics within this patient group.

METHODS

We performed a retrospective review of all patients admitted to our specialist tertiary unit for PJI who were managed with debridement and irrigation or arthroscopic washout of infected prosthetic joints between 1st January 1998 and 30th April 2003. Clinical and microbiological data sets were analysed using the Access database.

RESULTS

One hundred and twelve patients met the criteria for inclusion. 69% received their surgical intervention in the first three months after implantation ('early') and 21% after 12 months. Overall the most frequently isolated organisms were coagulase negative staphylococci (47% patients) and methicillin-sensitive Staphylococcus aureus (MSSA, 44% patients). 8% grew methicillin-resistant Staphylococcus aureus (MRSA) and 7% grew anaerobes. Most Gram-negative isolates were resistant to cefuroxime; all were sensitive to meropenem. Eighty-six percent of polymicrobial cultures occurred in early infections when 47% of patients grew more than one organism. MSSA was the most frequently isolated organism at all time points.

CONCLUSIONS

Most infections involved staphylococci. MRSA was infrequently isolated. Most polymicrobial infections occurred in early infection. A high rate of resistance to cephalosporins among Gram-negative organisms justifies the use of a broader agent such as a carbapenem in the early empirical antibiotic regime for PJI.

Relationship between E1A binding to cellular proteins, c-myc activation and S-phase induction

We recently showed that p300/CREB-binding protein (CBP) plays an important role in maintaining cells in G0/G1 phase by keeping c-myc in a repressed state. Consistent with this, adenovirus E1A oncoprotein induces c-myc in a p300-dependent manner, and the c-myc induction is linked to S-phase induction. The induction of S phase by E1A is dependent on its binding to and inactivating several host proteins including p300/CBP. To determine whether there is a correlation between the host proteins binding to the N-terminal region of E1A, activation of c-myc and induction of S phase, we assayed the c-myc and S-phase induction in quiescent human cells by infecting them with Ad N-terminal E1A mutants with mutations that specifically affect binding to different chromatin-associated proteins including pRb, p300, p400 and p300/CBP-associated factor (PCAF). We show that the mutants that failed to bind to p300 or pRb were severely defective for c-myc and S-phase induction. The induction of c-myc and S phase was only moderately affected when E1A failed to bind to p400. Furthermore, analysis of the E1A mutants that fail to bind to p300, and both p300 and PCAF suggests that PCAF may also play a role in c-myc repression, and that the two chromatin-associated proteins may repress c-myc independently. In summary, these results suggest that c-myc deregulation by E1A through its interaction with these chromatin-associated proteins is an important step in the E1A-mediated cell cycle deregulation and possibly in cell transformation.

Case of cryptic malaria

We report a case of falciparum malaria in a renal transplant patient with no history of foreign travel. Three weeks previously she had been a hospital inpatient with cellulitis and had stayed on the same ward as a man with falciparum malaria acquired in Nigeria. There were no cases of malaria in other patients on the ward at the same time. The parasites from the two cases were genotypically indistinguishable. Despite a thorough investigation, reviewed by an expert external panel, no clear route of infection between the cases was identified. Patients with malaria should be considered highly infectious by the parenteral route. They should be managed with the infection control precautions used for patients with bloodborne virus infections. Our case reinforces the need for high levels of compliance with universal infection control procedures.

128CHANGES WITHIN OXYGEN ENVIRONMENT DURING IVF AND IVC IMPROVE BOVINE EMBRYONIC DEVELOPMENT IN VITRO

Oxygen concentration during both IVF and IVC affects embryonic development. A low O2 atmosphere during IVC has been reported to be beneficial for embryos in culture without somatic cells. Similarly, a reduction in spermatozoa (sp) concentration can influence the oxygenation grade of fertilization medium, and O2 requirements can vary according to the embryonic stage of development. This experiment investigated whether prolonged contact with sperm cells interacts with effects of oxygen tension during the first days of culture. Slaughterhouse bovine COCs matured with Vero-cells in TCM199 with FCS and EGF were co-incubated (CI) with swim-up separated sp. COCs with attached sp were either removed after 2h and placed in IVF medium without sp up to completion of 18h (sp-restricted CI), or COCs and sp were left together for 18h (sp-prolonged CI). Zygotes were cultured in serum-free, B2 medium conditioned with Vero cells (Marquant-Le Guienne et al., 1999 Theriogenology 51, 386), modified as described by Gomez and Diez (2000 Anim. Reprod. Sci. 58, 23–37). According to IVF procedure (sp-restricted or sp-prolonged), embryo culture was made either in 20% O2 from Day 0 up to Day 3 and in 5% O2 later on, or in 5% O2 from Day 0 up to Day 8, in a 2×2 factorial design. IVF medium was monitored for Na+, K+, Ca2+, pH, O2, CO2 , HCO3− and lactate (i-STAT analyzer; 5 replicates -R-) at 0h, 2h and 18h without cells (controls), at 2h in CI and at 18h both in sp-restricted and sp-prolonged CI. Embryo development was analyzed by CATMOD for effects, and all data were processed by GLM and Duncan test and expressed as LSM±SE. The presence of cells decreased pO2 (P&lt;0.01) in IVF medium at 2h of CI (154±2.3 without cells v. 144±2.3 with cells). There were differences in pO2 at 18h (P&lt;0.05) between sp-prolonged (140.8±2.3) and sp-restricted CI (148.6±2.3). At 18h in CI there was K+ depletion (P&lt;0.05), while Na+, Ca2+, pH and pCO2 remained invariable throughout. Lactate production increased (P&lt;0.05) in CI at 2h and, together with HCO3− (P&lt;0.01), at 18h in sp-prolonged CI. Increasing O2 up to 20% during the first 3 days of culture improved total and medium to late (M+L; early blastocysts excluded) blastocyst rates upon sp-prolonged CI, which is comparable to sp-restricted CI under both % O2 conditions during embryo culture. Under 5% CO2 throughout culture, higher expansion rates occurred in sp-restricted CI, suggesting that this system could improve embryonic viability. Metabolic effects can be inferred from differences in pO2 , lactate and HCO3− , and research will explore the role of oxygen free radicals in these experimental conditions. Grant support: Eureka 2573; CDTI, PROFIT, and FICYT.

249BOVINE GRANULOSA CELLS MRNA EXPRESSION OF PEROXISOME PROLIFERATOR-ACTIVATED RECEPTOR-± AND THE PROTO-ONCOGENE C-FOS

PPARα and c-Fos are involved in regulation of gene expression and are known to be dependent on retinoic acid (RA), which in turn influences oocyte growth and developmental competence (Duque et al., 2002 Hum. Reprod. 17, 2706–2714; Hidalgo et al., 2003. Reproduction 125, 409–416), probably acting in part through granulosa cells. Peroxisome proliferator-activated receptor-α (PPARα) heterodimerizes with the retinoid receptor X (RXR), while c-Jun/c-Fos heterodimerizes with liganded retinoic acid receptors (RARs), then preventing formation of transcription factor activator protein 1 (AP-1) complexes capable of DNA binding. Cellular retinoic acid binding protein (CRABP) limits RA excess and regulates the transcriptional potential of RA;; CRABPII has been detected in rat granulosa cells from mature follicles and luteal cells. The aim of this study was to investigate PPARα, c-Fos and CRABPII mRNA expression in bovine granulosa cells. In parallel, other genes whose expression can be influenced by RA were analyzed: luteinizing hormone receptor (LHr), follicle stimulating hormone receptor (FSHr), aromatase and growth hormone (GH). Ovaries were collected at a local abattoir and kept in saline at 30–35°C. Granulosa cells were obtained by aspirating 2- to 7-mm antral follicle contents, pelleted at 700g for 4min and resuspended in RNA-later (Ambion®). Total RNA was isolated with a NucleoSpin® RNAII kit (Macherey-Nagel), and mRNA was reverse transcribed into single-stranded cDNA using a 1st Strand cDNA Synthesis Kit for RT-PCR (AMV) (Roche). A PCR standard method was made using 1μL of the cDNA as a template. All PCR primer couples were designed on the basis of the bovine sequence, but c-Fos and CRABPII primers were designed based on the human-murine sequences. Primers within the couple were located in different exons to distinguish DNA from RNA amplification. CRABPII was further investigated in bovine whole ovary, corpus luteum (CL) and liver, in a search for positive controls. Bovine β-actin, 18S and 28S were examined in each sample as positive controls for RNA isolation and cDNA synthesis efficiency. TenμL of product were loaded into an agarose 2% gel in TBE buffer containing ethidium bromide, and were separated by horizontal electrophoresis. Gels were visualized with ultraviolet light and photographed using a digital camera. Gene expression in granulosa was demonstrated for PPARα, c-Fos, LHr, FSHr, aromatase, GH and controls (β-actin, 18S and 28S) but CRABPII gene did not express in granulosa cells, whole ovary, CL or liver under our experimental conditions. While lacking CRABPII expression remains intriguing, the expressed genes support a role of retinoid pathway within granulosa cells under both in vivo and in vitro conditions, because granulosa cells used in the present experiments were derived from follicles providing oocytes for IVM-IVF. Grant support: Spanish Ministry of Science and Technology (AGL-2002-01175).

112EFFECT OF THE IVM PROTOCOL OF BOVINE OOCYTES ON SURVIVAL RATES AFTER VITRIFICATION BY OPEN PULLED STRAW METHOD

The meiotic stage and the cryopreservation protocol influence the ability of the oocytes to survive cryopreservation. The in vitro maturation (IVM) methods affect nuclear and cytoplasmic maturation and, consequently, the developmental competence of the oocytes. On the other hand, the cytoplasm of the bovine oocyte contains large amounts of lipids which, as demonstrated in the bovine embryo (Díez et al., 2001 Theriogenology 55; 923–936), can negatively affect post-thaw survival. The aim of this work was to analyze the effect of fetal calf serum (FCS) during IVM on the freezability of the bovine metaphase II oocyte. Cumulus-oocyte complexes (COCs) were recovered from slaughterhouse ovaries. Oocytes with compact cumulus cells and evenly granulated cytoplasm were matured for 22h in TCM199, NaHCO3, FSH, LH and 17βestradiol. Approximately half of the oocytes were allowed to mature in 10% FCS, and the remainder were matured in polyvinyl-alcohol (PVA; 0.3gL−1). For vitrification, oocytes were matured for 22h, partially denuded of cumulus cells, and then vitrified (v-FCS and v-PVA) by the OPS system (Vajta et al. 1988 Mol. Reprod. Dev. 51; 53–58). Fresh untreated controls (c-FCS and c-PVA) were allowed to mature for 24h and immediately fertilized in modified TALP medium with swim-up separated sperm, and cultured. After warming and dilution, vitrified oocytes were cultured in IVM medium for 2h and then fertilized (Day 0). Presumptive zygotes with normal morphology were cultured in SOFaa+amino-acids+myo-inositol+5% FCS (Day 3), and oocytes with a degenerated appearance were counted and discarded. Data were analyzed by ANOVA and Duncan’s test. Results are shown in the Table 1. After warming, we observed severe cryodamage in both v-FCS and v-PVA groups. Rates of degenerated oocytes were 17.8±9.6 and 12.0±9.6 for v-FCS and v-PVA groups, respectively (P&gt;0.05). The presence of PVA instead of FCS did not improve the blastocyst rates obtained from vitrified/warmed oocytes. The use of PVA during IVM (c-PVA) yielded lower (P&lt;0.05) blastocyst rates compared to the FCS control (c-FCS). Ultrastructural studies are in progress to analyze alterations in meiotic spindle, cytoplasmic organelles and cortical granules as possible causes of reduced oocyte competence after vitrification. Supported by CICYT, AGL2001-379. Table 1

325RETINOID-DEPENDENT POLY(A) MRNA CONTENTS IN BOVINE OOCYTES PREMATURED AND/OR MATURED IN VITRO

Retinoic acid (RA) can induce cell differentiation and plays a role in controlling events within the cell cycle, but little is known of RA post-transcriptional modifications in the oocyte. Bovine oocyte and cumulus cells express most of RA receptors, and the presence of 9-cis-RA during in vitro prematuration and maturation (IVM) improves oocyte developmental competence (Duque et al., 2002 Hum. Reprod. 17, 2706–2714; Hidalgo et al., 2003 Reproduction 125, 409–416). This work analyzes the mRNA stability in bovine oocytes during in vitro prematuration and/or maturation. Cumulus-oocyte complexes (COCs) were cultured in defined medium with polyvinyl alcohol (DM). Those COCs undergoing prematuration were cultured for 24h in DM with 25μM roscovitine. For IVM, COCs were cultured in DM containing pFSH, LH and E2 for 24h, and some prematured COCs were then allowed to mature. Incubations were made at 39°C in 5% CO2 in air and high humidity. Within experiments, COCs were cultured with 5nM 9-cis-RA, in 1% ethanol (both as a vehicle and as an inhibitor of endogenous RA synthesis), 3% ethanol, 5% ethanol and untreated. Groups of 10 COCs per treatment were cultured, and oocytes detached from cumulus cells were analyzed. Poly(A) mRNA quantification was based on the pyrophosphorylation property of the DNA polymerase (Klenow). ATP production was measured by luminometric assay as a function of numbers of poly(A) tails. Data (4 replicates) were analyzed by ANOVA and Duncan’s test (v,x,y,zP&lt;0.01; a,bP&lt;0.05), and poly(A) mRNA (pg oocyte−1) was expressed as LSM±SE. After prematuration, poly(A) mRNA contents differed between 9-cis-RA (125.7±4.8x) and untreated (95.5±4.8y) oocytes, as compared to 1% ethanol (72.2±4.8z) and immature (71.5±4.8z) oocytes. After IVM, untreated oocytes (23.0±2.2v) showed the lowest poly(A) mRNA amount, and poly(A) mRNA in 9-cis-RA (36.2±2.2y) basically equalled that in 1% ethanol (35.2±2.2y), while 3% (44.5±2.2yz) and 5% ethanol (52.0±2.2z) increased poly(A) mRNA levels. All groups of matured oocytes showed poly(A) mRNA contents lower than in immature (71.5±4.8x). After prematuration+maturation, poly(A) mRNA values were 34.2±2.2v (untreated+untreated), 36.5±2.2v (9-cis-RA+untreated), 49.5±2.2xa (untreated+9-cis-RA), 41.0±2.2vxb (9-cis-RA+9-cis-RA) and 59.0±2.2y (untreated+1% ethanol). Levels of poly(A) mRNA from prematured+matured oocytes were again lower than in immature (71.5±4.8x). Our study shows that beneficial effects of RA on the oocyte developmental competence can be represented in part as a gain in the quality of mRNAs stored. Grant support: Spanish Ministry of Science and Technology (AGL-2002-01175).

235RETINOID-DEPENDENT MRNA EXPRESSION IN BOVINE OOCYTES PREMATURED AND/OR MATURED IN VITRO

As a transcription factor, retinoic acid (RA) can activate or silence a wide number of genes, thus inducing differentiation in cell systems and playing a role in cell cycle regulation. However, little is known of RA-dependent gene expression in the oocyte. Bovine oocytes and cumulus cells express most RA receptors, and the presence of 9-cis-RA during in vitro maturation (IVM) is beneficial to oocyte development (Duque et al., 2002 Hum. Reprod. 17, 2706–2714; Hidalgo et al., 2003 Reproduction 125, 409–416). The present work analyzes the relative abundance of various developmentally important gene transcripts in bovine oocytes during in vitro prematuration and/or maturation. Cumulus-oocyte complexes (COCs) were manipulated in defined medium with polyvinyl-alcohol (DM-PVA). Those COCs undergoing prematuration were cultured for 24h in DM-PVA with 25μM roscovitine. For IVM, some prematured COCs were cultured for 24h in DM-PVA containing pFSH, LH and E2. Incubations were made at 39°C in an atmosphere of 5% CO2 in air and high humidity. Within experiments, COCs were cultured with nM 9-cis-RA 5, in 1% ethanol (both as vehicle and inhibitor of endogenous RA synthesis), 3% ethanol, 5% ethanol and untreated. Using Real Time PCR (10 oocytes per group) (Rizos et al., 2003 Biol. Reprod. 68, 236) we examined the relative mRNA expression of genes involved in protection against free oxygen radicals (Mn-superoxide dismutase, MnSOD), glucose metabolism (glucose-6-phosphate dehydrogenase, G6PDH) and cell cycle events (Cyclin B1 and H1). Data (of 4 replicates) were analyzed by ANOVA and Duncan test (P&lt;0.05). Regarding immature oocytes, prematuration in 1% ethanol increased cyclin B1 expression and decreased cyclin H1, while 9-cis-RA increased G6PDH. Maturation without additives increased cyclin B1 and G6PDH, but decreased cyclin H1 and MnSOD expression;; opposite trends were observed under increasing ethanol dosages (3% and 5%). Maturation with 1% ethanol or 9-cis-RA enhanced cyclin B1 and G6PDH, while reducing cyclin H1 and MnSOD expressions. The presence of 9-cis-RA during both prematuration and maturation processes tended to show more prominent effects than the ones observed when it was present only during prematuration or maturation alone. In our study, in presence of 9-cis-RA during both prematuration and maturation processes, the expression of cyclin B1 and G6PDH tended to increase, while cyclin H1 and MnSOD tended to decrease. However, the differences with the control group without additives were not significant. Our study during both prematuration and maturation processes show that beneficial effects of RA on oocyte developmental competence may not be related to the alteration of mRNA expression of the four genes analyzed. Grant support: Spanish Ministry of Science and Technology (AGL-2002-01175; 2003-05783).

Methods for generation of monoclonal antibodies to the very small drug hapten, 5-benzimidazolecarboxylic acid

Drug-specific monoclonal antibodies (MAbs) were produced against the very small drug hapten (162.15 Da), 5-benzimidazolecarboxylic acid, an analogue of 2-(4-Thiazolyl)benzimidazole (TBZ) but lacking the thiol group. TBZ is widely used as a broad-spectrum anthelmintic in various animal species and humans and also as a food preservative and agricultural fungicide. The anti-5-benzimidazolecarboxylic acid antibodies produced have potential use for extraction and/or detection of protein-bound residue forms of TBZ. Three in vivo immunisation regimes (with combinations of two related small drug haptens and two different adjuvants/carrier molecules) and an in vitro immunisation procedure using a combination of three related unconjugated small drug haptens were investigated. Specificity for the hapten immunogen/s was initially determined using two different ELISA procedures. BIACORE analysis, in conjunction with drug binding inhibition studies, was used to confirm the specificity of a small number of selected clones. In vivo immunisation with a drug molecule conjugated to a lipopeptide/T-cell epitope, which acts both as a carrier molecule and an adjuvant was the most useful of the methods tested for the production of specific MAbs to a typically very small hapten with low immunogenic properties.

Tethered cord in a patient with multiple vertebral segmentation defects: a case report

Short trunk dwarfism with multiple vertebral segmentation defects (MVSD) represents a heterogeneous group of disorders characterized by the presence of multiple vertebral and rib abnormalities. A two and one-half year-old female with the spondylothoracic dysostosisform of MVSD is presented. In addition to skeletal anomalies, a lumbar hemangioma, bilateral foot deformities, distal leg atrophy and weakness, and areflexia at the ankles were present. An underlying neuropathic process was suspected. Results of urodynamic studies were suggestive of a neurogenic bladder. Magnetic resonance imaging of the spine demonstrated a tethered spinal cord. Although various brain and spinal cord anomalies have been described in MVSD, this is the first reported case, to our knowledge, of a tethered spinal cord in a patient with MVSD. We recommend that the management of patients with MVSD include comprehensive neurological evaluation and monitoring with appropriate electrodiagnostic, urodynamic, and neuroimaging studies.

A new monoclonal antibody, P2A8(6), that specifically recognizes a novel epitope on the multidrug resistance-associated protein 1 (MRP1), but not on MRP2 nor MRP3

Multidrug resistance (MDR) is a major problem in the chemotherapeutic treatment of cancer. Overexpression of the multidrug resistance-associated protein 1 (MRP1), is associated with MDR in certain tumors. A number of MRP1-specific MAbs, which facilitate both clinical and experimental investigations of this protein, are available. To add to this panel of existing antibodies, we have now generated an additional MRP1-specific monoclonal antibody (MAb), P2A8(6), which detects a unique heat stable epitope on the MRP1 molecule. Female Wistar rats were immunized via footpad injections with a combination of two short synthetic peptides corresponding to amino acids 235-246 (peptide A) and 246-260 (peptide B) of the MRP1 protein. Immune reactive B cells were then isolated from the popliteal lymph nodes for fusion with SP2/O-Ag14 myeloma cells. Resultant hybridoma supernatants were screened for MRP1-specific antibody production. Antibody P2A8(6) was characterized by Western blotting and immunocytochemistry on paired multidrug resistant (MRP1 overexpressing) and sensitive parental cell lines. The antibody detects a protein of 190 kDa in MRP1-expressing cell lines but not in MRP2- or MRP3-transfected cell lines. P2A8(6) stains drug-selected and MRP1-transfected cell lines homogeneously by immunocytochemistry and recognizes MRP1 by immunohistochemistry on formalin-fixed paraffin wax-embedded tissue sections. Peptide inhibition studies confirm that P2A8(6) reacts with peptide B (amino acids 246-260), therefore recognizing a different epitope from that of all currently available MRP1 MAbs. This new MAb, chosen for its specificity to the MRP1 protein, may be a useful addition to the currently available range of MRP1-specific MAbs.

Axillary nerve injury: diagnosis and treatment

Axillary nerve injury is infrequently diagnosed but is not a rare occurrence. Injury to the nerve may result from a traction force or blunt trauma applied to the shoulder. The most common zone of injury is just proximal to the quadrilateral space. Atraumatic causes of neuropathy include brachial neuritis and quadrilateral space syndrome. The vast majority of patients recover with non-operative treatment. Baseline electromyographic and nerve conduction studies should be obtained within 4 weeks after injury, with a follow-up evaluation at 12 weeks. If no clinical or electromyographic improvement is noted, surgery may be appropriate. The results of operative repair are best if surgery is performed within 3 to 6 months from the injury. Surgical options include neurolysis, nerve grafting, and neurotization. The results of repair of axillary nerve injuries have been good compared with treatment of other peripheral nerve lesions, due to the monofascicular composition of the nerve and the relatively short distance between the zone of injury and the motor end-plate.

Hyperbaric oxygen therapy in the treatment of soft tissue necrosis resulting from a stingray puncture

Necrotizing soft tissue processes of the foot secondary to an acute stingray envenomation can be a challenge to manage. Very little is reported in the orthopaedic literature to aid the practicing surgeon faced with this problem. In this case report, we describe the wound management and team approach employed in this patient's care, including the indications for hyperbaric oxygen therapy, which, in this case, was ultimately successful.