Multiorgan MRI findings after hospitalisation with COVID-19 in the UK (C-MORE): a prospective, multicentre, observational cohort study

INTRODUCTION

The multiorgan impact of moderate to severe coronavirus infections in the post-acute phase is still poorly understood. We aimed to evaluate the excess burden of multiorgan abnormalities after hospitalisation with COVID-19, evaluate their determinants, and explore associations with patient-related outcome measures.

METHODS

In a prospective, UK-wide, multicentre MRI follow-up study (C-MORE), adults (aged ≥18 years) discharged from hospital following COVID-19 who were included in Tier 2 of the Post-hospitalisation COVID-19 study (PHOSP-COVID) and contemporary controls with no evidence of previous COVID-19 (SARS-CoV-2 nucleocapsid antibody negative) underwent multiorgan MRI (lungs, heart, brain, liver, and kidneys) with quantitative and qualitative assessment of images and clinical adjudication when relevant. Individuals with end-stage renal failure or contraindications to MRI were excluded. Participants also underwent detailed recording of symptoms, and physiological and biochemical tests. The primary outcome was the excess burden of multiorgan abnormalities (two or more organs) relative to controls, with further adjustments for potential confounders. The C-MORE study is ongoing and is registered with ClinicalTrials.gov, NCT04510025.

FINDINGS

Of 2710 participants in Tier 2 of PHOSP-COVID, 531 were recruited across 13 UK-wide C-MORE sites. After exclusions, 259 C-MORE patients (mean age 57 years [SD 12]; 158 [61%] male and 101 [39%] female) who were discharged from hospital with PCR-confirmed or clinically diagnosed COVID-19 between March 1, 2020, and Nov 1, 2021, and 52 non-COVID-19 controls from the community (mean age 49 years [SD 14]; 30 [58%] male and 22 [42%] female) were included in the analysis. Patients were assessed at a median of 5·0 months (IQR 4·2-6·3) after hospital discharge. Compared with non-COVID-19 controls, patients were older, living with more obesity, and had more comorbidities. Multiorgan abnormalities on MRI were more frequent in patients than in controls (157 [61%] of 259 vs 14 [27%] of 52; p<0·0001) and independently associated with COVID-19 status (odds ratio [OR] 2·9 [95% CI 1·5-5·8]; padjusted=0·0023) after adjusting for relevant confounders. Compared with controls, patients were more likely to have MRI evidence of lung abnormalities (p=0·0001; parenchymal abnormalities), brain abnormalities (p<0·0001; more white matter hyperintensities and regional brain volume reduction), and kidney abnormalities (p=0·014; lower medullary T1 and loss of corticomedullary differentiation), whereas cardiac and liver MRI abnormalities were similar between patients and controls. Patients with multiorgan abnormalities were older (difference in mean age 7 years [95% CI 4-10]; mean age of 59·8 years [SD 11·7] with multiorgan abnormalities vs mean age of 52·8 years [11·9] without multiorgan abnormalities; p<0·0001), more likely to have three or more comorbidities (OR 2·47 [1·32-4·82]; padjusted=0·0059), and more likely to have a more severe acute infection (acute CRP >5mg/L, OR 3·55 [1·23-11·88]; padjusted=0·025) than those without multiorgan abnormalities. Presence of lung MRI abnormalities was associated with a two-fold higher risk of chest tightness, and multiorgan MRI abnormalities were associated with severe and very severe persistent physical and mental health impairment (PHOSP-COVID symptom clusters) after hospitalisation.

INTERPRETATION

After hospitalisation for COVID-19, people are at risk of multiorgan abnormalities in the medium term. Our findings emphasise the need for proactive multidisciplinary care pathways, with the potential for imaging to guide surveillance frequency and therapeutic stratification.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Evidence of Antineutrinos from Distant Reactors Using Pure Water at SNO

The SNO+ Collaboration reports the first evidence of reactor antineutrinos in a Cherenkov detector. The nearest nuclear reactors are located 240 km away in Ontario, Canada. This analysis uses events with energies lower than in any previous analysis with a large water Cherenkov detector. Two analytical methods are used to distinguish reactor antineutrinos from background events in 190 days of data and yield consistent evidence for antineutrinos with a combined significance of 3.5σ.

The barriers and facilitators to research in practice: the experiences of a medicines optimisation team within a clinical commissioning group

Introduction

Research active healthcare organisations and staff have been shown to significantly improve performance and patient outcomes1. Undertaking research is a core element of the pharmacist role, however many pharmacists report not having the skills, knowledge and/or resources to take part2. There are many opportunities for the delivery of transformational research within primary care, however pharmacy team engagement is lacking.

Aim

To explore the barriers and facilitators to research engagement within a Clinical Commissioning Group (CCG) Medicines Optimisation team.

Methods

Twelve focus groups, guided by a semi-structured topic guide, were held over MS Teams between October 2021 and February 2022. 37 participants (pharmacists, pharmacy technicians and administrative support roles) attended and discussed topics relating to their experiences of engaging with research, as well as what helped or hindered them. Detailed notes were taken and analysed using Thematic Analysis. Following this inductive analysis, which aimed to capture all themes arising from the data, the Consolidated Framework for Implementation Research (CFIR)3 was applied. This helped to categorise the barriers and facilitators into domains which influence to what extent research is undertaken. The analysis was validated by the CCG team. This study was deemed to be service evaluation and therefore no ethical approval was needed.

Results

Three core themes emerged: People, Place and Practicalities. Individuals felt they had limited knowledge and capabilities in the field of research, despite having an internal motivation to engage in research activity. The perception of research was often linked in peoples’ thoughts to academia or secondary care/ acute Trusts or lab-based, and therefore not really something they would engage with in their current role. A lack of research culture, leadership and visibility of projects were all thought to hinder the team. A clear need for training and education in research (what it is, how it can be done, and available tools) was expressed, as well as appropriate resource allocation. Mapping to the CFIR illustrated that most barriers fell within the inner setting (i.e. the organisation itself) and with the process of conducting research, such as limited time, lack of encouragement from champions and poor feedback from projects. Enablers were also identified which included advice offered by external organisations, dissemination about work conducted in other primary care organisations and beliefs about the benefits of being research active.

Discussion/Conclusion

Participants perceived there to be many more barriers to research engagement than enablers, and these ranged from challenges with the individual projects, the process of conducting research within the organisation, things about the person themselves, their organisation or the wider setting of primary care. Areas for improvement were identified, mainly through increased training, visibility of projects and interested people, development of champions and role models, and stronger links with academia. This study was conducted with only one CCG and therefore further work needs to explore the experience within other integrated care boards and across secondary and community practice.

References

1. Hanney, S., Boaz, A., Soper, B. and Jones, T. Engagement in research: an innovative three-stage review of the benefits for health-care performance. Health Services and Delivery Research, 2013;1(8). ISSN (print) 2050-4349

2. Crilly P, Patel N, Ogunrinde A, Berko D, Kayyali R. Community Pharmacists’ Involvement in Research in the United Kingdom. Pharmacy. 2017;5(3):48. https://doi.org/10.3390/pharmacy5030048

3. Damschroder, L.J., Aron, D.C., Keith, R.E. et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implementation Sci 2009;4:50. https://doi.org/10.1186/1748-5908-4-50

Absence of antibody responses to SARS-CoV-2 N protein in COVID-19 vaccine breakthrough cases

Understanding the risk factors for breakthrough coronavirus disease 2019 (COVID-19) (BC19) is critical to inform policy. Herein, we assessed Delta (Lineage B.1.617.2) variant-specific effectiveness of the BNT162b2 (Pfizer) vaccine and characterized Delta-driven BC19 cases (fully vaccinated individuals who get infected) with known-time-since-vaccination. In this longitudinal prospective study (January 21-October 30, 2021), 90 naïve and 15 convalescent individuals were enrolled at the initiation of vaccination. Samples from 27 unvaccinated individuals with previous laboratory-confirmed COVID-19 diagnosis were collected at a single time point. Longitudinal serology profile (antibodies against severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] S and N proteins) and live-virus-based neutralization capacities were assessed while controlling for age. Sex, age, history of reactions to the COVID-19 vaccine, and viral neutralization capacities were identified as significant risk factors for breakthrough COVID-19. At 8 months postvaccination, male sex, individuals ⩾65 years of age, and individuals who experienced noticeable side effects with the COVID-19 vaccine were at 5.47 (p-value = 0.0102), 4.33 (p-value = 0.0236), and 4.95 (p-value = 0.0159) fold greater risk of BC19 as compared to their peers, respectively. Importantly, every five-fold increase in viral neutralization capacities (by live-virus-based assays) was significantly associated with ~4-fold reduction in the risk occurrence of breakthrough COVID-19 (p-value = 0.045). Vaccine boosting remarkably increased these viral neutralization capacities by 16.22-fold (p- value = 0.0005), supporting the importance of the BNT162b2 booster in efforts to control the incursion of future variants into the population at large. Strikingly, BC19 cases exhibited a delayed/absent antibody response to the N protein, suggesting limited exposure to the virus. Since antibodies against N protein are widely used to evaluate the extent of virus spread in communities, our finding has important implications on the utility of existing serological diagnostic and surveillance for COVID-19.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

Synoptic assessment of coastal total alkalinity through community science

Comprehensive sampling of the carbonate system in estuaries and coastal waters can be difficult and expensive because of the complex and heterogeneous nature of near-shore environments. We show that sample collection by community science programs is a viable strategy for expanding estuarine carbonate system monitoring and prioritizing regions for more targeted assessment. 'Shell Day' was a single-day regional water monitoring event coordinating coastal carbonate chemistry observations by 59 community science programs and seven research institutions in the northeastern United States, in which 410 total alkalinity (TA) samples from 86 stations were collected. Field replicates collected at both low and high tides had a mean standard deviation between replicates of 3.6 ± 0.3 μmol kg^-1 (σ _mean ± SE, n = 145) or 0.20 ± 0.02%. This level of precision demonstrates that with adequate protocols for sample collection, handling, storage, and analysis, community science programs are able to collect TA samples leading to high-quality analyses and data. Despite correlations between salinity, temperature, and TA observed at multiple spatial scales, empirical predictions of TA had relatively high root mean square error >48 μmol kg^-1. Additionally, ten stations displayed tidal variability in TA that was not likely driven by low TA freshwater inputs. As such, TA cannot be predicted accurately from salinity using a single relationship across the northeastern US region, though predictions may be viable at more localized scales where consistent freshwater and seawater endmembers can be defined. There was a high degree of geographic heterogeneity in both mean and tidal variability in TA, and this single-day snapshot sampling identified three patterns driving variation in TA, with certain locations exhibiting increased risk of acidification. The success of Shell Day implies that similar community science based events could be conducted in other regions to not only expand understanding of the coastal carbonate system, but also provide a way to inventory monitoring assets, build partnerships with stakeholders, and expand education and outreach to a broader constituency.

Synoptic assessment of coastal total alkalinity through community science

Comprehensive sampling of the carbonate system in estuaries and coastal waters can be difficult and expensive because of the complex and heterogeneous nature of near-shore environments. We show that sample collection by community science programs is a viable strategy for expanding estuarine carbonate system monitoring and prioritizing regions for more targeted assessment. 'Shell Day' was a single-day regional water monitoring event coordinating coastal carbonate chemistry observations by 59 community science programs and seven research institutions in the northeastern United States, in which 410 total alkalinity (TA) samples from 86 stations were collected. Field replicates collected at both low and high tides had a mean standard deviation between replicates of 3.6 ± 0.3 μmol kg-1 (σ mean ± SE, n = 145) or 0.20 ± 0.02%. This level of precision demonstrates that with adequate protocols for sample collection, handling, storage, and analysis, community science programs are able to collect TA samples leading to high-quality analyses and data. Despite correlations between salinity, temperature, and TA observed at multiple spatial scales, empirical predictions of TA had relatively high root mean square error >48 μmol kg-1. Additionally, ten stations displayed tidal variability in TA that was not likely driven by low TA freshwater inputs. As such, TA cannot be predicted accurately from salinity using a single relationship across the northeastern US region, though predictions may be viable at more localized scales where consistent freshwater and seawater endmembers can be defined. There was a high degree of geographic heterogeneity in both mean and tidal variability in TA, and this single-day snapshot sampling identified three patterns driving variation in TA, with certain locations exhibiting increased risk of acidification. The success of Shell Day implies that similar community science based events could be conducted in other regions to not only expand understanding of the coastal carbonate system, but also provide a way to inventory monitoring assets, build partnerships with stakeholders, and expand education and outreach to a broader constituency.

Quantum Spin Dynamics in Fock Space Following Quenches: Caustics and Vortices

Caustics occur widely in dynamics and take on shapes classified by catastrophe theory. At finite wavelengths they produce interference patterns containing networks of vortices (phase singularities). Here we investigate caustics in quantized fields, focusing on the collective dynamics of quantum spins. We show that, following a quench, caustics are generated in the Fock space amplitudes specifying the many-body configuration and which are accessible in experiments with cold atoms, ions, or photons. The granularity of quantum fields removes all singularities, including phase singularities, converting point vortices into nonlocal vortices that annihilate in pairs as the quantization scale is increased. Furthermore, the continuous scaling laws of wave catastrophes are replaced by discrete versions. Such "quantum catastrophes" are expected to be universal dynamical features of quantized fields.

The helping network approach: Community promotion of mental health

The Galt Helping Network Project was a two-year program to augment mental health and community services in a rural California community through the use of natural or informal resources. The experiment made use of a preventive intervention model which identified important needs of local youth and families, board and care residents, the entire community for recreation and for mental health services, and the Mexican American Community for recognition and participation. It brought a number of volunteers into the provision of direct services and created a number of institutional forms by which continued services and enlarged voluntary participation in community affairs are continuing beyond the official end of the project. This article concludes that the Galt Helping Network Model can provide a major contribution to mental health maintenance and community involvement through the recognition of natural helpers and the involvement of the community in an active form of problem solving. Through these methods a community with limited fiscal resources can take a major step toward providing a caring and helping environment for its members.

Momentum conserving one-dimensional system with a finite thermal conductivity

A one-dimensional system of particles is examined in which even numbered particles are bound to adjacent even particles by harmonic spring forces, while odd particles are free. Even and odd particles collide elastically. This is a momentum conserving modification of the famous "ding-a-ling" model. Molecular-dynamics simulations are carried out and the current power spectra are obtained. The energy current power spectrum has zero slope at low frequencies. This implies that the thermal conductivity κ is finite and independent of system length L , for L sufficiently large. Steady-state simulations provide further evidence that κ is independent of L at large values of L . The relevance of this result to the proof by Prosen and Campbell that momentum conservation with nonvanishing pressure implies an infinite thermal conductivity is discussed.

Reinforced postmating reproductive isolation barriers in Neurospora, an Ascomycete microfungus

Maladaptive hybridization promotes reinforcement, selection for stringent reproductive isolation barriers during speciation. Reinforcement is suspected when barriers between sympatric populations are stronger than allopatric barriers, and particularly when stronger barriers evolve in the species and sex suffering the greatest costs of hybridization. Canonically, reinforcement involves premating barriers. Selection for postmating barriers is controversial, but theoretically possible. We examined geographical patterns in reproductive isolation barriers between Neurospora crassa and Neurospora intermedia, fungi with pheromone-mediated mate recognition and maternal care. We find that isolation is stronger between sympatric populations than allopatric populations, and stronger barriers are associated with the species (N. crassa) and mating role (maternal) suffering the greater costs of hybridization. Notably, reinforced isolation involves a postmating barrier, abortion of fruitbodies. We hypothesize that fruitbody abortion is selectively advantageous if it increases the likelihood that maternal Neurospora individuals successfully mate conspecifically after maladaptive hybrid fertilization.

Hub-and-spoke model for a 5-day structured patient education programme for people with Type 1 diabetes

AIMS

Structured education programmes for people with Type 1 diabetes can deliver improved diabetes control (including reduced severe hypoglycaemia) and quality of life. They can be cost-effective but are resource intensive. We tested the ability to deliver an evidence-based 5-day programme in diabetes centres too small to deliver the courses.

METHODS

Specialist medical and nursing staff from three district general hospital diabetes services (the 'spokes') were trained in all aspects of the education programme, except those directly related to course delivery, by a larger centre (the 'hub'). The hub staff delivered the 5-day patient education courses, but all other patient education and management was managed locally. Diabetes control and quality of life were assessed at 1 year post-course.

RESULTS

In 63 patients with follow-up data, glycated haemoglobin (HbA(1c)) fell by 0.42 +/- 1.0% (P = 0.001), with a greater fall in those with high HbA(1c) at baseline, and no mean weight gain. Emergency call-out for severe hypoglycaemia fell from 10 episodes in seven patients the year before to one episode in one patient (P = 0.03). Quality-of-life measures improved, with reduced negative impact of diabetes on diabetes-related quality of life (P < 0.00004) and 'present quality of life' improving (P < 0.001).

CONCLUSIONS

The benefits of a 5-day structured education programme can be provided to patients with Type 1 diabetes attending centres without the resources to provide the teaching course itself, by a 'hub-and-spoke' methodology.

Required steps for the validation of a Laboratory Information Management System

The task of managing laboratory data is not a new one. Over the past two decades, the use of Laboratory Information Management Systems (LIMS) has revolutionized how laboratories manage their data. A LIMS is more than software; it has become the workhorse of the laboratory, encompassing laboratory work-flow combined with user input, data collection, instrument integration, data analysis, user notification, and delivery of information and reporting. Types of organizations that utilize LIMS vary greatly from research laboratories to manufacturing laboratories to environmental testing laboratories. Commercially-available LIMS have been around since the 1980s. In addition, many laboratories have designed, implemented, and maintained in-house LIMS. The heart of any LIMS is the software. Like other laboratory systems, the LIMS software is subject to quality control and quality assurance checks. In regulatory environments this associated QA/QC is referred to as "system validation." The primary purpose of system validation is to ensure that the software is performing in a manner for which it was designed. For example, the system acceptance criteria should be established and tested against quantifiable tasks to determine if the desired outcome has been achieved. LIMS features, such as autoreporting, reproducibility, throughput, and accuracy must be quantifiable and verifiable. System validation ensures that the entire system has been properly tested, incorporates required controls, and maintains and will continue to maintain data integrity. Laboratories must establish protocols and standards for the validation process and associated documentation. Although vendors of commercial LIMS perform initial internal system validations, the system must be revalidated whenever the end user, vendor or third party adds modifications or customizations to the LIMS. Currently, detailed guidance regarding system validation of LIMS is not available to the user. The issue is addressed in Good Automated Laboratory Practices (GALP) and National Environmental Laboratory Accreditation Conference (NELAC) documents which indicate specific requirements or recommendations for operational checks and periodic testing; however, it is up to the laboratory to determine suitable methods to accomplish these tasks. Proper validation of a LIMS will allow a laboratory to comply with regulations and also provide comprehensive documentation on the system that is necessary to troubleshoot future problems.

The case for responsibility of the IT industry to promote equality for women in computing

This paper investigates the relationship between the role that information technology (IT) has played in the development of women's employment, the possibility of women having a significant influence on the technology's development, and the way that the IT industry perceives women as computer scientists, users and consumers. The industry's perception of women and men is investigated through the portrayal of them in computing advertisements. While women are increasingly updating their technological skills and know-how, and through this process are entering some positions in the workplace traditionally occupied by men, these achievements are not mirrored in their social and occupational status. The computer industry and higher education have worryingly low numbers of women, while the possibility of women influencing the development of computer technology is just emerging in feminist research. This paper argues that, though the IT industry, through their self-regulatory codes, subscribes to equal treatment of sexes, races and persons with disabilities, the industry nevertheless paints a stereotyped picture of inequality when portraying men and women in computer advertisements. As long as such a perception of women prevails within the industry, it will stand as a barrier to women having equal access to computer technology. If advertisements influence the way society perceives major social constructs and issues, then the computing industry has a social responsibility to portray men and women in an equal and non-stereotypical fashion.

The impact of a structured programme of asthma care in general practice

The impact of a new GP programme of asthma care was examined using: a) a retrospective pre- and post-casenote survey of 400 asthma patients, comparing patients in practices using the health board programme (HBP) and other programmes (OP); and b) a patient satisfaction questionnaire, completed by 532 people on asthma clinic lists in HBP and OP practices. Outcomes assessed were health service use, perceived change in symptoms and asthma self-management. The casenote survey indicated improved health service use by patients in HBP practices, with fewer patient-initiated (p < 0.05), emergency (p < 0.05) and other chest-related attendances (p < 0.01) and increased clinic attendance (p < 0.05) post intervention. OP practices also showed reduced patient-initiated (p < 0.01) and increased asthma clinic use (p < 0.01). Increased use of management plans (p < 0.01) and peak flow diaries (p < 0.01) was noted post intervention for HBP practices. Responders to the questionnaire survey perceived that clinic attendance improved asthma symptoms, including severity and control, sleep disturbance and early morning wheeze. People in HBP practices were more likely than those in OP practices to possess a peak flow meter, a diary and a personal management plan (all p < 0.01 or above) but were not more likely to use a peak flow diary. Notwithstanding methodological difficulties in the selection of practices, both studies showed trends towards improvement in health service use and asthma self-management. The HBP was associated with greater improvement in self-management processes and outcomes, and greater patient satisfaction with asthma care.

First-line management of menorrhagia: findings from a survey of general practitioners in Forth Valley

This study was undertaken to determine local GPs' current management of menorrhagia, prior to the release of the Royal College of Obs tetricians and Gynaecologists' (RCOG) guideline on the initial management of menorrhagia. A postal questionnaire was sent to 204 GPs in the Forth Valley area. An 84% (n = 173) response rate was recorded. Responses were compared with RCOG guideline recommendations after its release. Fifty-two percent of respondents measured a full blood count and 56% performed a pelvic examination. Two thirds of GPs chose the recommended treatments (mefenamic acid or tranexamic acid) as their first or second choice of treatment in women not requiring contraception. One third chose cyclical progestogens. Only 10% of GPs selected an ineffective treatment (cyclical progestogens) as their first or second choice of treatment in women requiring contraception. This survey demonstrates that the majority of GPs are already prescribing the treatments recommended in the RCOG guidelines. There is a need for education amongst a minority to improve their practice. Half of the GPs reported compliance with the recommended investigations of full blood count and pelvic examination. The point at which these investigations are performed in the initial management of menorrhagia may need further discussion between primary and secondary care clinicians to clarify their purpose.

How reliable is a vasectomy? Long-term follow-up of vasectomised men

Around 42 million couples worldwide rely on vasectomy as a method of family planning. It is well recognised that a vasectomy can fall at any stage, and therefore warning couples of risk of failure forms an important part of the consent procedure.

Endothelial monocyte activating polypeptide II induces endothelial cell apoptosis and may inhibit tumor angiogenesis

Endothelial monocyte activating polypeptide II (EMAP-II) is a tumor-derived cytokine with potent effects on endothelial cells in vitro and in vivo including upregulation of tissue factor and the sensitization of human melanoma to systemic TNF treatment via its effects on the tumor vasculature. We investigated the effects of EMAP-II on tumor growth, angiogenesis, vasculogenesis, and apoptosis. EMAP-II inhibited endothelial cell proliferation, vasculogenesis, and neovessel formation. In vivo growth of human melanoma lines expressing high amounts of EMAP-II demonstrated slower growth, smaller tumors, and increased amounts of tumor necrosis than those expressing lower amounts of EMAP-II. EMAP-II induced endothelial-cell-specific apoptosis via a pathway that includes upregulation of the Fas-associated death domain and downregulation of Bcl-2. EMAP-II appears to have important effects on angiogenesis and may play a role in regulating tumor vascular growth.

Isolated organ perfusion does not result in systemic microembolization of tumor cells

BACKGROUND

Isolated organ perfusion with hyperthermia and melphalan with or without tumor necrosis factor-alpha has been effectively used to treat regionally confined, unresectable malignancies of both the limb and liver. Many patients, however, will eventually relapse at distant sites. We used reverse transcription-polymerase chain reaction (RT-PCR) to determine whether significant tumor microembolization occurs in patients undergoing isolated limb perfusion (ILP), isolated hepatic perfusion (IHP), or hepatic resection.

METHODS

Primers specific for the human tyrosinase gene or carcinoembryonic antigen gene were designed for RT-PCR to screen melanoma or colon adenocarcinoma, respectively. RNA from human melanoma lines (Pmel and 1286) and human colon adenocarcinoma lines (H508 and HT29) were used to generate positive control cDNA. Normal human blood was inoculated with tumor cells at concentrations that ranged from 10(-2) to 10(5) tumor cells/ml of blood to define the sensitivity. Systemic and perfusate blood samples were drawn from 15 patients (8 patients underwent IHP, 5 patients underwent ILP, and 2 patients underwent resection) before the start of the operation, immediately before and during the perfusion, and postoperatively. Mononuclear cell fractions were separated from the blood samples and RNA was extracted for the RT-PCR assay. Standard primers for human beta-actin were used to confirm that cDNA was generated after the RT reaction.

RESULTS

RT-PCR assay sensitivity was determined to be 10 tumor cells/ml of whole blood. Of the 8 IHP patients, 6 had colon metastases and 2 had ocular melanoma metastases to the liver. All 5 ILP patients had in transit melanoma of the extremity. Two patients with colon metastases to the liver were found to have resectable disease. There were no detectable circulating tumor cells in the systemic circulation either preoperatively or postoperatively in all 15 patients that were screened.

CONCLUSIONS

RT-PCR is a highly sensitive method of detecting tumor cells in perfusate or blood. Manipulation of the limb or liver followed by resection or isolated hyperthermic perfusion does not cause detectable release of circulating tumor cells. The late development of distant metastases observed in many of these patients does not correlate with the ability to measure circulating tumor cells during regional therapy.

The effects of seasons and light therapy on G protein levels in mononuclear leukocytes of patients with seasonal affective disorder

BACKGROUND

Information-transducing heterotrimeric G proteins have been implicated previously in the mechanism of action of mood stabilizers and in the pathophysiology of mood disorders. Mononuclear leukocytes of patients with unipolar and bipolar depression have been characterized by reduced measures of the stimulatory and inhibitory G proteins. In this study, patients with seasonal affective disorder (SAD) were measured for mononuclear leukocyte G protein levels while depressed during the winter, following light therapy, and in remission during the summer.

METHODS

Twenty-six patients with SAD and 28 healthy subjects were assessed in the study. The immunoreactivities of Gs alpha, Gi alpha, and Gbeta subunit proteins were determined by Western blot analysis of mononuclear leukocyte membranes with selective polyclonal antibodies for the various G subunit proteins, followed by densitometric quantitation using an image analysis system.

RESULTS

Untreated patients with SAD and winter, atypical-type depression showed significantly reduced mononuclear leukocyte immunoreactive levels of Gs alpha and Gi alpha proteins, similar to previous observations in patients with nonseasonal major depression. The reduced G protein levels were normalized with 2 weeks of light therapy. The same patients while in remission during the summer had G protein levels that were similar to those of healthy subjects.

CONCLUSIONS

G protein-immunoreactive measures in patients with SAD are suggested as a state marker for winter depression, which is normalized by light treatment and during the summer. We speculate that light may exert its effects via normalization of transducin (Gt protein) levels, which are thought to be reduced in winter depression.

In vivo sensitivity of human melanoma to tumor necrosis factor (TNF)-alpha is determined by tumor production of the novel cytokine endothelial-monocyte activating polypeptide II (EMAPII)

Tumor necrosis factor (TNF)-alpha is a potent anticancer agent that seems to selectively target tumor-associated vasculature resulting in hemorrhagic necrosis of tumors without injury to surrounding tissues. The major limitation in the clinical use of TNF has been severe dose-limiting toxicity when administered systemically. However, when administered in isolated organ perfusion it results in regression of advanced bulky tumors. A better understanding of the mechanisms of TNF-induced antitumor effects may provide valuable information into how its clinical use in cancer treatment may be expanded. We describe here that the release of a novel tumor-derived cytokine endothelial-monocyte-activating polypeptide II (EMAPII) renders the tumor-associated vasculature sensitive to TNF. EMAPII has the unique ability to induce tissue factor production by tumor vascular endothelial cells that initiates thrombogenic cascades, which may play a role in determining tumor sensitivity to TNF. We demonstrate here that constitutive overexpression of EMAPII in a TNF-resistant human melanoma line by retroviral-mediated transfer of EMAPII cDNA renders the tumor sensitive to the effects of systemic TNF in vivo, but not in vitro. This interaction between tumors and their associated neovasculature provides an explanation for the focal effects of TNF on tumors and possibly for the variable sensitivity of tumors to bioactive agents.

Augmented capillary leak during isolated hepatic perfusion (IHP) occurs via tumor necrosis factor-independent mechanisms

Isolated organ perfusion of the liver or extremity with tumor necrosis factor (TNF) and melphalan results in regression of bulky tumors in the majority of patients. The efficacy of TNF in this setting is not known, although data suggest that it may exert antitumor effects primarily on tumor-associated neovasculature. We studied the effects of TNF on capillary leak in liver and tumor tissue during isolated hepatic perfusion (IHP) with melphalan. Twenty-seven patients with unresectable cancer confined to the liver underwent a 60-min hyperthermic IHP using 1.5 mg/kg melphalan alone (n = 7) or with 1.0 mg of TNF (n = 20). Complete vascular isolation was confirmed in all patients using an intraoperative leak monitoring I-131 radiolabeled albumin technique. Samples of tumor and liver were collected just prior to and immediately after IHP. There was no difference in I-131 radiolabeled cpm/g of tissue (cpm) in liver versus tumor at baseline (P2 = 0.44). After IHP, I-131 albumin cpm were higher in tumor versus liver (10,999 +/- 1,976 versus 3,821 +/- 780, respectively; P2 < 0.005). However, I-131 albumin cpm in tumor were not effected by TNF (11,636 +/- 2,518 with TNF versus 9,180 +/- 2,674 without TNF; P2 = 0.59). TNF did not affect melphalan concentrations in tumor (1,883 +/- 540 ng/g versus 1,854 +/- 861 ng/g without TNF; P2 = 0.9). Capillary leak, as reflected by diffusion of I-131 radiolabeled albumin into the interstitial space, is comparable in liver and tumor before IHP but is significantly higher in tumor after IHP. The increased diffusion in the capillary tumor bed must occur through TNF-independent mechanisms such as intrinsic features of tumor neovasculature, hyperthermia, or other unrecognized perfusion-related factors. These data indicate that TNF must continue to be critically evaluated in clinical trials before it is routinely used with melphalan in isolated organ perfusion.

Placodal origin of Brn-3-expressing cranial sensory neurons

The Brn-3 class of POU-domain transcription factors includes three genes in mammals which have key roles in the development of specific groups of sensory neurons. Here, we have identified three avian genes which correspond to the murine genes Brn-3.0, Brn-3.1, and Brn-3.2. Using an in situ hybridization probe generic for this gene class, the earliest detectable expression of Brn-3 in the chick is at stage 15, in placodal and migrating precursors of the trigeminal ganglion. By stage 19, Brn-3.0 protein is detectable in the trigeminal and vestibulocochlear ganglia with Brn-3.0-specific antisera, and Brn-3 message expression has extended to the dorsal root ganglia. At later stages, when condensation of the trigeminal ganglion is complete, Brn-3.0-immunoreactive neurons are concentrated in the portion of the ganglion distal to the brain stem. To examine the developmental origin of the Brn-3 expressing cells, we combined lipophilic dye (DiI) labeling with in situ hybridization. DiI labeling of the placodal surface ectoderm and of premigratory neural crest cells in the neural tube reveals that all, or nearly all, of the Brn3-expressing neurons in the trigeminal ganglia are derived from the sensory placodes and not from the neural crest, and thus, that Brn-3 is an early marker of the placode-derived sensory neural lineage.

Vitamin D receptor gene polymorphism in men and its effect on bone density and calcium absorption

OBJECTIVE

Previous studies have suggested that polymorphism of the alleles of the vitamin D receptor (VDR) gene may account for the major part of the heritable component of bone density in women, possibly mediated in part by impaired calcium absorption from the bowel. In view of the increasing importance of osteoporosis in men, we have now investigated the association between common allelic variations in the vitamin D receptor gene, calcium absorption and bone density in men.

SUBJECTS

Forty-eight men (median age 64, range 27-77) with a wide range of bone density measurements, comprising 20 men with vertebral crush fractures and 28 male control subjects.

MEASUREMENTS

Analysis of the VDR gene polymorphism and measurement of fractional radiocalcium absorption and bone mineral density was performed in all subjects.

RESULTS

The distribution of the three genotypes (TT, tt, Tt) was comparable to that reported previously. There was no significant difference in femoral neck bone density Z-scores between the three genotypes (mean +/- SD TT -0.31 +/- 1.19, tt -0.08 +/- 1.28 and Tt -0.37 +/- 1.17). There were also no significant differences in mean femoral neck bone density T-scores or lumbar spine bone density Z or T-scores between the three genotypes. Fractional radiocalcium absorption was 0.59 +/- 0.27 for TT, 0.69 +/- 0.30 for tt and 0.60 +/- 0.30 for Tt, showing no significant difference between the genotypes.

CONCLUSIONS

This study shows no association between vitamin D receptor gene polymorphism and bone density or fractional calcium absorption in a group of men with a range of bone density values. We conclude that the vitamin D receptor gene alleles probably account at most for only a small part of the genetic component of bone density in men.

[The effect of convection warming during abdominal surgery on the early postoperative heat balance]

Hypothermia (core temperature < 36 degrees C) is common after longer-lasting surgical procedures. Heat loss mainly occurs during anaesthesia and surgery and leads to increased risk, especially in the early recovery period of elderly patients. In the present study we investigated the effects of intraoperative forced-air warming, administered via an upper-body blanket ("Warm Touch", Mallinckrodt, USA), with the specific aims of: (1) drawing up heat balances; and (2) analysing postoperative thermoregulation, oxygen consumption (VO2) and cardiovascular reactions of mechanically ventilated patients. The general aim of our study was to compare intraoperative forced-air-warming and conventional patient-insulation with cotton blankets.

METHODS

Twenty four ASA II and III patients scheduled for elective colon surgery were randomly assigned to a control group (n = 12, no warming therapy, upper body covered with a cotton hospital blanket) or a convective warming group (n = 12). Anaesthesia was administered with etomidate (0.2 mg/kg), fentanyl (approximately 10 micrograms/kg) and vecuronium bromide (0.1 mg/kg). During surgery the lungs were mechanically ventilated with 70% nitrous oxide in oxygen and enflurane (end-tidal-concentration max. 0.7%) using a semiclosed circuit with a fresh gas flow of 3 l/min. A hygrophobe heat and moisture exchanger ("Sterivent," Darex Corp., Italy) was used. At the end of surgery patients were transferred to the ICU, covered with a hospital cotton-quilt and normo-ventilated using a Bennett 7200 a. Patients were sedated/kept free of pain by administering titrated doses of midazolam and/or piritramide. Postoperative oxygen consumption (VO2) was recorded continuously with a Deltatrac Metabolic Monitor (Datex Corp., Finland). Pre-, intra- and postoperative measurements included heart rate, invasive blood pressure, core-temperature (before and after operation: urinary bladder-temperature, during surgery: oesophageal temperature) and mean-skin-temperature (according to Ramanathan) up to 180 min from the end of surgery. Shivering, pharmacological interventions (e.g. pethidine) and time of extubation were noted. Data are presented as median, minima and maxima. The results were analysed using the Mann-Whitney U test or Chi-Square test (shivering). Statistical significance was assumed when P < 0.05.

RESULTS

Both groups were comparable for gender, body weight, height, age, duration of their operations and amount of intraoperative fluids, narcotics and muscle relaxants. Room temperatures in the control group were significantly higher than in the forced air group (24 vs 22 degrees C). Initial setting of the forced-air blower was "high" (42-46 degrees high air flow). When the oesophageal-temperature reached 36.5 degrees C, the blower temperature was reduced to 36-40 degrees C. Reduction was necessary approximately 60 min from start in the operation. At the end of surgery/administration to the ICU core-temperatures of both groups differed significantly (35.2/ 35.4 degrees C vs 36.3/36.2 degrees C). Mean-skin temperatures were higher, too, but no statistical analysis was carried out for the intraoperative period, because warm air influenced skin thermometers located on the upper body. At admission to the ICU patients in the control group had a heat loss of 4.4 kJ/kg; those in the convective warming group had a heat-gain of 0.8 kJ/kg. Further measurements of postoperative core temperatures did not differ significantly, but the skin-temperatures of patients who received forced-air warming in the theatre remained higher (P < 0.05) until 120 min from the end of surgery. Shivering was more frequent and lasted longer in the control group (8 patients, 20 min vs 4 patients, 9 min; P < 0.05). Patients in the control group needed more drugs to stop increased cardiovascular reactions (hypertension, tachycardia) or shivering.(ABSTRACT TRUNCATED)

Temporary reappearance of sperm 12 months after vasectomy clearance

OBJECTIVES

To determine the incidence of positive semen analysis 12 months after vasectomy clearance.

SUBJECTS AND METHODS

A prospective study was undertaken, starting in 1990, of men undergoing vasectomy. Azoospermia was confirmed by two successive semen analyses 16 weeks after vasectomy. One year later a further sample was analysed for the presence of sperm.

RESULTS

Of 1000 men who provided a sample for analysis, six men (0.6%) have had positive semen analyses 1 year after the initial tests showed azoospermia. In all six the sperm count was <10,000 per mL. Five of the six men produced a repeat sample 1 month later which, in all five cases, showed azoospermia. No pregnancies have been reported to date.

CONCLUSION

Transitory reappearance of sperm following successful vasectomy occurs in about 0.6% of men. This incidence is 18 times greater than the reported pregnancy rate following successful vasectomy.