The Measurement of Preoperative Anxiety

Preoperative anxiety was assessed using the hospital anxiety and depression (HAD) scale, multiple affect adjective check list (MAACL) and linear analogue anxiety scale (LAAS) in 100 consecutive day case patients undergoing termination of pregnancy. The HAD scale, a recently introduced self assessment scale comprising 7 multiple choice questions, was readily accepted and easily understood by patients. There was a high degree of correlation between the HAD scale and both the MAACL (correlation coefficient 0.74) and the LAAS (correlation coefficient 0.67). There was only a moderate degree of correlation between the HAD scale and the anaesthetist's assessment of anxiety (correlation coefficient 0.46). The HAD scale is a useful method of subjective measurement of preoperative anxiety.

Identification of target genes and pathways associated with chicken microRNA miR-143

MicroRNA (miRNA) is a family of small regulatory RNAs that post-transcriptionally regulate many biological functions including growth and development. Recently, the expression of chicken miRNA miR-143 was identified by using a deep sequencing approach. In other vertebrate species, miR-143 functions as a regulator of adipocyte differentiation and as a tumour suppressor. However, little is known about the biological function(s) of miR-143 in chickens. To study the functions of chicken miR-143, DNA microarray analysis and a dual luciferase reporter assay were employed to identify genes directly targeted by miR-143 as well as other biologically relevant genes. Microarray analysis indicated that 124 genes were differentially expressed upon in vitro anti-miR-143 treatment in embryonic chick splenocytes (P-value cutoff <0.01). Many of these genes are associated with cell proliferation, apoptosis and tumourigenesis. Six of the up-regulated genes possess at least one potential miR-143 binding site in their 3'UTRs, of these the binding sites of PYCR2, PSTPIP1 and PDCD5 were validated by an in vitro luciferase reporter assay. In addition, several potential targets with important biological functions were identified by the miRanda algorithm and experimentally confirmed. These targets include KLF5, MAP3K7, TARDBP and UBE2E3, which have conserved miR-143 binding sites across multiple vertebrate species. Potential chicken specific miR-143 target sites were also validated for LPIN1, PCK2, PYCR2, METTL14, SLC2A2 and TNFSF10. Overall, the current study suggests that miR-143 is ubiquitously expressed among tissues and is likely to be involved in the regulation of cell proliferation and apoptosis.

Proteins involved in iron metabolism in beef cattle are affected by copper deficiency in combination with high dietary manganese, but not by copper deficiency alone

A 493-d study was conducted to determine the impact of a severe, long-term Cu deficiency on Fe metabolism in beef cattle. Twenty-one Angus calves were born to cows receiving one of the following treatments: 1) adequate Cu (+Cu), 2) Cu deficient (-Cu), and 3) Cu deficient plus high Mn (-Cu+Mn). Copper deficiency was induced through the addition of 2 mg of Mo/kg of DM. After weaning, calves remained on the same treatment as their dam through growing (basal diet analyzed 7 mg of Cu/kg of DM) and finishing (analyzed 4 mg of Cu/kg of DM) phases. Plasma Fe concentrations were positively correlated (P < 0.01; r = 0.49) with plasma Cu concentrations. Liver Fe concentrations were greater (P = 0.05) in -Cu vs. +Cu calves and further increased (P = 0.07) in -Cu+Mn vs. -Cu calves. There was a negative relationship (P < 0.01; r = -0.31) between liver Cu and Fe concentrations. This relationship is likely explained by less (P < 0.01) plasma ceruloplasmin activity in -Cu than +Cu calves. As determined by real-time reverse transcription-PCR, relative expression of hepatic hepcidin was significantly downregulated (>1.5 fold) in -Cu compared with +Cu calves (P = 0.03), and expression of hepatic ferroportin tended (P = 0.09) to be downregulated in -Cu vs. +Cu. In the duodenum, ferritin tended to be upregulated in -Cu. vs. +Cu calves (P < 0.06). No significant change (P > 0.2) due to Cu-deficiency was detected at the transcriptional level for either isoform of divalent metal transporter 1 (DMT1 mRNA with or without an iron responsive element; dmt1IRE and dmt1-nonIRE) in liver or intestine. Duodenal expression of hephaestin and ferroportin protein was not affected by dietary treatment (P > 0.20). However, duodenal expression of DMT1 protein was less (P = 0.04) in -Cu+Mn steers vs. -Cu steers. In summary, Cu deficiency alone did affect hepatic gene expression of hepcidin and ferroportin, but did not affect duodenal expression of proteins important in Fe metabolism. However, the addition of 500 mg of Mn/kg of DM to a diet low in Cu reduced duodenal expression of the Fe import protein DMT1.

MicroRNA expression in chicken embryos

MicroRNA (miRNA) are small single-stranded noncoding RNA that posttranscriptionally regulate gene expression. A major role of miRNA is the regulation of gene expression in developmental processes. In this study, we constructed a small RNA library from 11-d-old chick embryos and used this library to examine the miRNA expression profile of the embryos. This small RNA library was sequenced by using 454 Life Sciences pyrosequencing technology. A total of 10,466 sequences were obtained and annotated as either known chicken miRNA, miRNA that shared homology with other species, or novel miRNA. We identified the expression of 110 known chicken miRNA, 36 homologous chicken miRNA (previously unannotated in the chicken but conserved with miRNA from other species), and 14 novel chicken-specific miRNA not identified in any other species. We also demonstrated that some of the identified chicken embryonic miRNA are differentially expressed among the developing spleen, liver, or bursa. The current study demonstrates that a very diverse and dynamic set of miRNA is expressed in the embryonic chick at 11 d of incubation. The identification of miRNA present in the embryonic chicken will further aid in understanding the complexity of gene regulation during vertebrate development.

A pressing diagnosis - a compromised testicle secondary to compartment syndrome

Hydrocoeles are a common cause of scrotal swelling and discomfort in a significant proportion of men. We report a case of compartment syndrome within the tunica vaginalis. This is an unusual and previously unreported complication of a hydrocoele.

Is there an association between functional bladder outlet obstruction and Down's syndrome?

OBJECTIVE

The incidence of urinary tract abnormalities in patients with Down's syndrome (DS) is estimated to be 3-7%. Abnormalities included are renal hypoplasia, renal cysts, ureterovesical and ureteropelvic junction obstruction and, more recently, an association between males with DS and the non-neurogenic neurogenic bladder has been reported. Based on clinical experience, the hypothesis is tested that patients with DS have functional bladder outflow obstruction secondary to detrusor sphincter dyssynergia.

METHODS

This study comprised three parts: an initial retrospective review of case notes of existing patients, followed by a prospective community-based study of all patients with DS to assess the incidence and types of bladder dysfunction, and a final hospital-based assessment where a problem was identified following return of the questionnaire.

RESULTS

The retrospective study identified a high potential for renal injury with three out of seven patients requiring urinary diversion for dilated upper tracts secondary to bladder outflow obstruction. The prospective study identified a high incidence (77%) of bladder dysfunction with 68% having a history of wetting.

CONCLUSION

There is a potentially serious problem in children with DS that is not widely appreciated. We recommend that, at the very least, such children have a detailed history of bladder function taken, and where a problem is detected a urinary tract ultrasound scan should be performed.

Using Proteomics to Understand Avian Systems Biology and Infectious Disease

The proteome is defined as the protein complement to the genome. Proteomics is the study of the proteome. Several techniques are frequently used in proteomics; these include 2-hybrid systems, 2-dimensional gel electrophoresis, and mass spectrometry. Systems biology is a scientific approach that takes into account the complex relationships among and between genes and proteins and determines how all of these interactions come together to form a functional organism. Proteomic tools can simultaneously probe the properties of numerous proteins and thus are a great aid to the emerging field of systems biology, in which the functional interactions of numerous proteins are studied instead of studying individual proteins as isolated entities. In the field of avian biology, proteomics has been used to study everything from the development and function of organs and systems to the interactions of infectious agents and the altered states that they induce in their hosts.

A right-sided renal carcinoma uniquely presenting as a mass in the spermatic cord

Renal cell carcinoma presenting as a mass in the left testis or spermatic cord has previously been described with retrograde venous spread along the gonadal artery as the suggested mechanism. However a right-sided presenting lesion has not been described and suggests an alternative method of spread.

Randomised controlled study of sleep after nefazodone or paroxetine treatment in out-patients with depression

BACKGROUND

Sleep effects of antidepressants are important clinically and for elucidating mechanism of action: selective serotonin reuptake inhibitors disturb sleep and 5-HT(2) receptor-blocking compounds may enhance sleep quality.

AIMS

To compare the objective and subjective effects on sleep of paroxetine and nefazodone in patients with moderate to severe depression.

METHOD

Forty patients with depression were randomised to take paroxetine 20-40 mg/day or nefazodone 400-600 mg/day for 8 weeks. Objective and subjective quality of sleep and depression measures were assessed throughout.

RESULTS

Nefazodone significantly increased objective sleep efficiency and total sleep time, and improved subjective sleep on days 3 and 10. Paroxetine decreased sleep efficiency early in treatment and some sleep disruption remained at week 8. Paroxetine but not nefazodone produced marked suppression of rapid eye movement (REM) sleep.

CONCLUSIONS

Nefazodone improves sleep in early treatment compared with paroxetine in patients with moderate to severe depression. These effects are seen within the first 2 weeks of treatment and diminish thereafter.

Causes of end-stage renal failure in black patients starting renal replacement therapy

In the United States, blacks are more frequently diagnosed than whites with end-stage renal failure (ESRF) from primary hypertension or diabetic nephropathy. We performed a validation retrospective case-note study of all blacks with ESRF who started renal replacement therapy (RRT) at three teaching hospitals in London, England, during 1991 to 1995 to investigate and validate the causes of primary renal disease using standard criteria. We identified 144 black patients with a mean age of 52.0 +/- 16.0 (SD) years; 59% were men and 32% had renal histological data. One hundred forty-four whites who were matched for age, sex, and onset of RRT (42% with renal histological data) underwent a similar validation exercise. Before the validation, the principal working diagnosis in the black patients had been diabetic nephropathy in 35% (89%, type 2; 11%, type 1); primary hypertension, 19%; glomerulonephritis (GN), 18%; and uncertain cause, 15%. After validation analysis, this changed to diabetes, 38% (16% biopsy proven); uncertain, 24%; GN, 20%; and primary hypertension, only 10% (28% biopsy proven). Among the uncertain cases (n = 34), 19 patients had hypertension, but this could not be established as the primary disease; 94% of all blacks had hypertension, accelerated in 21%. Among whites, only 3.5% had primary hypertension, and this proportion was not changed by the validation study. Type 2 diabetes is the most common single cause of ESRF in black patients in London, and although hypertension is more common and more severe in blacks, the proportion of renal failure attributed to primary hypertension is overestimated, and the diagnosis is often made using inadequate criteria.

Pseudo-narcolepsy: case report

This report describes the case of a 44-year-old woman presenting to a Sleep and Alertness clinic with symptoms of narcolepsy. The patient had clinical and polysomnographic features of narcolepsy, which disappeared after disclosure of severe psychological stress. Following a discussion of the differential diagnosis of narcolepsy, alternative diagnoses are considered. The authors suggest that the patient had a hysterical conversion disorder, or "pseudo-narcolepsy." Careful inquiry into psychological factors in unusual cases of narcolepsy may be warranted.

The very long-term prognosis and complications of lupus nephritis and its treatment

Although the short- and medium-term (5-10 years) outcome of patients with lupus nephritis has been studied extensively, there are very few data on the second and subsequent decades. We studied outcome in 110 local patients investigated at a single centre before 1986, who all had potential follow-up of more than 10 years (actual 2-31 years, median 15.5 years). At last follow-up, 40 patients were dead and 70 alive, nine of whom were on maintenance dialysis or transplanted, actuarial survivals being 84%, 72%, 62%, 61% and 54% at 5, 10, 15, 20 and 25 years for the group as a whole. Survival was better in the cohort 1976-86 (n = 60) than in that from 1963-75 (n = 50) (90, 81 and 76% vs. 78, 56 and 43% at 5, 10 and 15 years, p < 0.001). Sepsis (12) and myocardial infarction (8) were the principal causes of death. Of living patients with renal function, 38% had normal urine and renal function, 11 were off all treatment (19%), 62% had persistent proteinuria and 18% had reduced but generally stable renal function. Renal failure, in those patients who developed it, occurred during the first decade and none of 67 patients actually followed more than 10 years subsequently went into renal failure. Induction treatment was with prednisolone, combined with azathioprine in more severe forms of nephritis, and from the middle 1970s to 1986, 30 with methylprednisolone and in 12 cases plasma exchange. Seventeen other patients were treated using oral cyclophosphamide during the 1960s. No patient received i.v. cyclophosphamide as induction therapy, although nine patients had this form of treatment later, largely because of non-compliance. Serious complications of lupus and/or its treatment occurred in 49%: sepsis in 32, ischaemic heart disease in 20, thrombosis in one and avascular necrosis of bone in eight. In contrast, fracturing osteoporosis occurred in only three, and cataracts requiring surgery and diabetes mellitus in none. The very long-term outlook of lupus nephritis, especially its more severe forms, has improved, but that with current management strategies only a minority of patients are able to stop treatment altogether, and the incidence of serious complications is high.

Impaired outcome of continuous ambulatory peritoneal dialysis in immunosuppressed patients

BACKGROUND

Although immunodeficiency predisposes to CAPD peritonitis with fungal or unusual organisms, the role of immunosuppression as a predisposing factor for CAPD peritonitis, as well as the outcome of such episodes, remains uncertain.

METHODS

The incidence, spectrum of infectious organisms, and outcome of CAPD peritonitis was retrospectively reviewed in 39 immunosuppressed and 146 non-immunosuppressed patients treated with CAPD over the calendar year 1993.

RESULTS

Immunosuppressed patients were younger (mean 44 vs 57 years, P<0.001) and had an increased incidence of previous transplantation, glomerulonephritis, systemic lupus erythematosus, and vasculitis. Immunosuppressed patients had more episodes of peritonitis (69/29 patients vs 99/147, P<0.001), required more frequent hospital admission (25/39 vs 33/146, P<0.001), had more days off CAPD (331 vs 242, P<0.001), and required more laparotomies to remove infected CAPD catheters (11/39 vs 14/146, P<0. 01). Immunosuppression was associated with increased infection due to S.aureus and fungi, which may have contributed towards increased morbidity in this group. Current immunosuppression or a recent history of immunosuppression appeared to be equally potent risk factors for infection. There was a trend for the incidence of infection to parallel the aggressiveness of immunosuppression.

CONCLUSIONS

Immunosuppression is an important risk factor for CAPD peritonitis. A high index of suspicion for infection and aggressive chemotherapy are mandatory. CAPD may not be the initial therapy of choice in this high-risk group.

Unusual presentations of anti-glomerular basement membrane antibody mediated disease are associated with delayed diagnosis and poor outcome

Anti-glomerular basement membrane antibody mediated disease (anti-GBM disease) is an uncommon cause of renal failure. Presentation is usually dramatic, with renal failure and alveolar hemorrhage leading to an early diagnosis. In contrast, we here describe 3 cases which presented with atypical features, and where diagnosis was delayed due to the presence of other factors which were initially felt sufficient to explain the clinical status. No patient recovered renal function, and one died from sepsis. We also present data on 15 patients presenting to Guy's Hospital over the past 10 years with anti-GBM disease and creatinine > 500 mumol/l. The median delay from presentation to diagnosis was 7 days, range 1-81 days. Two patients died, and only one recovered renal function. We speculate that earlier referral and renal biopsy might have improved outcome in these patients, and recommend a policy of early biopsy in all cases of acute renal failure with atypical feature, delay in recovery, or where a clearcut cause is not established.

Improved survival in lupus nephritis in the modern era (1979 - 1989)

We analysed outcome retrospectively in relation to treatment and disease stage in patients with systemic lupus erythematosus and glomerulonephritis, and compared these with similar patients referred to us during 1969 - 78, and other published series from the same period. Eighty two patients with lupus nephritis were referred during 1979 - 89. Of these, 73 were followed up for a mean of 58.1 (SD 34.5) months. The histological pattern in renal biopsies was WHO Class IV (diffuse proliferative glomerulonephritis) in 59% of patients. In the acute phase 43 patients received intravenous nethyl-prednisolone IG daily, for three days, in 25 accompanied by daily 4 litre plasma exchanges on 5 to 10 days. Twelve patients received induction therapy using oral cyclophosphamide during the acute phase, for 8 - 12 weeks only. Maintenance therapy was with oral prednisolone in all patients, accompanied by azathioprine in 84% of cases. Long- term cyclophosphamide was never used, neither intravenously nor orally. At 10 years actuarially calculated patient survival was 87% and survival of renal function 86% compared with 57% and 65% respectively in 1970 - 78 ([P < 0.01]). Survival was no different in patients with renal biopsies classified into the various WHO classes. In patients with Class IV biopsies, survival in those treated with prednisolone and azathioprine only was the same as that in those given intravenous methylprednisolone and/or plasma exchange as well. However, patients treated with methylprednisolone or plasma exchange tended to have more severe disease. At last followup, 24/82 patients were in complete remission, 23 had normal plasma creatinine concentrations but abnormal urine, ie proteinuria, haematuria, or both, 16 had abnormal urine and elevated plasma creatinine concentrations, and 9 had started renal replacement therapy. Eight patients had died. The survival of patients with lupus nephritis has improved in the past decade in patients with comparable severity of disease, and renal failure is no longer the principle cause of death. Results of maintenance treatment using azathioprine as adjunct to oral prednisolone in patients with severe nephritis are as good as those in series published elsewhere describing regular intravenous cyclophosphamide. No clear advantage was evident from the additional use of intravenous methylprednisolone and/or plasma exchange in the acute phase, in patients with WHO Class IV severe diffuse proliferative glomerulonephritis.

Long-term follow-up after total parathyroidectomy without parathyroid reimplantation in chronic renal failure

Forty-three patients with secondary or autonomous hyperparathyroidism complicating chronic renal failure (CRF) underwent total parathyroidectomy (PTX) (follow-up 2-18 years, mean 8.7 years). Five were on conservative treatment for CRF, 35 on regular dialysis, and only three had a functioning allograft. At PTX, the most frequent findings were uncontrollable hypercalcaemia, musculo-skeletal pain, radiographic changes in the phalanges, and raised plasma parathyroid hormone (PTH) concentration. Pre-operatively, all patients were loaded with dihydrotachysterol or 1-alpha-OH cholecalciferol. Postoperatively, they were maintained on tapering doses of the same drugs and, briefly, oral calcium supplements. Five glands were identified and removed in two patients, four in 35 patients, three in three patients and only two in one patient. All had changes of hyperplasia and adenoma formation, except for one with a parathyroid carcinoma. Prompt symptomatic and radiographic improvement occurred, with normalization of plasma calcium and alkaline phosphatase. Postoperative PTH levels were available in 33 patients (23 by intact PTH assay): they were persistently high in 10/33 (2/23 intact); normal in seven (6 intact); low in 11 (3 intact), and undetectable in four (3 intact). Thus, PTX was incomplete in the majority of patients. Following transplantation, 3/20 (3/18 intact) patients still had detectable PTH. Only one patient developed symptomatic recurrent parathyroid disease requiring re-operation, and complications were few. Small dosages of vitamin D continue to be required, but not calcium supplementation, and no clinical effects of possible adynamic bone have been noted. At later renal transplantation in 27 patients, an easily treatable, uncomplicated hypocalcaemia was noted in 33%.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous epidural infusion of 0.075% bupivacaine for pain relief in labour. A comparison with intermittent top-ups of 0.5% bupivacaine

Seventy-three women who requested epidural analgesia during labour were randomly allocated in a prospective study to receive either a continuous epidural infusion of 0.075% bupivacaine at a rate of 12-18 ml/hour (38 mothers) or intermittent top-ups of 0.5% bupivacaine (35 mothers). Both groups received an initial dose of 6-8 ml bupivacaine 0.5%. Patients were asked to score their pain using a 10-cm linear scale prior to insertion of the epidural, 30 minutes after its insertion and hourly thereafter. The quality of analgesia in the continuous infusion group was significantly better than in the intermittent top-up group (p less than 0.025). There was no significant difference in the total dose of bupivacaine given to the two groups.

End-stage renal failure in systemic lupus erythematosus with nephritis

The survival of patients in end-stage renal failure from lupus nephritis offered renal substitution therapy has been the subject of conflicting reports. Trying to clarify the reasons for this discrepancy, we analysed our experience with dialysis and transplantation in systemic lupus erythematosus (SLE). Of our 138 patients with lupus nephritis, 26 reached end-stage renal failure, of whom 24 received replacement therapy. Fourteen patients had a marked acute deterioration in renal function immediately before reaching terminal uremia, associated with active SLE in 12 and acute tubular necrosis after hypotension in one. Nine patients in this group died, 8 within 1 month of beginning dialysis. Nine patients progressed slowly to endstage renal failure over 2 to 7 years, without evidence of active SLE: only 1 required aggressive treatment and only 3 patients died, 1 five years after transplantation. Eight patients received altogether 10 allografted kidneys; 4 still functioning 10-24 months later; 2 patients are back on dialysis and 2 died, 1 of a myocardial infarct. There was no evidence of active SLE after transplantation. Ten patients were dialysed for more than 3 months; most were maintained on prednisolone and azathioprine whilst on dialysis and lupus activity tended to abate. The exclusion of the group of patients with rapid pre-terminal decrease in renal function from some series may explain some of the differences in reported survival. Stable patients with SLE present few problems in end-stage renal failure or after transplantation.

A transient thermotolerant survival response produced by single thermal doses in HeLa cells

Continuous exposure of HeLa cells in culture to elevated temperatures (41-45 degrees) results in cell killing which increases exponentially as the time at the elevated temperature increases linearly. When cells are returned to 37 degrees after an initial thermal dose, cellular sensitivity to subsequent hyperthermic doses is reduced. Cell inactivation rates for cultures previously treated with 44 degrees for either 0.5 or 1 hr followed by incubation at 37 degrees for 2 hr, showed D0's of 1.1 and 1.5 hr, respectively, for subsequent thermal treatments at 44 degrees. Cultures receiving no prior hyperthermic dose had a D0 of 0.5 hr for treatments at 44 degrees for up to 3.5 hr. The viable progeny of cells treated with 44 degrees for 1 hr, however, had the same sensitivity to thermal doses at 44 degrees as did previously unheated cells. These results and others demonstrate that (a) single thermal dose produce a state of thermotolerance in HeLa cells to subsequent hyperthermic doses; (b) the degree of thermotolerance produced is dependent on the magnitude (i.e., temperature and time at the elevated temperature) of the first thermal dose; (cy thermotolerance does not develop at the elevated temperature but requires a return of culture temperatures to 37 degrees; (d) cellular acquisition of thermal tolerance is dependent on cell metabolism, as demonstrated by an inhibition of the effect at 0 degrees; and (e) this effect is a transient phenomenon which is lost as cells divide following the first thermal dose.

Evaluation of B-mode ultrasound as a means of improving radium dosimetry in the treatment of gynecologic cancer

The radiation dose to the base of the bladder and anterior rectal wall during radium applications for gynecologic cancer is a function of the distances between the source and the bladder and rectum. Precise measurement of these distances depends on a number of factors and cannot be obtained with current radiographic localization techniques. B-mode ultrasound is useful as a means of supplementing available information. While it is not necessarily more accurate than standard radiographs, it offers a three-dimensional appreciation of pelvic anatomy and does appear to be more accurate than transverse axial tomography.

A Pedunculated Intra-bronchial Tumour (Sarcoma) causing Bronchiectasis

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