Sex Differences in Right Ventricular Dysfunction: Insights From the Bench to Bedside

There are inherent distinctions in right ventricular (RV) performance based on sex as females have better RV function than males. These differences are magnified and have very important prognostic implications in two RV-centric diseases, pulmonary hypertension (PH), and arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D). In both PH and ARVC/D, RV dysfunction results in poor patient outcomes. However, there are no currently approved therapies specifically targeting the failing RV, an important unmet need for these two life-threatening disorders. In this review, we highlight human data demonstrating divergent RV phenotypes in healthy, PH, and ARVC/D patients based on sex. Furthermore, we discuss the links between estrogen (the female predominant sex hormone), testosterone (the male predominant sex hormone), and dehydroepiandrosterone (a precursor hormone for multiple sex hormones in males and females) and RV function in both disorders. To provide potential mechanistic insights into sex differences in RV function, we review data that investigate how sex hormones combat or contribute to pathophysiological changes in the RV. Finally, we highlight the ongoing clinical trials in pulmonary arterial hypertension targeting estrogen and dehydroepiandrosterone signaling. Hopefully, a greater understanding of the factors that promote superior RV function in females will lead to novel therapeutic approaches to combat RV dysfunction in PH and ARVC/D.

The epidemiological status of African swine fever in domestic swine herds in the Tavush Province region, Armenia

KEEN The factors associated with the spread and persistence of African swine fever (ASF) in the Caucasus region remain to be fully identified. It is assumed that large naive populations of domestic free-ranging and wild pigs are critical to disease transmission and maintenance. Nonetheless, 11 years since its epidemic introduction into the region in 2007, ASF virus (ASFV) is still circulating, suggesting that an endemic cycle has been established based on contact between free-ranging domestic pigs and wild pigs, and that native Ornithodoros ticks probably serve as reservoirs for the virus. Therefore, research is required to gather information on the epidemiological status of ASF in the Caucasus region, focusing particularly on understanding modes of ASFV spread and persistence in this new virus environment. The authors established an ASFV survey targeting domestic pigs in the Tavush province of northern Armenia, an area of the country considered to be at high risk of disease incursion/occurrence. All tested samples collected for this survey were negative for ASF. The probability of observing no reactors by antibody enzyme-linked immunosorbent assay in a sample of this size (n = 1,506) from a population with an estimated disease prevalence of 1% is very low (< 0.0001). Therefore, it is possible but very unlikely for ASFV to be present among domestic pigs in the Tavush province region.

"Building strength in coming together": A mixed methods study using the arts to explore smoking with staff working in Indigenous tobacco control

ISSUE ADDRESSED

Tobacco is a major risk factor contributing to Indigenous health disparities. Art may be a powerful and transformative tool to enable health providers to develop targeted messages for tobacco control.

METHODS

Indigenous and non-Indigenous staff, working in Indigenous tobacco control, attended a 2-hour workshop, and were led through a process to create individual artworks. Participants completed surveys before and after the workshop. Scales compared understandings of how art can be used in tobacco control, and the likelihood of utilising arts in future programs. Three pairs of Indigenous and non-Indigenous researchers analysed the artworks, using the Four Frames (New South Wales Board of Studies), explored themes, and developed a model.

RESULTS

Nineteen participants completed both surveys; 17 artworks were analysed. Pre- to post-workshop increases in "understanding" about the use of arts (P < 0.00001) for tobacco control, and "likelihood" of use of arts in the next 6 months (P < 0.006) were significant. Participants expressed personal and professional benefits from the workshop. Artworks demonstrated themes of optimism, the strength of family and culture, smoking as a barrier, resilience, recovery and urgency.

CONCLUSIONS

The workshop increased the understanding and likelihood of using the arts for tobacco control. Artworks revealed contemporary challenges impacting on equity; health staff expressed optimism for being engaged in their work. SO WHAT?: The Framework Convention for Tobacco Control supports novel techniques to increase the reach and relevance of health messages for diverse populations. This study successfully demonstrated how a novel, positively framed art-based technique proved to be advantageous for health professionals, working in an area of Indigenous tobacco control, where behavioural change can be complex.

Engineering the expression of an anti-interleukin-13 antibody through rational design and mutagenesis

High levels of protein expression are key to the successful development and manufacture of a therapeutic antibody. Here, we describe two related antibodies, Ab001 and Ab008, where Ab001 shows a markedly lower level of expression relative to Ab008 when stably expressed in Chinese hamster ovary cells. We use single-gene expression vectors and structural analysis to show that the reduced titer is associated with the VL CDR2 of Ab001. We adopted two approaches to improve the expression of Ab001. First, we used mutagenesis to change single amino-acid residues in the Ab001 VL back to the equivalent Ab008 residues but this resulted in limited improvements in expression. In contrast when we used an in silico structure-based design approach to generate a set of five individual single-point variants in a discrete region of the VL, all exhibited significantly improved expression relative to Ab001. The most successful of these, D53N, exhibited a 25-fold increase in stable transfectants relative to Ab001. The functional potency of these VL-modified antibodies was unaffected. We expect that this in silico engineering strategy can be used to improve the expression of other antibodies and proteins.

Structural Characterisation Reveals Mechanism of IL-13-Neutralising Monoclonal Antibody Tralokinumab as Inhibition of Binding to IL-13Rα1 and IL-13Rα2

Interleukin (IL)-13 is a pleiotropic T helper type 2 cytokine frequently associated with asthma and atopic dermatitis. IL-13-mediated signalling is initiated by binding to IL-13Rα1, which then recruits IL-4Rα to form a heterodimeric receptor complex. IL-13 also binds to IL-13Rα2, considered as either a decoy or a key mediator of fibrosis. IL-13-neutralising antibodies act by preventing IL-13 binding to IL-13Rα1, IL-4Rα and/or IL-13Rα2. Tralokinumab (CAT-354) is an IL-13-neutralising human IgG4 monoclonal antibody that has shown clinical benefit in patients with asthma. To decipher how tralokinumab inhibits the effects of IL-13, we determined the structure of tralokinumab Fab in complex with human IL-13 to 2 Å resolution. The structure analysis reveals that tralokinumab prevents IL-13 from binding to both IL-13Rα1 and IL-13Rα2. This is supported by biochemical ligand-receptor interaction assay data. The tralokinumab epitope is mainly composed of residues in helices D and A of IL-13. It is mostly light chain complementarity-determining regions that are driving paratope interactions; the variable light complementarity-determining region 2 plays a key role by providing residue contacts for a network of hydrogen bonds and a salt bridge in the core of binding. The key residues within the paratope contributing to binding were identified as Asp50, Asp51, Ser30 and Lys31. This study demonstrates that tralokinumab prevents the IL-13 pharmacodynamic effect by binding to IL-13 helices A and D, thus preventing IL-13 from interacting with IL-13Rα1 and IL-13Rα2.

Using cognitive pre-testing methods in the development of a new evidenced-based pressure ulcer risk assessment instrument

Background

Variation in development methods of Pressure Ulcer Risk Assessment Instruments has led to inconsistent inclusion of risk factors and concerns about content validity. A new evidenced-based Risk Assessment Instrument, the Pressure Ulcer Risk Primary Or Secondary Evaluation Tool - PURPOSE-T was developed as part of a National Institute for Health Research (NIHR) funded Pressure Ulcer Research Programme (PURPOSE: RP-PG-0407-10056). This paper reports the pre-test phase to assess and improve PURPOSE-T acceptability, usability and confirm content validity.

Methods

A descriptive study incorporating cognitive pre-testing methods and integration of service user views was undertaken over 3 cycles comprising PURPOSE-T training, a focus group and one-to-one think-aloud interviews. Clinical nurses from 2 acute and 2 community NHS Trusts, were grouped according to job role. Focus group participants used 3 vignettes to complete PURPOSE-T assessments and then participated in the focus group. Think-aloud participants were interviewed during their completion of PURPOSE-T.

After each pre-test cycle analysis was undertaken and adjustment/improvements made to PURPOSE-T in an iterative process. This incorporated the use of descriptive statistics for data completeness and decision rule compliance and directed content analysis for interview and focus group data. Data were collected April 2012-June 2012.

Results

Thirty-four nurses participated in 3 pre-test cycles. Data from 3 focus groups, 12 think-aloud interviews incorporating 101 PURPOSE-T assessments led to changes to improve instrument content and design, flow and format, decision support and item-specific wording. Acceptability and usability were demonstrated by improved data completion and appropriate risk pathway allocation. The pre-test also confirmed content validity with clinical nurses.

Conclusions

The pre-test was an important step in the development of the preliminary PURPOSE-T and the methods used may have wider instrument development application. PURPOSE-T proposes a new approach to pressure ulcer risk assessment, incorporating a screening stage, the inclusion of skin status to distinguish between those who require primary prevention and those who require secondary prevention/treatment and the use of colour to support pathway allocation and decision making. Further clinical evaluation is planned to assess the reliability and validity of PURPOSE-T and it’s impact on care processes and patient outcomes.

Repeatability and intra- and inter-observer agreement of cervical vertebral sagittal diameter ratios in horses with neurological disease

BACKGROUND

Sagittal ratio values (SRVs) of cervical vertebrae are used for ante-mortem diagnosis of cervical vertebral stenotic myelopathy, but intraobserver and interobserver variability in measurement may influence radiographic interpretation of vertebral stenosis in horses with neurological disease.

OBJECTIVES

To determine intraobserver repeatability in SRVs, intra- and interobserver agreement in SRVs and whether or not agreement was influenced by animal age.

ANIMALS

Forty-two horses (>1 year old) with neurological disease from which laterolateral computed radiographic images of C2-C7 were obtained.

METHODS

Four observers made measurements from C2 to C7 for each horse and interobserver agreement for intra- and intervertebral SRVs was determined using Bland-Altman analysis (acceptable agreement: limits of agreement [LOA] ≤ 0.05) on all horses and those ≤3 (n = 25) and >3 (n = 17) years old. Each observer also made repeated measurements for 10 horses and intraobserver repeatability and agreement were determined.

RESULTS

Adequate intraobserver repeatability was achieved for 6 sites. Within observers, paired measurements had a median difference ≤5.7%, but a large range in differences often occurred, most frequently at intervertebral sites. For C5, C6, C7, and C3-4, LOA ≤ 0.05 were achieved by at least 1 observer. With the exception of C5 for 1 pair, LOA were >0.05 for interobserver agreement, regardless of animal age. LOA were largest at intervertebral sites.

CONCLUSIONS AND CLINICAL IMPORTANCE

Within and between observers, measurement error may limit the diagnostic accuracy of SRVs and result in discrepancies of diagnosis and treatment and warrants consideration when used clinically in horses with neurological disease.

Equine metabolic syndrome

Laminitis is one of the most common and frustrating clinical presentations in equine practice. While the principles of treatment for laminitis have not changed for several decades, there have been some important paradigm shifts in our understanding of laminitis. Most importantly, it is essential to consider laminitis as a clinical sign of disease and not as a disease in its own right. Once this shift in thinking has occurred, it is logical to then question what disease caused the laminitis. More than 90 per cent of horses presented with laminitis as their primary clinical sign will have developed it as a consequence of endocrine disease; most commonly equine metabolic syndrome (EMS). Given the fact that many horses will have painful protracted and/or chronic recurrent disease, a good understanding of the predisposing factors and how to diagnose and manage them is crucial. Current evidence suggests that early diagnosis and effective management of EMS should be a key aim for practising veterinary surgeons to prevent the devastating consequences of laminitis. This review will focus on EMS, its diagnosis and management.

Resistance to Innate Immunity Contributes to Colonization of the Insect Gut by Yersinia pestis

Yersinia pestis, the causative agent of bubonic and pneumonic plague, is typically a zoonotic vector-borne disease of wild rodents. Bacterial biofilm formation in the proventriculus of the flea contributes to chronic infection of fleas and facilitates efficient disease transmission. However prior to biofilm formation, ingested bacteria must survive within the flea midgut, and yet little is known about vector-pathogen interactions that are required for flea gut colonization. Here we establish a Drosophila melanogaster model system to gain insight into Y. pestis colonization of the insect vector. We show that Y. pestis establishes a stable infection in the anterior midgut of fly larvae, and we used this model system to study the roles of genes involved in biofilm production and/or resistance to gut immunity stressors. We find that PhoP and GmhA both contribute to colonization and resistance to antimicrobial peptides in flies, and furthermore, the data suggest biofilm formation may afford protection against antimicrobial peptides. Production of reactive oxygen species in the fly gut, as in fleas, also serves to limit bacterial infection, and OxyR mediates Y. pestis survival in both insect models. Overall, our data establish the fruit fly as an informative model to elucidate the relationship between Y. pestis and its flea vector.

Dietary, lifestyle and clinicopathological factors associated with APC mutations and promoter methylation in colorectal cancers from the EPIC-Norfolk study

The tumour suppressor APC is the most commonly altered gene in colorectal cancer (CRC). Genetic and epigenetic alterations of APC may therefore be associated with dietary and lifestyle risk factors for CRC. Analysis of APC mutations in the extended mutation cluster region (codons 1276-1556) and APC promoter 1A methylation was performed on 185 archival CRC samples collected from participants of the European Prospective Investigation into Cancer (EPIC)-Norfolk study, with the aim of relating these to high-quality seven-day dietary and lifestyle data collected prospectively. Truncating APC mutations (APC(+) ) and promoter 1A methylation (PM(+) ) were identified in 43% and 23% of CRCs analysed, respectively. Distal CRCs were more likely than proximal CRCs to be APC(+) or PM(+) (p = 0.04). APC(+) CRCs were more likely to be moderately/well differentiated and microsatellite stable than APC(-) CRCs (p = 0.05 and 0.03). APC(+) CRC cases consumed more alcohol than their counterparts (p = 0.01) and PM(+) CRC cases consumed lower levels of folate and fibre (p = 0.01 and 0.004). APC(+) or PM(+) CRC cases consumed higher levels of processed meat and iron from red meat and red meat products (p = 0.007 and 0.006). Specifically, CRC cases harbouring GC-to-AT transition mutations consumed higher levels of processed meat (35 versus 24 g/day, p = 0.04) and iron from red meat and red meat products (0.8 versus 0.6 mg/day, p = 0.05). In a logistic regression model adjusted for age, sex and cigarette-smoking status, each 19 g/day (1SD) increment increase in processed meat consumption was associated with cases with GC-to-AT mutations (OR 1.68, 95% CI 1.03-2.75). In conclusion, APC(+) and PM(+) CRCs may be influenced by diet and GC-to-AT mutations in APC are associated with processed meat consumption, suggesting a mechanistic link with dietary alkylating agents, such as N-nitroso compounds.

Abstract 934: Chromokinesin KIF4 facilitates chromatin organization critical for immunoglobulin class switch recombination and prevents lymphoma formation

Un-repaired DNA damage and chromosomal translocations are the major causes of genomic instability found in various human cancers. We have observed spontaneous B-cell Follicular lymphomas (FL) in a knock-out (KO) mouse model generated by gene trapping of KIF4, a unique DNA-binding, nuclear and chromatin-associated molecular motor. We have previously shown that KIF4 is an important modulator of higher-order chromatin structure and is required for maintaining genomic stability. Since FL often results from altered levels of DNA recombination of the immune system caused by chromosome structural changes, we investigated the contributions of KIF4 in regulating chromatin structure for B cell function. We show that there is an abnormal proliferation of B cells in mice in both bone marrow and spleen of young adult mice lacking KIF4 function. Chromosome spread from young adult knockout and neoplastic splenocytes show abnormal chromosome numbers (aneuploidy) and structure in the absence of KIF4 indicating that KIF4 is critical in maintaining genome integrity in vivo. Maintaining and establishing a stable but dynamic chromatin organization is critical for successful class switch recombination during B cell development. We observed that immunoglobulin (Ig) class switch recombination (CSR) in activated B cells is severely impaired in the absence of KIF4. Moreover, our biochemical and proteomic analysis reveals that repressive chromatin marks such as trimethylation of histone H3 lysine 9 or 27 that regulate global gene expression patterns, are significantly altered in maturing B cells in the absence of KIF4 compared to wild type control cells. This data demonstrates that KIF4 is necessary for modulating dynamic chromatin structure via a remodeling activity that allows or restricts access to the Igh locus for CSR and antibody diversity.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 934. doi:10.1158/1538-7445.AM2011-934

Lifestyle factors and p53 mutation patterns in colorectal cancer patients in the EPIC-Norfolk study

The tumour suppressor p53 is one of the most commonly altered genes in colorectal cancer (CRC) development. Genetic alterations in p53 may therefore be associated with postulated lifestyle risk factors for CRC, such as red meat consumption. In the European Prospective Investigation into Cancer and Nutrition-Norfolk study, we examined whether detailed estimates of dietary and lifestyle factors measured at baseline related to later development of p53 mutations in CRCs. After 10-year follow-up, there were 185 incident CRCs of which 34% had somatic p53 mutations (p53+). We observed significantly higher mean intakes of alcohol, total meat and red meat, in the group with p53 mutations and advanced Dukes' stage disease (daily alcohol intake was 7 and 12 g for p53- and p53+ cases, respectively, P = 0.04; daily total meat intake was 69 and 100 g for p53- and p53+ cases, respectively, P = 0.03 and daily red meat intake was 39 and 75 g for p53- and p53+ cases, respectively, P = 0.01). Each 50 g/day increment in total meat intake was associated with having p53 mutations in cases with advanced Dukes' stages [odds ratio (OR): 3.43, 95% confidence interval (CI): 1.47-7.96]. Similarly, each 50 g/day increment in red meat intake was also significantly associated with having consistent p53 mutations in cases with advanced Dukes' stages (OR: 2.42, 95% CI: 1.18-4.96). These effects of total meat or red meat intake and advanced Dukes' stages were independent of age, sex, body mass index, smoking and alcohol intake. Furthermore, P values for interaction between daily total meat or red meat intake and Dukes' stages were statistically significant in multivariable models (Pinteraction < 0.001). Our results suggest that p53 mutations accelerate progression of CRC to advanced Dukes' stage in association with higher meat especially red meat intakes.

Electronic health records: is the evidence base any use?

Information-technology policies in many countries are full of aspirational statements and not generally based on the available evidence. This paper aims to contribute to a proper discussion of the evidence on electronic health records (EHR). The paper describes the methods we used in a review of the impact of EHR on clinical work and administration, summarizes our findings, and discusses their relevance in the context of policy makers' information requirements. We argue that the literature has, to date, largely failed to deliver usable findings.

Systematic reviews of clinical decision tools for acute abdominal pain

OBJECTIVES

To review for acute abdominal pain (AAP), the diagnostic accuracies of combining decision tools (DTs) and doctors aided by DTs compared with those of unaided doctors. Also to evaluate the impact of providing doctors with an AAP DT on patient outcomes, clinical decisions and actions, what factors are likely to determine the usage rates and usability of a DT and the associated costs and likely cost-effectiveness of these DTs in routine use in the UK.

DESIGN

Electronic databases were searched up to 1 July 2003.

REVIEW METHODS

Data from each eligible study were extracted. Potential sources of heterogeneity were extracted for both questions. For the accuracy review, meta-analysis was conducted. Among studies comparing diagnostic accuracies of DTs with unaided doctors, error rate ratios provided estimates of the differences between the false-negative and false-positive rates of the DT and unaided doctors' performance. Pooled error rate ratios and 95% confidence intervals (CIs) for false-negative rates and false-positive rates were computed. Metaregression was used to explore heterogeneity.

RESULTS

Thirty-two studies from 27 articles, all based in secondary care, were eligible for the review of DT accuracies, while two were eligible for the review of the accuracy of hospital doctors aided by DTs. Sensitivities and specificities for DTs ranged from 53 to 99% and from 30 to 99%, respectively. Those for unaided doctors ranged from 64 to 93% and from 39 to 91%, respectively. Thirteen studies reported false-positive and false-negative rates for both DTs and unaided doctors, enabling a direct comparison of their performance. In random effects meta-analyses, DTs had significantly lower false-positive rates (error rate ratio 0.62, 95% CI 0.46 to 0.83) than unaided doctors. DTs may have higher false-negative rates than unaided doctors (error rate ratio 1.34, 95% CI 0.93 to 1.93). Significant heterogeneity was present. Two studies compared the diagnostic accuracies of doctors aided by DTs to unaided doctors. In a multiarm cluster randomised controlled trial (n = 5193), the diagnostic accuracy of doctors not given access to DTs was not significantly worse (sensitivity 28.4% and specificity 96.0%) than that of three groups of aided doctors (sensitivities of 42.4-47.9%, and specificities of 95.5-96.5%, respectively). In an uncontrolled before-and-after study (n = 1484), the sensitivities and specificities of aided and unaided doctors were 95.5% and 91.5% (p = 0.24) and 78.1% and 86.4% (p < 0.001), respectively. The metaregression of DTs showed that prospective test-set validation at the site of the tool's development was associated with considerably higher diagnostic accuracy than prospective test-set validation at an independent centre [relative diagnostic odds ratio (RDOR) 8.2; 95% CI 3.1 to 14.7]. It also showed that the earlier in the year the study was performed the higher the performance (RDOR 0.88, 0.83 to 0.92), that when developers evaluated their own DT there was better performance than when independent evaluators carried out the study (RDOR = 3.0, 1.3 to 6.8), and that there was no evidence of association between other quality indicators and DT accuracy. The one eligible study of the impact study review, a four-arm cluster randomised trial (n = 5193), showed that hospital admission rates of patients by doctors not allocated to a DT (42.8%) were significantly higher than those by doctors allocated to three combinations of decision support (34.2-38.5%) (p < 0.001). There was no evidence of a difference between perforation rates (p = 0.19) and negative laparotomy rates in the four trial arms (p = 0.46). Usage rates of DTs by doctors in accident and emergency departments ranged from 10 to 77% in the six studies that reported them. Possible determinants of usability include the reasoning method used, the number of items used and the output format. A deterministic cost-effectiveness comparison demonstrated that a paper checklist is likely to be 100-900 times more cost-effective than a computer-based DT, under stated assumptions.

CONCLUSIONS

With their significantly greater specificity and lower false-positive rates than doctors, DTs are potentially useful in confirming a diagnosis of acute appendicitis, but not in ruling it out. The clinical use of well-designed, condition-specific paper or computer-based structured checklists is promising as a way to improve impact on patient outcomes, subject to further research.

Shoulder and elbow function 2 years following long head triceps interposition flap transfer for massive rotator cuff tear reconstruction

INTRODUCTION

Patient outcomes were determined at a minimum of 2 years following massive rotator cuff tear ( > or = 5 cm(2)) reconstruction using a triceps brachii long head interposition flap. A physiotherapist at an independent clinic performed all measurements.

PATIENTS AND METHODS

Of 24 total eligible patients, 19 completed pre-operative and follow-up UCLA Shoulder Scores and ASES Function Scores. Of these 19 patients, 14 who did not have co-morbidities that negatively impacted their ability to perform intense exercise underwent a comprehensive clinical examination of involved and uninvolved side shoulder and elbow active range of motion and strength (both isometric instrumented manual muscle testing and concentric isokinetic measurements).

RESULTS

At 2 years following surgery, pre-operative UCLA Shoulder Scores improved from 10.6 +/- 3 to 27.4 +/- 5 and pre-operative ASES Function Scores improved from 20.1 +/- 10 to 43.2 +/- 5. However, isometric involved side shoulder abductor torque was decreased by 28.2% with instrumented manual muscle testing, and concentric shoulder external rotator torque was decreased by 44.6% at 60 degrees/s and by 53.8% at 120 degrees/s with isokinetic testing. Isometric involved side elbow extensor torque was decreased by 39% with instrumented manual muscle testing, and concentric elbow extensor torque was decreased by 17.7% and 19.2% at 60 and 120 degrees/s, respectively, with isokinetic testing. Including three additional patients who were contacted via telephone, the majority of patients (21 of 22, 95.4%) were satisfied with their improved shoulder function and reduced pain.

CONCLUSIONS

Despite reduced pain and improved shoulder function, residual involved side shoulder abductor; shoulder external rotator and elbow extensor strength deficits were evident at 2 years following surgery. This suggests the need for more focused rehabilitation, particularly for involved side elbow extensor strengthening to further improve patient function and minimize disability.

Candidate tumor suppressor LUCA-15/RBM5/H37 modulates expression of apoptosis and cell cycle genes

RBM5 (RNA-binding motif protein 5/LUCA-15/H37) is encoded at the lung cancer tumor suppressor locus 3p21.3 and itself has several important characteristics of a tumor suppressor, including both potentiation of apoptosis and inhibition of the cell cycle. Here, we report the effects of both upregulation and downregulation of LUCA-15/RBM5 on gene expression monitored using cDNA microarrays. Many of the genes modulated by LUCA-15/RBM5 are involved in the control of apoptosis, the cell cycle, or both. These effects were confirmed for the most significant genes using real-time RT-PCR and/or Western blotting. In particular, LUCA-15/RBM5 increased the expression of Stat5b and BMP5 and decreased the expression of AIB1 (Amplified In Breast Cancer 1), proto-oncogene Pim-1, caspase antagonist BIRC3 (cIAP-2, MIHC), and CDK2 (cyclin-dependent kinase 2). These effects on multiple genes controlling both apoptosis and proliferation are in line with the functional effects of LUCA-15/RBM5 and indicate that it plays a central role in regulating cell fate consistent with its tumor suppressor activity.

The relationship between measures of executive function, motor performance and externalising behaviour in 5- and 6-year-old children

In his cognitive-energetic model of information processing Sergeant [Sergeant, J. (2000). The cognitive-energetic model: An empirical approach to ADHD. Neuroscience and Biobehavioral Reviews, 24, 7-12] links executive function (EF) to motor behaviour. This link has been supported by evidence from a number of sources including studies of attention deficit hyperactivity disorder (ADHD) and developmental coordination disorder (DCD). Little is known developmentally about this association. Given the rapid change in both motor proficiency and EF that takes place in the pre-school years, this appears an important time to look for the emergence of the link between these factors. In this study we tested 5- and 6-year-old children on motor tasks from the movement assessment battery for children and on measures of response inhibition (Stroop and stop-signal task) and examined the relationship between scores on these measures. Additionally, in order to relate this behaviour to everyday function, the Rowe behavioural rating inventory (RBRI), a teachers' behavioural rating of externalising behaviour, was also gathered and this related to EF and motor performance. It was found that motor performance correlated significantly with RBRI scores (better motor performance with lower externalising behaviour) and with Stroop performance. The relationship between motor performance and stop-signal task performance was in the expected direction but failed to reach significance and there was no clear association between performance on the stop-signal task and either Stroop or RBRI scores. The results are discussed in relation to different aspects of response inhibition (inhibition of a pre-potent response, interference control) and how these might relate to motor control.

Lower extremity neuromuscular recovery following anterior cruciate ligament reconstruction; a 2-week case study

The lower extremity neuromuscular recovery of a 31-year-old male physical therapy student during the initial 2-weeks following anterior cruciate ligament reconstruction was evaluated by measuring involved side vastus medialis (VM), gluteus maximus (GMAX) and gastrocnemius (GASTROC) electromyographic (EMG) signals (1000 Hz), plantar forces (50 Hz), and knee pain as the subject performed a series of volitional, maximal effort unilateral, isometric leg presses (6 sec) in a modified continuous passive motion device. Data were standardized to pre-operative values and graphically plotted for split middle technique, celeration line assessment. From 1-8 hours post-surgery, EMG amplitudes and plantar forces decreased, pain increased, and plantar force location shifted toward the forefoot. From 9-12 hours post-surgery, EMG amplitudes and plantar forces increased and pain decreased. By 24 hours post-surgery, pain decreased to pre-operative levels. From 24-72 hours post-surgery, EMG amplitudes and plantar forces increased. From 1-2 weeks post-surgery, EMG amplitudes and plantar forces increased. From 9 hours-2 weeks post-surgery, plantar force location shifted toward the pre-operative location. Sequential increases were observed for GMAX, GASTROC, and VM EMG amplitudes. By 2 weeks post-surgery, plantar forces and VM EMG amplitudes remained reduced. Reduced plantar forces and VM EMG amplitude at 2 weeks post-surgery suggest a need for greater focus on restoring VM function before attempting closed kinetic chain exercises that require the full shock absorption capabilities of the quadriceps femoris muscle group.

Yin-Yang 1 activates interleukin-4 gene expression in T cells

Interleukin-4 (IL-4) is a multifunctional cytokine that plays an important role in immune and inflammatory responses. Expression of the IL-4 gene is tightly controlled at the level of gene transcription by both positive and negative regulatory elements in the IL-4 promoter. Several constitutive nuclear factors have been identified that can interact with IL-4 promoter elements in DNA binding assays. Here we report that the zinc-finger protein YY-1 (Yin-Yang 1) can bind to multiple elements within the human IL-4 promoter. Cotransfection of Jurkat T cells with different IL-4 promoter/reporter constructs together with expression vectors encoding antisense, wild-type, or zinc finger-deleted mutant YY-1 suggested that YY-1 enhanced IL-4 promoter activity in a DNA-binding domain-dependent manner. Site-directed mutagenesis revealed that a proximal YY-1-binding site, termed Y0 ((-59)TCATTTT(-53)), was essential for YY-1-driven IL-4 promoter activity. In addition, cotransfected YY-1 enhanced both IL-4 promoter activity and endogenous IL-4 gene expression in nontransformed peripheral blood T cells. Thus, YY-1 positively regulates IL-4 gene expression in lymphocytes.

High leptin levels acutely inhibit insulin-stimulated glucose uptake without affecting glucose transporter 4 translocation in l6 rat skeletal muscle cells

Obesity is a major risk factor for the development of insulin resistance, characterized by impaired stimulation of glucose disposal into muscle. The mechanisms underlying insulin resistance are unknown. Here we examine the direct effect of leptin, the product of the obesity gene, on insulin-stimulated glucose uptake in cultured rat skeletal muscle cells. Preincubation of L6 myotubes with leptin (2 or 100 nM, 30 min) had no effect on basal glucose uptake but reduced insulin-stimulated glucose uptake. However, leptin had no effect on the insulin-induced gain in myc-tagged glucose transporter 4 (GLUT4) appearance at the cell surface of L6 myotubes. Preincubation of cells with leptin also had no effect on insulin-stimulated tyrosine phosphorylation of insulin receptor, IRS-1 and IRS-2, phosphatidylinositol 3-kinase activity, or Akt phosphorylation. We have previously shown that insulin regulates glucose uptake via a signaling pathway sensitive to inhibitors of p38 MAP kinase. Here, leptin pretreatment reduced the extent of insulin-stimulated p38 MAP kinase phosphorylation and phosphorylation of cAMP response element binder, a downstream effector of p38 MAP kinase. These results show that high leptin levels can directly reduce insulin-stimulated glucose uptake in L6 muscle cells despite normal GLUT4 translocation. The mechanism of this effect could involve inhibition of insulin-stimulated p38 MAP kinase and GLUT4 activation.

Residential rehabilitation for drug users: a review of 13 months' intake to a therapeutic community

BACKGROUND

Residential rehabilitation based on 'therapeutic community' treatment for drug users is a treatment option which is attractive to GPs and others referring drug users for treatment. Whilst there is evidence that maintenance-based programmes for drug users are effective, there have been fewer attempts to evaluate the effectiveness of abstinence-based programmes which are relatively more intensive and expensive interventions.

OBJECTIVE

This paper reports and evaluates the outcomes for 13 months' intake of 138 drug users to a residential community.

METHODS

We carried out a retrospective cohort study using existing clinical and residential record data. The setting is a residential rehabilitation centre run by the charity Phoenix House in Sheffield, UK, offering a 1-year programme for heroin addicts including community detoxification overseen by primary care specialist doctors and residential rehabilitation. Participants were all patients who entered treatment between 1 February 1998 and 28 February 1999 inclusive. An analysis was carried out of clinical records and other records kept by clinicians and staff at the centre. Outcome measures were numbers of days of retention in treatment and reasons for departure, categorized as completed treatment, planned or unplanned departure and expulsion from the programme. For patients who underwent in-house detoxification, a further outcome measure was whether or not detoxification was complete at discharge.

RESULTS

Heroin was the main drug of abuse in 85% of admissions. Mean length of time for which individuals had been drug dependent was 8 years (range 1.3-20.1 years). The mean length of stay was 80.2 days (range 1-394, 95% confidence interval 61.8-98.6). Thirty-four individuals (25%) completed 90 days or more. No association was found between length of stay and age, sex, route of administration, polydrug use, length of time addicted or age of first addiction. Sixty-five per cent of those who received in-house detoxification completed the detoxification period. When patients were classified as 'successes' or 'failures' by reason for departure from the programme, 94 (68.1%) were classified as failures and 18 (13.0%) as successes. Data were unavailable for 26 patients. Success was not associated with any characteristic at entry apart from being drug free as opposed to requiring detoxification (P = 0.048, chi-square = 6.06, df = 2).

CONCLUSION

This study shows overall low levels of programme completion and high levels of unplanned departure and eviction from the programme amongst these long-term drug users. On the other hand, the importance of abstinence for those who achieve it in residential rehabilitation should not be underestimated, nor should the possibility that long-term outcomes are influenced by the learning process involved in the intervention. It may be possible to operate better selection procedures in order to optimize outcomes.

Deaths from drugs of abuse in Sheffield, 1998: the role of prescribed medication

Characteristics of recent drug abuse-related deaths in the city of Sheffield were examined from the coroner's records. Almost all of those who died of poisoning from a drug of abuse were known to be dependent on heroin yet less than half were receiving treatment. Benzodiazepines were frequently detected alongside opiates during toxicology, the source of which was likely to be the deceased's own prescription.

Keeping families of heroin addicts together: results of 13 months' intake for community detoxification and rehabilitation at a family centre for drug users

BACKGROUND

Heroin addiction is a major public health problem affecting both the addicted individuals and their children, who have been shown to have poor social, educational and health status and to be at higher risk of abuse than their peers. Whilst the antenatal effects of parental drug use and the overall poor outcomes for these children have been widely studied, there has been little emphasis on the effectiveness of treatment interventions and even less emphasis on evaluating the effect on children of the standard treatments aimed at their parents' drug use.

OBJECTIVES

The aim of the present study was to evaluate the effect on heroin-addicted parents and their children of a family-based drug treatment intervention using a records-based methodology, and to identify any factors at admission which may influence outcome. This study is a pilot for a prospective Europe-wide study using a similar methodology prospectively in several treatment modalities.

METHODS

A retrospective cohort study was carried out using existing clinical and residential record data. The setting was a residential family centre run by the charity Phoenix House in Sheffield, UK, offering a 6-month (180 days) family-based programme for heroin addicts including community detoxification overseen by primary care specialist doctors and residential rehabilitation. All adults and children who entered the centre between July 1997 and July 1998 were included in the study (26 adults and 33 children, in 23 family groups). An analysis was made of clinical records and records kept on the adults and children by the clinicians and staff at the centre. The main outcome measures for the adults were length of stay and reason for departure (treatment complete, early planned discharge, unplanned discharge, eviction); and for the children were reason for departure and discharge destination (with parent or taken into care).

RESULTS

Mean length of stay was 110 days, and only 11 children (33%) and nine adults (35%) completed 150 days or more. Length of stay was found to be significantly correlated with parental age at admission (P < 0.01). Twelve children (37%) and nine adults (35%) were deemed to have completed treatment successfully. Of the remainder, 14 children (42%) and 11 adults (42%) left because of definite treatment failure. Successful treatment completion was found to be correlated with increased parental age (Pearson's r = 0.612, P = 0. 001). Poly-drug users were significantly less likely to complete treatment successfully (Fisher's exact test, P = 0.012). Twenty children were in the care of their parents on admission, and 24 were able to go home with their parents. There was no association between residence with parents pre- and post-admission (McNemar's chi-squared test = 1.6, P > or = 0.1).

CONCLUSIONS

Whilst overall high rates of treatment success are not expected in abstinence-based programmes, the outcomes for the adults in this setting are comparable with published results in other residential settings, and there is some evidence that some families may have stayed together who might otherwise have been separated. Older adults who were not poly-drug users had significantly better outcomes. The records-based methodology proved successful, but centres need to keep detailed and preferably long-term records on children if their outcomes are to be evaluated more fully.

Activation of p38 mitogen-activated protein kinase alpha and beta by insulin and contraction in rat skeletal muscle: potential role in the stimulation of glucose transport

The stress-activated p38 mitogen-activated protein kinase (MAPK) was recently shown to be activated by insulin in muscle and adipose cells in culture. Here, we explore whether such stimulation is observed in rat skeletal muscle and whether muscle contraction can also affect the enzyme. Insulin injection (2 U over 3.5 min) resulted in increases in p38 MAPK phosphorylation measured in soleus (3.2-fold) and quadriceps (2.2-fold) muscles. Increased phosphorylation (3.5-fold) of an endogenous substrate of p38 MAPK, cAMP response element binder (CREB), was also observed. After in vivo insulin treatment, p38 MAPKalpha and p38 MAPKbeta isoforms were found to be activated (2.1- and 2.4-fold, respectively), using an in vitro kinase assay, in immunoprecipitates from quadriceps muscle extracts. In vitro insulin treatment (1 nmol/l over 4 min) and electrically-induced contraction of isolated extensor digitorum longus (EDL) muscle also doubled the kinase activity of p38 MAPKalpha and p38 MAPKbeta. The activity of both isoforms was inhibited in vitro by 10 micromol/l SB203580 in all muscles. To explore the possible participation of p38 MAPK in the stimulation of glucose uptake, EDL and soleus muscles were exposed to increasing doses of SB203580 before and during stimulation by insulin or contraction. SB203580 caused a significant reduction in the insulin- or contraction-stimulated 2-deoxyglucose uptake. Maximal inhibition (50-60%) occurred with 10 micromol/l SB203580. These results show that p38 MAPKalpha and -beta isoforms are activated by insulin and contraction in skeletal muscle. The data further suggest that activation of p38 MAPK may participate in the stimulation of glucose uptake by both stimuli in rat skeletal muscle.

Can methadone maintenance for heroin-dependent patients retained in general practice reduce criminal conviction rates and time spent in prison?

A retrospective analysis was made of the criminal records of 57 patients successfully retained in methadone maintenance at two general practices in Sheffield. Their criminal conviction rates and time spent in prison per year were compared for the periods before and after the start of their methadone programme. Overall, patients retained on methadone programmes in the general practices studied had significantly fewer convictions and cautions, and spent significantly less time in prison than they had before the start of treatment.

Freedom of information. Quietly does it

The forthcoming legislation on freedom of information is likely to be far less radical than originally envisaged. Decisions over what information to release will rest with civil servants. The legislation is likely to require primary care groups to respond to requests for information about allocation of resources between services. Access to the workings of government and the evidence underlying policy decisions would enable people to become active citizens. It would also stimulate sympathy for managers' and clinicians' rationing dilemmas. Current restrictions are at odds with government policy to modernize the NHS.

Evaluation of a hospital picture archiving and communication system

OBJECTIVES

To establish the net costs to the hospital and the broad range of benefits associated with a hospital-wide picture archiving and communication system (PACS) that comprised digital acquisition, storage and transmission of radiological images via a hospital-wide network to 150 workstations.

METHODS

'Before and after' comparisons and time series analyses at Hammersmith Hospital (London, UK), and comparison with five other British hospitals where PACS was not being installed. The cost analysis considered implementation costs and changes in key elements of hospital running costs, including the impact of changes in the length of inpatient stays. A range of benefit measures were investigated, including image availability, avoidance of repeat imaging, avoidance of exposure to radiation, patient turn-round speed, time from examination to image availability in intensive care, avoidance of diagnostic 'errors' by casualty doctors, the additional diagnostic value of PACS-based images and clinician satisfaction.

RESULTS

The annual equivalent capital cost of the PACS was 1.7 million Pounds (annual equivalent replacement cost: 0.8 million Pound). Overall, the PACS substantially increased running costs. No convincing evidence of a PACS-induced change in length of inpatient stay was found. PACS was associated with some improvements in the performance of the radiology department: improved image availability (97.7% versus 86.9%), lower repeat imaging rate (7.3% versus 9.9%) and 20% lower total radiation doses for examinations of the lateral lumbar spine. No improvements were identified in the quality of the radiology reporting service. Benefits outside radiology included shorter time from examination to image availability for routine uses in intensive care (19 versus 37 minutes), and a lower rate of diagnostic 'errors' in casualty (0.65% versus 1.51%). High levels of satisfaction with PACS were found amongst both providers and clinical users.

CONCLUSIONS

PACS was almost universally preferred by users and brought many operational and clinical benefits. However, these advantages came at a significant capital and net running cost.

Skeletal muscle and small-conductance calcium-activated potassium channels

Skeletal muscle becomes hyperexcitable following denervation and when cultured in the absence of nerve cells. In these circumstances, the bee venom peptide toxin apamin, a blocker of small-conductance calcium-activated potassium (SK) channels, dramatically reduces the hyperexcitability. In this report, we show that SK3 channels are expressed in denervated skeletal muscle and in L6 cells. Action potentials evoked from normal innervated rat skeletal muscle did not exhibit an afterhyperpolarization, indicating a lack of SK channel activity; very low levels of apamin binding sites, SK3 protein, or SK3 mRNA were present. However, denervation resulted in apamin-sensitive afterhyperpolarizations and increased apamin binding sites, SK3 protein, and SK3 mRNA. Cultured rat L6 myoblasts and differentiated L6 myotubes contained similar levels of SK3 mRNA, although apamin-sensitive SK currents and apamin binding sites were detected only following myotube differentiation. Therefore, different molecular mechanisms govern SK3 expression levels in denervated muscle compared with muscle cells differentiated in culture.

Radiology report times: impact of picture archiving and communication systems

OBJECTIVE

We investigated the impact on radiologist reporting time of the change from conventional film to hard-copy computerized radiography and of the subsequent move to soft-copy images on picture archiving and communication system (PACS) workstations.

MATERIALS AND METHODS

A controlled before and after research design was undertaken. Data were collected on four occasions: two relating to conventional film, one relating to hard-copy computerized radiography, and one relating to soft-copy PACS images. Data collection was by direct observation of radiology reporting sessions by independent health service researchers. Data were collected on report times, details of images viewed, characteristics of the radiologist, and details of interruptions. To control for potential biases in the before and after comparisons, ordinary least squares multiple regression analysis was used. The principal comparison was between reports with PACS and reports with computerized radiography hard-copy because no change was noted in the organization of the reporting process between these two data collection rounds other than the introduction of the PACS.

RESULTS

Data were collected on a total of 5568 report observations. Report time in the PACS data collection period was not significantly different (p = .32) than that in the computerized radiography hard-copy period. Reporting with the PACS was associated with significantly more (p < .01) historical images (i.e., images of the same patient obtained in previous examinations) being viewed.

CONCLUSION

Report time was not lengthened by the introduction of the PACS. The finding that more historical images were viewed when the PACS was in use indicates that the PACS brought about a positive change in reporting practice.

Evidence for the existence of a novel pregnancy-associated soluble variant of the vascular endothelial growth factor receptor, Flt-1

Angiogenesis is essential in physiological processes including ovulation, implantation and pregnancy. One of the most potent regulators is the cytokine vascular endothelial growth factor (VEGF). We provide evidence for a novel pregnancy-associated soluble variant of the VEGF receptor Flt-1. VEGF ranged from undetectable to 157.3 pg/ml (mean 49.9 pg/ml, SD 48.4 pg/ml) in plasma samples from normal volunteers (n = 10), but was undetectable in plasma from pregnant women (n = 12) and amniotic fluid (n = 10). Recoveries of spiked VEGF were poor in pregnancy-related samples, indicating the presence of VEGF-binding activity which was confirmed using biosensor and chromatographic techniques. Partial purification and protein sequencing indicated a novel soluble form of Flt-1 with a subunit size of 150 kDa. Normally present as a multimeric structure of approximately 400-550 kDa, complexes of 600-700 kDa were formed following binding of multiple VEGF molecules. Reverse transcriptase polymerase chain reaction of Flt-1 in placenta, amnion, chorion, human umbilical vein endothelial cells and cord blood samples produced bands of the predicted sizes but failed to identify any additional RNA species, and possible reasons for this are discussed. Soluble Flt-1 may be important in regulating the actions of VEGF in angiogenesis and trophoblast invasion and may have therapeutic implications in diseases with inappropriate angiogenesis such as proliferative retinopathies and cancer.

Development of a blocking enzyme-linked immunosorbent assay for detection of serum antibodies to O157 antigen of Escherichia coli

The O157 antigen of Escherichia coli shares structural elements with lipopolysaccharide (LPS) antigens of other bacterial species, notably Brucella abortus and Yersinia enterocolitica 09, a fact that confounds the interpretation of assays for anti-O157 antibodies. To address this problem, a blocking enzyme-linked immunosorbent assay (bELISA) was designed with E. coli O157:H7 LPS as the antigen and a monoclonal antibody specific for E. coli O157, designated 13B3, as the competing antibody. The bELISA had equivalent sensitivity to, and significantly higher specificity than, the indirect ELISA (iELISA), detecting anti-O157 antibodies in sera from cattle experimentally inoculated with O157:H7. Only 13% of sera from naive heifers vaccinated for or experimentally infected with B. abortus had increased anti-O157 bELISA titers, while 61% of anti-O157 iELISA titers were increased. The bELISA is a sensitive and specific method for the detection of serum antibodies resulting from exposure to E. coli O157.

Release of atrial natriuretic factor prohormone peptides 1-30, 31-67 and 99-126 from freshwater- and seawater-acclimated perfused trout (Oncorhynchus mykiss) hearts

Atrial natriuretic factor (ANF), a 28-amino-acid peptide hormone produced in the heart, circulates in both freshwater and seawater rainbow trout. In mammals, two other peptide hormones, proANF 1-30 and proANF 31-67, derived from the same 126-amino-acid prohormone as ANF (amino acids 99&shyp;126), circulate and have natriuretic and diuretic properties. It has never been determined whether these peptides circulate in fish. The present investigation was designed to determine (1) whether proANF 1-30 and/or proANF 31-67 circulate in perfused hearts from freshwater- and seawater-acclimated rainbow trout (Oncorhynchus mykiss) in situ, and (2) if they do, to determine whether increasing the filling pressure of the heart causes their release in trout as it does in mammals. High-performance gel-permeation chromatography of fish plasma revealed that both proANF 1-30 and 31-67 circulate in freshwater- and seawater-acclimated trout plasma at threefold higher concentrations than does ANF. The basal rates of release of ANF and proANF 1-30 and 31-67 were similar in both freshwater and seawater trout, with the rate of release of proANF 1-30 being 10 times higher and that of proANF 31-67 20 times higher than that of ANF. When the filling pressure was increased to the peak of the Starling curve (max), the rate of release of ANF and proANFs 1-30 and 31-67 increased fivefold for each peptide in the freshwater trout, while in seawater trout the rates of release increased six- to ninefold. We conclude that proANF 1-30 and 31-67, as well as ANF, circulate in both freshwater-and seawater-acclimated trout and do so at concentrations higher than that of ANF. Increasing the filling pressure to the trout heart was found to cause a similar increase in the release rates for each of these peptides, but the maximal increase was higher in the seawater-acclimated trout, apparently because they showed a larger increase in cardiac output.

A nested set of C-terminal deletions of the alpha subunit of Escherichia coli RNA polymerase define regions concerned with assembly, proteolysis, stabilization and transcriptional activation in vivo

BACKGROUND

The alpha subunit of eubacterial RNA polymerase comprises an N-terminal assembly domain and a mobile C-terminal domain which provides an activation contact site for class I transcription activators. One particular C-terminal alpha mutant, rpoA341, impairs the response of Escherichia coli RNA polymerase to several activators, including MelR.

RESULTS

The in vivo properties of a set of C-terminally truncated alpha variants were investigated. Derivatives of 230 amino acids or longer were assembled into functional RNA polymerase. However, derivatives greater than 271 residues in length were sensitised to proteolysis near K271. Deletion of only 13 C-terminal amino acids impaired the response to CRP at a class I promoter whereas the complete removal of the alpha C-terminal domain did not prevent complementation of MelR-dependent PmelAB activity in the rpoA341 mutant.

CONCLUSIONS

Our results refine the C-terminal limit of the alpha assembly domain to between residues 221 and 230. The 13 extreme C-terminal amino acids are exposed in the holoenzyme and participate in the protection of an otherwise proteolytically sensitive bond near K271. Their presence is also essential for transcription activation at class I CRP-dependent promoters. The rpoA341-mediated substitution, K271E, does not define an activation contact site for MelR.