Assessing domain match and feasibility of candidate instruments matching with OMERACT endorsed domains to measure flare in knee and hip osteoarthritis

PURPOSE

To evaluate the domain match (truth) and feasibility of candidate instruments assessing flare in knee and hip osteoarthritis (OA) according to the identified domains.

MATERIAL AND METHODS

From a literature review (575 papers), instruments were selected and evaluated using the truth and feasibility elements of the OMERACT Filter 2.2. These were evaluated by 26 experts, including patients, in two Delphi survey rounds. The final selection was obtained by a vote.

RESULTS

44 instruments were identified. In Delphi Round 1, five instruments were selected. In Round 2, all instruments obtained at least 75 % in terms of content match with the endorsed domains and feasibility. In the final selection, the Flare-OA questionnaire obtained 100 % favorable votes.

CONCLUSION

Through consensus of the working group, the Flare-OA questionnaire was selected as the best candidate instrument to move into a full assessment of its measurement properties using the OMERACT Filter 2.2.

Exploration of the contribution of physiotherapy students to the delivery of health services: a qualitative study

OBJECTIVE

To understand the perspectives of physiotherapists on the contribution of students to the delivery of health services during clinical placements.

METHODS

Focus groups with a semi-structured interview guide were completed separately with new graduate physiotherapists reflecting on their student experience and experienced physiotherapists from five Queensland public health-sector hospitals. Interviews were transcribed verbatim in preparation for thematic analysis. Interview manuscripts were read independently and initially coding completed. Codes were compared and further refinement of themes occurred. Themes were reviewed by two investigators.

RESULTS

There were 38 new graduate participants across nine focus groups and 35 experienced physiotherapists across six focus groups who participated in this study. Students participate in a range of activities during clinical placements some of which contribute to delivery of health services and others which support student learning. Three major themes were identified: 1) tangible student contribution; 2) non-tangible student contribution; and 3) factors that influence the student contribution.

CONCLUSIONS

Overwhelmingly, both new graduate and experienced physiotherapists felt that students do contribute to the delivery of health services however careful consideration of a variety of factors is necessary to maximize the student contribution.

A collaborative clinical placement model for physiotherapy students results in equivalent (or greater) direct patient care activity than that delivered by physiotherapists alone: an observational study

BACKGROUND

The demand for physiotherapy clinical placements is rising which requires innovative approaches and an understanding of clinical placement models.

OBJECTIVE

To determine physiotherapy student contribution to direct patient care activity during a collaborative clinical placement model. Secondary aims determined the impact of clinical area and clinical educator to student (CE:student) ratio and if a group of students could reach equivalent direct patient care activity of a junior or senior physiotherapist.

METHOD

Physiotherapy student, and junior and senior physiotherapist occasions of service (OOS) were collected from five Queensland Public Health Sector hospital information management systems from four physiotherapy clinical areas (i.e. cardiorespiratory, musculoskeletal, neurorehabilitation, and orthopedics). Number of days of clinical activity was recorded to provide average OOS/day.

RESULTS

Across a 5-week clinical placement a group of physiotherapy students in a collaborative clinical placement model provided on average 10.6 OOS/day (95%CI 10.1-11.2). In three (75%) clinical areas, a group of students participating in higher CE:student ratios produced more OOS/day. Clinical area and CE:student ratio predicted 39% of the variance in student average OOS/day. On average a group of students reached the equivalent direct patient care activity of a junior and senior physiotherapist by week two of a 5-week clinical placement.

CONCLUSION

Physiotherapy students in a collaborative clinical placement model met or exceeded the direct patient care activity of a physiotherapist, irrespective of clinical area and CE:student ratio.

Physiotherapy service provision in a specialist adult cystic fibrosis service: A pre-post design study with the inclusion of an allied health assistant

What is the impact of including an allied health assistant (AHA) role on physiotherapy service delivery in an acute respiratory service? A pragmatic pre-post design study examined physiotherapy services across two 3-month periods: current service delivery [P1] and current service delivery plus AHA [P2]. Clinical and non-clinical activity quantified as number, type and duration (per day) of all staff activity categorised for skill level (AHA, junior, senior). Physiotherapy service delivery increased in P2 compared to P1 (n = 4730 vs n = 3048). Physiotherapists undertook fewer respiratory (p < 0.001) and exercise treatments (p < 0.001) but increased reviews for inpatients (p < 0.001) and at multidisciplinary clinics in P2 (56% vs 76%, p < 0.01). The AHA accounted for 20% of all service provision. AHA activity comprised mainly non-direct clinical care including oversight of respiratory equipment use (e.g. supply, set-up, cleaning, loan audits) and other patient-related administrative tasks associated with delegation handovers, supervision and clinical documentation (72%), delegated supervision of established respiratory (5%) and exercise treatments (10%) and delegated exercise tests (3%). The AHA completed most of the exercise tests (n = 25). AHA non-direct clinical tasks included departmental management activities (11%). No adverse events were reported. AHA inclusion in an acute respiratory care service changed physiotherapy service provision. The AHA completed delegated routine clinical and non-clinical tasks. Physiotherapists increased clinic activity and annual reviews. Including an AHA role offers sustainable options for enhancing physiotherapy service provision in acute respiratory care.

Benchmarking service provision, scope of practice, and skill mix for physiotherapists in adult cystic fibrosis care delivery

BACKGROUND

Increasing age, numbers, and complexity of care are potentially impacting physiotherapy service delivery for adults with cystic fibrosis (CF).

PURPOSE

This study aimed to describe physiotherapy service provision, scope of practice, and skill mix in a large tertiary adult CF center, and determine if services were meeting clinical practice recommendations.

METHODS

A prospective cross-sectional study examined inpatient and outpatient physiotherapy care across a three-month period in a tertiary adult CF center. Physiotherapy services were described by number and skill level of physiotherapists, total hours of activity, and number, type, and duration of each physiotherapy activity.

RESULTS

Twenty-two physiotherapists provided care. Respiratory (n = 1058, 38%), and exercise treatments (n = 338, 12%) were the most frequent. Exercise testing (n = 20, 1%), and detailed treatment reviews (n = 79, 3%) occurred infrequently. Time for research was limited. Junior physiotherapists undertook more exercise treatments per day (p < .01), with senior physiotherapists attending outpatient clinics (p < .01).

CONCLUSION

A large number of physiotherapists were involved in the delivery of services. Recommended respiratory and exercise treatments were frequently provided; however, other recommended activities occurred infrequently. The impact of increasing age, numbers of patients, and complexity of care may be contributing to demand exceeding supply for physiotherapy services. Future studies are required to determine innovative approaches to address the gaps in clinical practice recommendations.

THU0614-HPR ASSESSING THE EFFECT OF INTERVENTIONS FOR AXIAL SPONDYLOARTHRITIS ACCORDING TO THE ENDORSED ASAS/OMERACT CORE OUTCOME SET: A META-RESEARCH STUDY OF TRIALS INCLUDED IN COCHRANE REVIEWS

Background:

The Assessment of SpondyloArthritis international Society (ASAS) has defined separate core sets for: i) symptom-modifying anti-rheumatic drugs (SM-ARD), ii) clinical record keeping, and iii) disease-controlling anti-rheumatic therapy (DC-ART). These all include the following domains: ‘physical function’, ‘pain’, ‘spinal mobility’, ‘spinal stiffness’ and ‘patient global assessment’ (PGA). The core set for clinical record keeping further includes the domains ‘peripheral joints’ and ‘acute phase reactants’, and the core set for DC-ART further includes the domains ‘fatigue’, ‘spine/hip radiographs’.

Objectives:

To assess the effect of interventions for each of the 9 axSpA core domains.

Methods:

We investigated the efficacy across all interventions included in Cochrane reviews according to the core outcome set for axSpA, as reported in these eligible axSpA trials. We combined data using the standardized mean difference (SMD) to meta-analyze outcomes involving similar constructs. By meta-regression analysis, we examined the effect for each of the nine separate SMD measures on the primary endpoint across all trials.

Results:

Among 85 articles screened, we included 43 trials with 63 randomized comparisons. Mean (SD) number of core outcomes domains measured for SM-ARD trials was 4.2 (1.7). 6 trials assessed all 5 proposed domains. Mean (SD) for number of core outcome domains for DC-ART trials was 5.8 (1.7). Unfortunately, no trials assessed all 9 domains. 8 trials were judged to have high risk of selective outcome reporting. The most responsible core domains for achieving success in meeting the primary objective per trial were pain; OR (95% CI) 5.19 (2.28, 11.77) and PGA; OR (95% CI) 1.87 (1.14, 3.07).

Conclusion:

Overall outcome reporting was good for SM-ARD trials, and poor for DC-ART trials. None of the DC-ART trials assessed all 9 domains. Outcome-reporting bias and ‘missing data’ should be reduced by implementing the endorsed ASAS/OMERACT outcome domains in all clinical trials. Our findings suggest that PGA and pain likely provide a holistic assessment of disease beyond “objective measures” of spinal inflammation.

Disclosure of Interests:

Rikke Asmussen Andreasen: None declared, Lars Erik Kristensen Consultant of: UCB Pharma (Advisory Board), Sannofi (Advisory Board), Abbvie (Advisory Board), Biogen (Advisory Board), Speakers bureau: AbbVie, Amgen, Biogen, Bristol-Myers Squibb,Celgene, Eli Lilly, Gilead, Forward Pharma, Janssen Pharmaceuticals, MSD, Novartis, Pfizer, and UCB Pharma, Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Vibeke Strand Consultant of: AbbVie, Amgen, Biogen, Celltrion, Consortium of Rheumatology Researchers of North America, Crescendo Bioscience, Eli Lilly, Genentech/Roche, GlaxoSmithKline, Hospira, Janssen, Merck, Novartis, Pfizer, Regeneron Pharmaceuticals, Inc., Sanofi, UCB, Philip J Mease Grant/research support from: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – grant/research support, Consultant of: Abbott, Amgen, Biogen Idec, BMS, Celgene Corporation, Eli Lilly, Novartis, Pfizer, Sun Pharmaceutical, UCB – consultant, Speakers bureau: Abbott, Amgen, Biogen Idec, BMS, Eli Lilly, Genentech, Janssen, Pfizer, UCB – speakers bureau, Maarten de Wit Grant/research support from: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Consultant of: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Speakers bureau: Dr. de Wit reports personal fees from Ely Lilly, 2019, personal fees from Celgene, 2019, personal fees from Pfizer, 2019, personal fees from Janssen-Cilag, 2017, outside the submitted work., Torkell Ellingsen: None declared, Inger Marie Jensen Hansen: None declared, Jamie Kirkham: None declared, George Wells: None declared, Peter Tugwell: None declared, Lara Maxwell: None declared, Maarten Boers: None declared, Kenneth Egstrup: None declared, Robin Christensen Grant/research support from: Dr. Christensen reports non-financial support from Board membership, grants from Consultancy (AbbVie, Amgen, Axellus A/S, Biogen, Bristol-Myers Squibb, Cambridge Weight Plan, Celgene, Eli Lilly, Hospira, MSD, Norpharma, Novartis, Orkla Health, Pfizer, Roche, Sobi, Takeda), personal fees from Employment (Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark), non-financial support from Expert testimony, grants from Grants/grants pending (Axellus A/S, AbbVie, Cambridge Weight Plan, Janssen, MSD, Mundipharma, Novartis, and Roche), grants from Payment for lectures including service on speakers bureaus (Abbott, Amgen, Axellus, Bayer HealthCare Pharmaceuticals, Biogen Idec, Bristol-Myers Squibb, Cambridge Weight Plan, Ipsen, Janssen, Laboratoires Expanscience, MSD, Mundipharma, Norpharma, Novartis, Pfizer, Roche, Rottapharm-Madaus, Sobi, and Wyeth), grants from Payment for manuscript preparation (Axellus, Bristol-Myers Squibb, and Cambridge Weight Plan, Aleris-Hamlet (via Norpharma)), non-financial support from Patents (planned, pending or issued), non-financial support from Royalties, grants from Payment for development of educational presentations (Bristol-Myers Squibb, MSD, Pfizer), non-financial support from Stock/stock options, grants from Travel/accommodations/meeting expenses unrelated to activities listed (Abbott, AbbVie, Axellus, Biogen, Bristol-Myers Squibb, Cambridge Weight Plan, Celgene, Laboratoires Expanscience, Norpharma, Novartis, Pfizer, Roche, Rottapharm-Madaus, and Wyeth), non-financial support from Other (err on the side of full disclosure), outside the submitted work; and I am involved in many health-care initiatives and research that could benefit from wide uptake of this publication (including Cochrane, OMERACT, IDEOM, RADS, and the GRADE Working Group).

Musculoskeletal Statistics Unit, The Parker Institute is grateful for the financial support received from public and private foundations, companies and private individuals over the years. The Parker Institute is supported by a core grant from the Oak Foundation; The Oak Foundation is a group of philanthropic organizations that, since its establishment in 1983, has given grants to not-for-profit organizations around the world.., Consultant of: Dr. Christensen reports non-financial support from Board membership, grants from Consultancy (AbbVie, Amgen, Axellus A/S, Biogen, Bristol-Myers Squibb, Cambridge Weight Plan, Celgene, Eli Lilly, Hospira, MSD, Norpharma, Novartis, Orkla Health, Pfizer, Roche, Sobi, Takeda), personal fees from Employment (Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark), non-financial support from Expert testimony, grants from Grants/grants pending (Axellus A/S, AbbVie, Cambridge Weight Plan, Janssen, MSD, Mundipharma, Novartis, and Roche), grants from Payment for lectures including service on speakers bureaus (Abbott, Amgen, Axellus, Bayer HealthCare Pharmaceuticals, Biogen Idec, Bristol-Myers Squibb, Cambridge Weight Plan, Ipsen, Janssen, Laboratoires Expanscience, MSD, Mundipharma, Norpharma, Novartis, Pfizer, Roche, Rottapharm-Madaus, Sobi, and Wyeth), grants from Payment for manuscript preparation (Axellus, Bristol-Myers Squibb, and Cambridge Weight Plan, Aleris-Hamlet (via Norpharma)), non-financial support from Patents (planned, pending or issued), non-financial support from Royalties, grants from Payment for development of educational presentations (Bristol-Myers Squibb, MSD, Pfizer), non-financial support from Stock/stock options, grants from Travel/accommodations/meeting expenses unrelated to activities listed (Abbott, AbbVie, Axellus, Biogen, Bristol-Myers Squibb, Cambridge Weight Plan, Celgene, Laboratoires Expanscience, Norpharma, Novartis, Pfizer, Roche, Rottapharm-Madaus, and Wyeth), non-financial support from Other (err on the side of full disclosure), outside the submitted work; and I am involved in many health-care initiatives and research that could benefit from wide uptake of this publication (including Cochrane, OMERACT, IDEOM, RADS, and the GRADE Working Group).

Musculoskeletal Statistics Unit, The Parker Institute is grateful for the financial support received from public and private foundations, companies and private individuals over the years. The Parker Institute is supported by a core grant from the Oak Foundation; The Oak Foundation is a group of philanthropic organizations that, since its establishment in 1983, has given grants to not-for-profit organizations around the world.., Speakers bureau: Dr. Christensen reports non-financial support from Board membership, grants from Consultancy (AbbVie, Amgen, Axellus A/S, Biogen, Bristol-Myers Squibb, Cambridge Weight Plan, Celgene, Eli Lilly, Hospira, MSD, Norpharma, Novartis, Orkla Health, Pfizer, Roche, Sobi, Takeda), personal fees from Employment (Research Unit for Musculoskeletal Function and Physiotherapy, Institute of Sports Science and Clinical Biomechanics, University of Southern Denmark), non-financial support from Expert testimony, grants from Grants/grants pending (Axellus A/S, AbbVie, Cambridge Weight Plan, Janssen, MSD, Mundipharma, Novartis, and Roche), grants from Payment for lectures including service on speakers bureaus (Abbott, Amgen, Axellus, Bayer HealthCare Pharmaceuticals, Biogen Idec, Bristol-Myers Squibb, Cambridge Weight Plan, Ipsen, Janssen, Laboratoires Expanscience, MSD, Mundipharma, Norpharma, Novartis, Pfizer, Roche, Rottapharm-Madaus, Sobi, and Wyeth), grants from Payment for manuscript preparation (Axellus, Bristol-Myers Squibb, and Cambridge Weight Plan, Aleris-Hamlet (via Norpharma)), non-financial support from Patents (planned, pending or issued), non-financial support from Royalties, grants from Payment for development of educational presentations (Bristol-Myers Squibb, MSD, Pfizer), non-financial support from Stock/stock options, grants from Travel/accommodations/meeting expenses unrelated to activities listed (Abbott, AbbVie, Axellus, Biogen, Bristol-Myers Squibb, Cambridge Weight Plan, Celgene, Laboratoires Expanscience, Norpharma, Novartis, Pfizer, Roche, Rottapharm-Madaus, and Wyeth), non-financial support from Other (err on the side of full disclosure), outside the submitted work; and I am involved in many health-care initiatives and research that could benefit from wide uptake of this publication (including Cochrane, OMERACT, IDEOM, RADS, and the GRADE Working Group).

Musculoskeletal Statistics Unit, The Parker Institute is grateful for the financial support received from public and private foundations, companies and private individuals over the years. The Parker Institute is supported by a core grant from the Oak Foundation; The Oak Foundation is a group of philanthropic organizations that, since its establishment in 1983, has given grants to not-for-profit organizations around the world.

Changes in direct patient care from physiotherapy student to new graduate

Background: Clinical placements offer students an opportunity to provide direct patient care and are essential to develop safe and effective practitioners. It is unknown what changes in direct patient care activities are required as students transition to graduate physiotherapists. Objective: To determine the change in direct patient care activity from physiotherapy student to new graduate. Methods: Five hospitals provided clinical activity data from 412 physiotherapy students and 50 new graduate physiotherapists working in four physiotherapy clinical areas. Main Outcome Measures: Percentage of day spent in direct patient care, average occasions of service (OOS) per day and average length of one OOS (LOOS) for physiotherapy students and new graduates. Results: Students spent less time during their day providing direct patient care (24%, 95% confidence interval (CI) 19 to 29), performed fewer OOS (4.4, 95%CI 4.0 to 4.8) and had longer LOOS (18 min, 95%CI 13 to 23) compared to new graduates. This was consistent across all clinical areas. Conclusions: Physiotherapy student caseload is half that of a new graduate physiotherapist, with students taking longer to complete an OOS. Given this disparity in workload, active stakeholder engagement is essential to implement strategies that support and optimize the transition from student to graduate.

A Content Analysis of Personal Safety Apps: Are They Keeping Us Safe or Making Us More Vulnerable?

Despite personal safety apps claiming to increase safety, few studies have examined the usefulness of such apps in reducing public stranger violence. A content analysis of personal safety apps available in the iTunes store and Google Play identified location-based services, personal alarms, crowd-sourced hot spot data, and geofencing as the most common features. The majority of apps offered interventions either at the time of the event or post-event, suggesting that they may reduce a user's fear of crime but have limited usefulness in reducing vulnerability to victimization. Implications for users, app designers, and key stakeholders are discussed.

B Cell Depletion With an Anti-CD20 Antibody Enhances Alloreactive Memory T Cell Responses After Transplantation

Alloreactive memory T cells mediate accelerated allograft rejection and transplant tolerance resistance. Recent studies have shown that B cell deficient-μMT mice fail to mount donor-specific memory T cell responses after transplantation. At the same time, other studies showed that pretransplant B cell depletion using rituximab (IgG1 anti-CD20 mAb) combined with cyclosporine A promoted the survival of islet allografts in monkeys. In this study, we investigated the effect of anti-CD20 antibody-mediated B cell depletion on the memory T cell alloresponse in mice. Wild-type and anti-OVA TCR transgenic mice were treated with an IgG2a anti-CD20 monoclonal antibody, which depleted nearly all B cells in the peripheral blood and secondary lymphoid organs but spared some B cells in the bone marrow. B cell depletion did not affect the direct alloresponse but resulted in a marked increase of indirect alloresponse after skin transplantation of naïve mice. Furthermore, in allosensitized mice, anti-CD20 mAb treatment enhanced the reactivation of allospecific memory T cells and accelerated second set rejection of skin allografts. This suggests that the effect of anti-CD20 antibodies on alloimmunity and allograft rejection might vary upon the nature of the antibodies as well as the circumstances under which they are delivered.

Prospective analysis of vitamin D and endometrial cancer risk

BACKGROUND

This is the first prospective cohort analysis on the association between vitamin D and endometrial cancer incorporating time-varying predicted plasma 25-hydroxyvitamin D [25(OH)D].

METHODS

The prospective cohort analysis of predicted 25(OH)D and total dietary vitamin D intake used the Cox proportional hazards model, and involved 644 incident endometrial cancer events from 1986 to 2006 in the Nurses' Health Study. Genotyping and unconditional logistic regression were carried out on 572 endometrial cancer cases and their matched controls on 12 single nucleotide polymorphisms (SNPs) in vitamin D-related genes.

RESULTS

There was no significant association between predicted 25(OH)D and endometrial cancer incidence, with the hazard ratio for the highest (versus the lowest) quintile of predicted 25(OH)D as 1.00 (95% CI 0.73-1.36) (p-trend = 0.33). There was also no significant association involving total dietary vitamin D. No significant associations between any of the vitamin D-related SNPs and endometrial cancer were observed.

CONCLUSION

Both predicted 25(OH)D and total dietary vitamin D intake were not associated with endometrial cancer incidence. These results suggest that vitamin D may not protect against the development of endometrial cancer. However, the low and narrow vitamin D exposure range in the cohort may limit generalizability of the results.

Prospective analysis of vitamin D and endometrial cancer risk

BACKGROUND

This is the first prospective cohort analysis on the association between vitamin D and endometrial cancer incorporating time-varying predicted plasma 25-hydroxyvitamin D [25(OH)D].

METHODS

The prospective cohort analysis of predicted 25(OH)D and total dietary vitamin D intake used the Cox proportional hazards model, and involved 644 incident endometrial cancer events from 1986 to 2006 in the Nurses' Health Study. Genotyping and unconditional logistic regression were carried out on 572 endometrial cancer cases and their matched controls on 12 single nucleotide polymorphisms (SNPs) in vitamin D-related genes.

RESULTS

There was no significant association between predicted 25(OH)D and endometrial cancer incidence, with the hazard ratio for the highest (versus the lowest) quintile of predicted 25(OH)D as 1.00 (95% CI 0.73-1.36) (p-trend = 0.33). There was also no significant association involving total dietary vitamin D. No significant associations between any of the vitamin D-related SNPs and endometrial cancer were observed.

CONCLUSION

Both predicted 25(OH)D and total dietary vitamin D intake were not associated with endometrial cancer incidence. These results suggest that vitamin D may not protect against the development of endometrial cancer. However, the low and narrow vitamin D exposure range in the cohort may limit generalizability of the results.

A Gynecologic Oncology Group study of frequent copy number aberrations in African American versus Caucasian women with stage I versus stage IIIC/IV endometrioid endometrial cancer

e16501

Background: An array-based comparative genomic hybridization (aCGH) analysis was performed to determine if frequent (>40%) copy number aberrations (CNAs) exist in African American (AA) versus Caucasian (C) women with stage I versus stage IIIC/IV endometrioid endometrial cancers (EEC). Methods: Tumor DNA was isolated from 80 frozen primary tumors from the GOG-210 protocol. RPCI 19K BAC arrays were hybridized (GeneTAC HybStation) and scanned (Gene Pix 4200AL Laser Scanner). Spot fluorescence values were quantified using ImaGene, vetted for quality and loess corrected with adjustments for chip-specific spatial effects. The genome was segmented to identify regions with common copy number means (DNAcopy software). Posterior aberration probabilities for the regions were obtained using CGHcall and data was visualized and annotated using iGenomicViewer in R. Validation will be performed by fluorescence in situ hybridization using select BAC probes and endometrial cancer tissue microarrays (TMAs) with either 400 cases linked with clinical, treatment and outcome data or 180 AA versus 120 C women from GOG-136. Results: Recurrent CNAs were identified in all stage and race groups. Distinct genomic losses and gains were observed that appear to segregate Caucasian women with stage I disease from African American women with stage I disease and African American or Caucasian women with stage IIIC/IV disease. Conclusions: The GOG-210 bank yielded high quality DNA for detecting and mapping CNAs in frozen primary tumors with high resolution. Our results would imply that racial disparity for AA EEC has a genetic basis regardless of stage. Validation studies are currently underway in two endometrial cancer TMAs. [Table: see text]

No significant financial relationships to disclose.

Responsiveness of patient reported outcomes including fatigue, sleep quality, activity limitation, and quality of life following treatment with abatacept for rheumatoid arthritis

OBJECTIVE

To evaluate the responsiveness of patient reported outcomes (PROs), including fatigue, sleep, activity limitation, and quality of life, in patients with rheumatoid arthritis (RA).

METHODS

Data were considered from a randomised controlled trial comparing abatacept (n = 258) with placebo (n = 133) on a background of DMARD treatment in RA patients who were inadequate responders to anti-TNF therapy (ATTAIN study). PROs assessed included SF-36, activity limitation, fatigue, and sleep. For each outcome the treatment difference, relative per cent improvement, standardised response mean (SRM), and relative efficiency for assessing an outcome's ability to detect a treatment effect relative to tender joint count (TJC) were calculated. A relative efficiency >1 suggests a measure that is more efficient than TJC in detecting treatment effect.

RESULTS

Moderate to large SRMs (>or=0.6) were observed for the PRO measures. In particular, SRMs (95% confidence interval) were: physician global, 0.72 (0.51 to 0.94); HAQ, 0.63 (0.42 to 0.85); SF-36 physical component score, 0.62 (0.40 to 0.83); SF-36 bodily pain, 0.68 (0.46 to 0.90); and fatigue, 0.59 (0.38 to 0.81). Relative efficiencies for physician global (1.6), SF-36 bodily pain domain (1.4), pain intensity (1.4), HAQ (1.2), SF-36 physical component score (1.2), fatigue (1.1), and patient global assessment (1.04) were all more responsive than TJC. The SF-36 mental component score (0.3), swollen joint count (0.6), activity limitation (0.8), sleep (0.7), and C reactive protein (0.9) were less responsive.

CONCLUSIONS

Using PROs for evaluating treatments for RA can detect improvements and will identify changes that are important to patients. In general, physical assessments are more responsive to an effective treatment than mental assessments.

Colchicine for acute gout

BACKGROUND

Gout is one of the most common rheumatic diseases worldwide. Colchicine is regarded as beneficial in the treatment of acute gout, but has a high frequency of gastrointestinal adverse events.

OBJECTIVES

To evaluate the efficacy and safety of colchicine for relief of the signs and symptoms of acute gouty arthritis, compared to placebo and other treatment interventions.

SEARCH STRATEGY

We searched the following electronic databases to March 2006: Cochrane Central Register of Controlled Trials (CENTRAL, Issue 1, 2006), MEDLINE (from 1966), EMBASE (from 1980), CINAHL (from 1982), AMED (from 1985), Web of Science (from 1945) and Current Controlled Trials.

SELECTION CRITERIA

Published randomised controlled trials (RCTs) and controlled clinical trials evaluating symptom relief and adverse outcomes of colchicine therapy in acute gout were considered for this review.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened search results for inclusion, collected the data in a standardized form and assessed the methodological quality of the trial using validated criteria. Results for continuous outcome measures were expressed as weighted mean differences. Dichotomous outcome measures were pooled using relative risk. The number needed to treat was calculated for significant outcomes.

MAIN RESULTS

One RCT (N=43) comparing colchicine to placebo for the treatment of acute gout was included in this review. The results favour the use of colchicine over placebo with an absolute reduction of 34% for pain and a 30% reduction in clinical symptoms such as tenderness on palpation, swelling, redness, and pain. The number needed to treat (NNT) with colchicine versus placebo to reduce pain was 3 and the NNT to reduce clinical symptoms was 2. All participants treated with colchicine experienced gastrointestinal side effects (diarrhea and/or vomiting) and the number needed to harm (NNH) with colchicine versus placebo was 1. No studies comparing colchicine to NSAIDs or other treatments such as corticosteroids or ACTH were identified.

AUTHORS' CONCLUSIONS

Colchicine is an effective treatment for the reduction of pain and clinical symptoms in patients experiencing acute attacks of gout, although in the regimen studied its low benefit to toxicity ratio limits its usefulness. It should be used as a second line therapy when NSAIDs or corticosteroids are contraindicated or ineffective. More evidence is needed to compare the efficacy of colchicine to that of NSAIDs or corticosteroids, the current first line therapy for acute gout.

Acetaminophen for osteoarthritis

BACKGROUND

Osteoarthritis (OA) is the most common form of arthritis. Published guidelines and expert opinion are divided over the relative role of acetaminophen (also called paracetamol or Tylenol) and non-steroidal anti-inflammatory drugs (NSAIDs) as first-line pharmacologic therapy. The comparative safety of acetaminophen and NSAIDs is also important to consider. This update to the original 2003 review includes nine additional RCTs.

OBJECTIVES

To assess the efficacy and safety of acetaminophen versus placebo and versus NSAIDs (ibuprofen, diclofenac, arthrotec, celecoxib, naproxen, rofecoxib) for treating OA.

SEARCH STRATEGY

We searched MEDLINE (up to July 2005), EMBASE (2002-July 2005), Cochrane Central Register of Controlled Trials (CENTRAL), ACP Journal Club, DARE, Cochrane Database of Systematic Reviews (all from 1994 to July 2005). Reference lists of identified RCTs and pertinent review articles were also hand searched.

SELECTION CRITERIA

Published randomized controlled trials (RCTs) evaluating the efficacy and safety of acetaminophen alone in OA were considered for inclusion.

DATA COLLECTION AND ANALYSIS

Pain, physical function and global assessment outcomes were reported. Results for continuous outcome measures were expressed as standardized mean differences (SMD). Dichotomous outcome measures were pooled using relative risk (RR) and the number needed to treat (NNT) was calculated.

MAIN RESULTS

Fifteen RCTs involving 5986 participants were included in this review. Seven RCTs compared acetaminophen to placebo and ten RCTs compared acetaminophen to NSAIDs. In the placebo-controlled RCTs, acetaminophen was superior to placebo in five of the seven RCTs and had a similar safety profile. Compared to placebo, a pooled analysis of five trials of overall pain using multiple methods demonstrated a statistically significant reduction in pain (SMD -0.13, 95% CI -0.22 to -0.04), which is of questionable clinical significance. The relative percent improvement from baseline was 5% with an absolute change of 4 points on a 0 to 100 scale. The NNT to achieve an improvement in pain ranged from 4 to 16. In the comparator-controlled RCTs, acetaminophen was less effective overall than NSAIDs in terms of pain reduction, global assessments and in terms of improvements in functional status. No significant difference was found overall between the safety of acetaminophen and NSAIDs, although patients taking traditional NSAIDS were more likely to experience an adverse GI event (RR 1.47, (95% CI 1.08 to 2.00). 19% of patients in the traditional NSAID group versus 13% in the acetaminophen group experienced an adverse GI event. However, the median trial duration was only 6 weeks and it is difficult to assess adverse outcomes in a relatively short time period.

AUTHORS' CONCLUSIONS

The evidence to date suggests that NSAIDs are superior to acetaminophen for improving knee and hip pain in people with OA. The size of the treatment effect was modest, and the median trial duration was only six weeks, therefore, additional considerations need to be factored in when making the decision between using acetaminophen or NSAIDs. In OA subjects with moderate-to-severe levels of pain, NSAIDs appear to be more effective than acetaminophen.

Cardiothoracic physiotherapy: levels of evidence underpinning entry-level curricula

BACKGROUND AND PURPOSE

In theory, educational materials should reflect the underlying source and evidence base of the curricula. The purpose of the present study was to identify the levels of evidence represented within the cardiothoracic curricula in undergraduate (entry-level) physiotherapy programmes within Australia.

METHOD

Using a retrospective document review, all tertiary institutions providing entry-level physiotherapy programmes were invited to submit paper copies of course materials used during 2003 to the Centre for Allied Health Evidence (CAHE), University of South Australia. A single independent reviewer collated all references cited within the teaching materials and ranked each reference according to a hierarchy of evidence where systematic reviews were regarded as the highest level of evidence and expert opinion or case studies as the lowest level.

RESULTS

A total of 974 references were cited within educational materials from the five participating universities. The number of references per university rangedfrom 71 to 256. Each ranking category was calculated as a percentage of the total number of references submitted by each university. All five universities demonstrated the same pattern of reference hierarchy where the lower levels of evidence represented approximately 70% of all references. Less than one per cent of all references were common to all five universities.

CONCLUSIONS

Although auditing references cited within education material does not reflect educational process, the results from the present study provide a baseline from which to review and create strategies to strengthen the evidence base of the cardiothoracic curriculum.

Glucosamine therapy for treating osteoarthritis

BACKGROUND

Osteoarthritis (OA) is the most common form of arthritis, and it is often associated with significant disability and an impaired quality of life.

OBJECTIVES

To review all randomized controlled trials (RCTs) evaluating the effectiveness and toxicity of glucosamine in OA.

SEARCH STRATEGY

We searched MEDLINE, PREMEDLINE, EMBASE, AMED, ACP Journal Club, DARE, CDSR, and the CCTR. We also wrote letters to content experts, and hand searched reference lists of identified RCTs and pertinent review articles. All searches were updated in January 2005.

SELECTION CRITERIA

Relevant studies met the following criteria: 1) RCTs evaluating the effectiveness and safety of glucosamine in OA, 2) Both placebo controlled and comparative studies were eligible, 3) Both single blinded and double blinded studies were eligible.

DATA COLLECTION AND ANALYSIS

Data abstraction was performed independently by two investigators and the results were compared for degree of agreement. Gotzsche's method and a validated tool (Jadad 1996) were used to score the quality of the RCTs. Continuous outcome measures were pooled using standardized mean differences (SMD) as the measure of effect size. Dichotomous outcome measures were pooled using relative risk ratios (RR).

MAIN RESULTS

Analysis restricted to eight studies with adequate allocation concealment failed to show benefit of glucosamine for pain and WOMAC function. Collectively, the 20 analyzed RCTs found glucosamine favoured placebo with a 28% (change from baseline) improvement in pain (SMD -0.61, 95% CI -0.95, -0.28) and a 21% (change from baseline) improvement in function using the Lequesne index (SMD -0.51 95% CI -0.96, -0.05). However, the results are not uniformly positive, and the reasons for this remain unexplained. WOMAC pain, function and stiffness outcomes did not reach statistical significance. In the 10 RCTs in which the Rotta preparation of glucosamine was compared to placebo, glucosamine was found to be superior for pain (SMD -1.31, 95% CI -1.99, -0.64) and function using the Lequesne index (SMD -0.51, 95% CI -0.96, -0.05). Pooled results for pain (SMD -0.15, 95% CI -0.35, 0.05) and function using the WOMAC index (SMD 0.03, 95% CI -0.18, 0.25) in those RCTs in which a non-Rotta preparation of glucosamine was compared to placebo did not reach statistical significance. In the four RCTs in which the Rotta preparation of glucosamine was compared to an NSAID, glucosamine was superior in two, and equivalent in two. Two RCTs using the Rotta preparation showed that glucosamine was able to slow radiological progression of OA of the knee over a three year period (SMD 0.24, 95% CI 0.04, 0.43). Glucosamine was as safe as placebo in terms of the number of subjects reporting adverse reactions (RR=0.97, 95% CI, 0.88, 1.08).

AUTHORS' CONCLUSIONS

This update includes 20 studies with 2570 patients. Pooled results from studies using a non-Rotta preparation or adequate allocation concealment failed to show benefit in pain and WOMAC function while those studies evaluating the Rotta preparation show that glucosamine was superior to placebo in the treatment of pain and functional impairment resulting from symptomatic OA. WOMAC outcomes of pain, stiffness and function did not show a superiority of glucosamine over placebo for both Rotta and non-Rotta preparations of glucosamine. Glucosamine was as safe as placebo.

Rofecoxib for osteoarthritis

BACKGROUND

Editor's note: The anti-inflammatory drug rofecoxib (Vioxx) was withdrawn from the market at the end of September 2004 after it was shown that long-term use (greater than 18 months) could increase the risk of heart attack and stroke. Further information is available at www.vioxx.com. Osteoarthritis is a chronic disease of the joints, characterised by joint pain, stiffness and loss of physical function. Its onset is age-related and occurs usually between the ages of 50 and 60. It is the commonest cause of disability in those aged over 65, with OA of the knee and/or hip affecting over 20 per cent of the elderly population.

OBJECTIVES

To establish the efficacy and safety of rofecoxib in the management of OA by systematic review of available evidence.

SEARCH STRATEGY

We searched the following databases up to August 2004: MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Research Register, NHS Economic Evaluation Database, Health Technology Assessment Database. The bibliographies of retrieved papers and content experts were consulted for additional references.

SELECTION CRITERIA

All eligible randomised controlled trials (RCTs) were included. No unpublished RCTs were included in this edition of the review.

DATA COLLECTION AND ANALYSIS

Data were abstracted independently by two reviewers. A validated checklist was used to score the quality of the RCTs. Comparable trials were pooled using fixed effects model.

MAIN RESULTS

Twenty-six RCTs were included. The comparators were placebo, diclofenac, ibuprofen, naproxen, nimesulide, nabumetone, paracetamol, celecoxib and Arthrotec. The evidence reviewed indicated that rofecoxib was more effective than placebo (patient global response RR 1.75 95% CI: 1.35, 2.26) but was associated with more adverse events (RR 1.32 95% CI 1.11, 1.56). There were no consistent differences in efficacy between rofecoxib and any of the active comparators at equivalent doses. Endoscopic studies indicated that compared to ibuprofen 800 mg three times a day, rofecoxib caused fewer erosions and gastric ulcers at doses of 25mg and 50mg; the difference in duodenal ulcers was evident only at a dose of 25mg. Rofecoxib 50mg also caused more endoscopically observed ulcers greater than rofecoxib 25mg (RR 2.48 CI: 1.21, 5.11). Very few of the trials reported overall rates of GI adverse events although rofecoxib was found to cause fewer GI events than naproxen. Only one of the nine trials comparing rofecoxib to celecoxib reported on the overall rates of GI events and this was a comparison of the higher recommended dose of rofecoxib with the lower recommended dose of celecoxib. Similarly, the three trials in older hypertensive patients that examined the cardiovascular safety of rofecoxib and celecoxib used non-comparable doses; the results of these studies indicated that rofecoxib caused more patients to have oedema and a clinically significant increase in systolic blood pressure. This difference between rofecoxib and celecoxib was not evident in studies conducted in more general populations.

AUTHORS' CONCLUSIONS

Rofecoxib was voluntarily withdrawn from global markets in October 2004 therefore there are no implications for practice concerning its use. There remains a number of questions over both the benefits and risks associated with Cox II selective agents and further work is ongoing.

Detection and quantification of cocaine metabolites in urine samples from horses administered cocaine

Cocaine is a naturally occurring alkaloid that is commonly abused by human-beings for its psychostimulatory effects. Occasionally, very small concentrations (i.e. <100 ng/mL) of the primary cocaine metabolite, benzoylecgonine (BZE) have been detected in urine collected from horses competing in athletic events. In this study urine samples, collected from four horses following the administration of 2.5 and 20 mg of cocaine sublingually and 50 mg of cocaine intravenously, were analyzed for the presence of cocaine and/or its metabolites by enzyme-linked immunosorbent assay (ELISA) and gas chromatography-mass spectrometry (GC-MS). The results of ELISA analysis of urine samples collected from all four horses suggested the presence of cocaine and/or its metabolites up to 10, 48, and 72 h after administration of 2.5, 20, and 50 mg of cocaine, respectively. The results of GC-MS analysis confirmed the presence of BZE above the limit of quantification (LOQ = 5 ng/mL) in urine samples collected from all four horses for up to 24 h after administration of 2.5 mg of cocaine and for up to 48 h after administration of 20 and 50 mg of cocaine. No obvious behavioral effects or overt alterations of heart rate or rhythm were noted in any of these horses after cocaine administration.

The effects of three manual hyperinflation techniques on pattern of ventilation in a test lung model

Manual hyperinflation (MHI) is used by physiotherapists as a treatment technique in intubated patients. This study investigated the effect of three different MHI techniques using a Mapleson-C circuit configuration with a CIG Medishield valve on volume delivered (Vt), peak inspiratory (PIFR) and expiratory flow rates (PEFR), and peak airway pressure (PAP) in a test lung model. The protocols differed in the degree of valve closure and inclusion of an inspiratory pause. For protocols 1, 2 and 3 the measures were Vt-1.33 (0.21), 2.74 (0.13), 3.55 (0.12) litres; PAP-14.30 (0.82), 24.00 (0.47), 30.20 (0.92) cmH2O and PIFR-1.13 (0.05), 1.51 (0.15), 1.32 (0.09) l/s respectively. All pair comparisons were statistically significant except for PEFR (l/s), which was significantly lower for protocol 1 [1.62 (0.06)], compared to protocols 2 [2.01 (0.25)] and 3 [2.10 (0.19)] but not between protocols 2 and 3. Circuit and technique choice should be considered in relation to the specific therapeutic aim of treatment.

A randomized multicenter study of remifentanil compared with halothane in neonates and infants undergoing pyloromyotomy. I. Emergence and recovery profiles

Pyloric stenosis is sometimes associated with hemodynamic instability and postoperative apnea. In this multicenter study we examined the hemodynamic response and recovery profile of remifentanil and compared it with that of halothane in infants undergoing pyloromyotomy. After atropine, propofol, and succinylcholine administration and tracheal intubation, patients were randomized (2:1 ratio) to receive either remifentanil with nitrous oxide and oxygen or halothane with nitrous oxide and oxygen as the maintenance anesthetic. Pre- and postoperative pneumograms were done and evaluated by an observer blinded to the study. Intraoperative hemodynamic data and postanesthesia care unit (PACU) discharge times, PACU recovery scores, pain medications, and adverse events (vomiting, bradycardia, dysrhythmia, and hypoxemia) were recorded by the study's research nurse. There were no significant differences in patient age or weight between the two groups. There were no significant differences in hemodynamic values between the two groups at the various intraoperative stress points. The extubation times, PACU discharge times, pain medications, and adverse events were similar for both groups. No patient anesthetized with remifentanil who had a normal preoperative pneumogram had an abnormal postoperative pneumogram, whereas three patients with a normal preoperative pneumogram who were anesthetized with halothane had abnormal pneumograms after.

IMPLICATIONS

The use of ultra-short-acting opioids may be an appropriate technique for infants less than 2 mo old when tracheal extubation after surgery is anticipated.

A randomized multicenter study of remifentanil compared with halothane in neonates and infants undergoing pyloromyotomy. II. Perioperative breathing patterns in neonates and infants with pyloric stenosis

Although former preterm birth infants are at risk for postoperative apnea after surgery, it is unclear whether the same is true of full-term birth infants. We evaluated the incidence of apnea in 60 full-term neonates and infants undergoing pyloromyotomy both before and after anesthesia. All subjects were randomized to a remifentanil- or halothane-based anesthetic. Apnea was defined by the presence of prolonged apnea (>15 s) or frequent brief apnea, as observed on the pneumocardiogram. Apnea occurred before surgery in 27% of subjects and after surgery in 16% of subjects, with no significant difference between subjects randomized to remifentanil or halothane anesthesia. This apnea was primarily central in origin, occurred throughout the recording epochs, and was associated with severe desaturation in some instances. Of the subjects with normal preoperative pneumocardiograms, new onset postoperative apnea occurred in 3 (23%) of 13 subjects who received halothane-based anesthetics versus 0 (0%) of 22 subjects who received remifentanil-based anesthetics (P = 0.04). Thus, postoperative apnea can follow anesthesia in otherwise healthy full-term infants after pyloromyotomy and is occasionally severe with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic.

IMPLICATIONS

Abnormal breathing patterns can follow anesthesia in infants after surgical repair of pyloric stenosis. Occasionally, these patterns can be associated with desaturation. New-onset postoperative apnea was not seen with a remifentanil-based anesthetic.

The metabolic effects of endotoxin are differentially affected by the pattern of GH administration in the rat

GH treatment can increase the mortality and morbidity of critically ill patients. The mechanisms of these harmful effects of GH are unknown but have been, in part, ascribed to interactions between GH and the immune system. Because GH has pattern-dependent actions we have now compared the dose-related effects of continuous and intermittent GH treatment given with or without an endotoxin (lipopolysaccharide; LPS) challenge. Male Wistar rats (n=6 per group) were treated for 5 days with recombinant human GH (0, 10, 100 or 1000 microg/kg per day) using either continuous s.c. infusion by osmotic minipump or intermittent twice daily s.c. injections. On day 4, endotoxin (5 mg/kg, i.p.) was injected and the animals monitored for a further 16 h. LPS administration alone led to neutrophilia and lymphopoenia, with increased plasma concentrations of urea, cholesterol, triglyceride, insulin and leptin, and decreased levels of IGF-I. High dose GH infusion (1000 microg/kg per day) followed by LPS caused greater increases in plasma urea, cholesterol, triglyceride, sodium and magnesium, but lower plasma glucose and insulin levels, than treatment with LPS alone. In contrast, twice daily injections of GH did not enhance these effects of endotoxin. In conclusion, the effects of endotoxin on plasma electrolytes, lipids, urea, glucose and insulin are differentially affected by the pattern of GH administration in the rat.

Altered response of intestinal mucosal fibroblasts to profibrogenic cytokines in inflammatory bowel disease

BACKGROUND AND AIMS

Fibrosis is a major complication of inflammatory bowel disease (IBD), which may be mediated by the intestinal fibroblast. Our aim was to isolate and characterize mucosal fibroblasts from histologically normal intestine (control), ulcerative colitis (UC), inflamed Crohn's disease (CD), and fibrosed CD intestine.

METHODS

Fibroblasts were characterized by light and electron microscopy and immunohistochemistry. Fibroblast collagen secretion and proliferation were determined by 3H-proline and 3H-thymidine incorporation, and the effects of exposure to interleukin (IL)-1beta, basic fibroblast growth factor (bFGF), platelet-derived growth factor (PDGF), transforming growth factor (TGF)-beta1, insulin-like growth factor (IGF)-1, and macrophage colony stimulating factor (M-CSF) were determined.

RESULTS

No difference in doubling time was observed between the fibroblast populations from UC and CD intestine. All proliferated faster than fibroblasts from control intestine. Collagen secretion from IBD fibroblasts, independent of type, was increased compared with control fibroblasts and PDGF, bFGF, and TGF-beta1-induced collagen secretion from IBD fibroblasts.

CONCLUSIONS

These results suggest the presence of an activated subpopulation of fibroblasts in both UC and CD tissue irrespective of the presence of tissue fibrosis or disease type.

Exercise-enhanced satellite cell proliferation and new myonuclear accretion in rat skeletal muscle

The effects of increased functional loading on early cellular regenerative events after exercise-induced injury in adult skeletal muscle were examined with the use of in vivo labeling of replicating myofiber nuclei and immunocyto- and histochemical techniques. Satellite cell proliferation in the soleus (Sol) of nonexercised rats (0.4 +/- 0.2% of fibers) was unchanged after an initial bout of declined treadmill exercise but was elevated after two (1.0 +/- 0.2%, P < or = 0.01), but not four or seven, daily bouts of the same task. Myonuclei produced over the 7-day period comprised 0.9-1.9% of myonuclei in isolated fibers of Sol, tibialis anterior, and vastus intermedius of nonexercised rats. The accretion of new myonuclei was enhanced (P < or = 0.05) in Sol and vastus intermedius by the initial exercise followed by normal activity (to 3.1-3.4% of myonuclei) and more so by continued daily exercise (4.2-5.3%). Observed coincident with a lower incidence of histological fiber injury and unchanged fiber diameter and myonuclei per millimeter, the greater new myonuclear accretion induced by continued muscle loading may contribute to an enhanced fiber repair and regeneration after exercise-induced injury.

Nonimmune hydrops fetalis and activation of the renin-angiotensin system after asphyxia in preterm fetal sheep

This study examined the hypothesis that the development of hydrops fetalis after asphyxia in the 0.6 gestation sheep fetus would be associated with activation of the fetal renin-angiotensin system (RAS). Fetuses were randomly assigned to either sham occlusion (n = 7) or to 30 min of asphyxia induced by complete umbilical cord occlusion for 30 min (n = 8). Asphyxia led to severe bradycardia and hypotension that resolved after release of occlusion. After occlusion, plasma renin concentration was significantly increased in the asphyxia group compared with controls (P < 0.005) after 3 min (16.3 +/- 5.3 vs. 4.1 +/- 1.3 ng. ml(-1). h(-1)), and 72 h (30.6 +/- 6.3 vs. 3.7 +/- 1.2 ng. ml(-1). h(-1)). Renal renin concentrations and mRNA levels were significantly greater in the asphyxia group after 72 h of recovery. All fetuses in the asphyxia group showed generalized tissue edema, ascites, and pleural effusions after 72 h of recovery. In conclusion, asphyxia in the preterm fetus caused sustained activation of the RAS, which was associated with hydrops fetalis.

Inflammation location, but not type, determines the increase in TGF-beta1 and IGF-1 expression and collagen deposition in IBD intestine

BACKGROUND AND AIMS

Inflammatory bowel disease (IBD) is frequently complicated by extracellular matrix (ECM) changes that may result in fibrosis. Transforming growth factor (TGF)-beta1 and insulin-like growth factor (IGF)-1 mediate numerous ECM changes. Our aim was to determine whether TGF-beta1 and IGF-1 are involved in intestinal ECM collagen regulation and what impact the inflammatory infiltrate has on their expression.

METHODS

TGF-beta1 and IGF-1 mRNA and protein were assessed in fibrosed Crohn's disease (CD), inflamed CD, inflamed ulcerative colitis (UC), and control intestine using in situ hybridization and immunohistochemistry. Collagen types I and III were quantified by electron immunohistochemistry.

RESULTS

In CD, increased TGF-beta1 and IGF-1 mRNA expression was transmural. In UC, the increase was confined to the lamina propria and submucosa. In both, distribution of TGF-beta1 and IGF-1 protein matched mRNA expression and coincided with the distribution of the inflammatory infiltrate. An increase in the collagen type III:I ratio in both CD and UC also coincided with the inflammatory infiltrate.

CONCLUSIONS

These findings suggest that TGF-beta1 and IGF-1 are involved in intestinal ECM remodeling in IBD, and their enhanced expression depends on the presence and location of inflammatory infiltrates rather than the type of IBD.

Delayed hypotension and subendocardial injury after repeated umbilical cord occlusion in near-term fetal lambs

OBJECTIVE

This study was undertaken to determine whether myocardial injury occurs after repeated intrauterine asphyxia.

STUDY DESIGN

Near-term fetal sheep with implanted instrumentation underwent either sham occlusions (n = 8) or repeated brief umbilical cord occlusions (n = 12) continued until the onset of severe (<20 mm Hg) or sustained hypotension. After 3 days of recovery, the fetal hearts were perfusion fixed.

RESULTS

Repeated umbilical cord occlusions led to a severe metabolic acidosis (pH, 6.84 +/- 0.09; lactate concentration, 14.1 +/- 1.5 mmol/L) with increasing hypotension during occlusions, which were terminated after 128 +/- 38 minutes. After the occlusions, the mean arterial pressure showed a delayed fall, which resolved after 12 hours. Ultrastructural examination showed evidence of subendocardial injury, with dilatation of sarcoplasmic reticulum, margination and clumping of nuclear chromatin, and mitochondrial swelling. The most severe morphologic changes, including electron-dense mitochondrial inclusions, were found in the fetuses with delayed recovery of the fetal heart rate after the final occlusion.

CONCLUSION

Subendocardial injury occurs after severe repeated intrauterine asphyxia in the late-gestation fetus, and this may contribute to cardiovascular compromise and the development of late decelerations.

Nuclear DNA fragmentation and morphological alterations in adult rabbit skeletal muscle after short-term immobilization

Nuclear DNA fragmentation and ultrastructural changes, indicative of myonuclear apoptosis, were examined in adult skeletal muscle in response to short-term immobilization. Adult rabbits were allocated to 2 days (n=5) or 6 days (n=5) of unilateral casting of the ankle in full plantar flexion or were used as untreated controls (n=2). Atrophy of the soleus muscle was apparent by significant reductions in wet mass of 15% and 26% after 2 days and 6 days of casting (P< or =0.05), respectively. Mean fibre cross-sectional area and myonuclear number per section were also lower (17% and 9.1%, respectively) after 6 days of casting, in comparison with contralateral control muscles (P< or =0.05). Electron-microscopic examination showed condensed chromatin and irregularly shaped myonuclei in muscles immobilized for either 2 days or 6 days. Myofibrillar disruption and abnormalities of the subsarcolemmal mitochondria were also apparent in the absence of inflammation or plasma membrane alterations in cast muscles. Longitudinal and transverse sections showed abundant in situ end-labelling of DNA strand breaks (TUNEL) after 2 days, with less after 6 days, of immobilization. Positive labelling corresponded to myonuclear locations within fibres, yet the number of TUNEL-positive nuclei indicated DNA fragmentation in additional cell types such as capillary endothelial cells or fibroblasts. The data indicate that the immobilization of slow-twitch skeletal muscle in a shortened position rapidly induces morphological alterations consistent with mitochondrial injury and apoptotic myonuclear elimination.

Endothelin antagonists diminish postischemic microvascular incompetence and necrosis in the heart

The endothelin receptor antagonists BQ-610 and BQ-123 were used to clarify the role of endothelin in the pathogenesis of postischemic microvascular incompetence in the myocardium. Forty-five isolated rat hearts were perfused with Krebs-Henseleit buffer (KHB) for 15 min and then subjected to 0, 15, or 60 min of ischemia followed by 5 min of reperfusion with KHB, KHB + BQ-610, or KHB + BQ-123. They were fixed by perfusion with 2.5% glutaraldehyde and then perfused with nuclear track emulsion as an indicator of vascular flow. Transmural sections of resin-embedded myocardium were examined by scanning and transmission electron microscopy. Following 60 min of ischemia, the subendocardial third of the LV wall of hearts treated with BQ-123 showed nearly three times the proportion (P < 0.001) of competent capillaries in untreated hearts. Reperfusion after 15 min of ischemia of hearts treated with BQ-123 showed a 30% increase in the proportion of competent capillaries compared to controls (P < 0. 002). Treatment of corresponding groups with BQ-610 increased the proportion of competent capillaries but these differences were not statistically significant. In addition, both ET-I antagonists dramatically reduced the amount of ultrastructural change evident in myocardium reperfused after 60 min of ischemia. Thus endothelin plays a significant role in the pathogenesis of postischemic microvascular incompetence in the myocardium and, probably by its effects on Ca(2+) uptake, contributes also to the ultrastructural damage to the myocytes and endothelium which follows postischemic reperfusion of irreversibly injured myocardium.

Kinetics and polarization of the membrane expression of cytokine-induced ICAM-1 on rat brain endothelial cells

ICAM-1 is a major cellular adhesion molecule by which lymphocytes attach to vascular endothelial cells. Rat brain endothelial cells (RBEC) in culture show very low levels of ICAM-1. However, after exposure to IL-1beta and IFN-gamma, the ICAM-1 expression increases up to 20-fold (as judged by FACS analysis). We used immunogold electron microscopy to examine the kinetics in distribution of cytokine-induced ICAM-1 on the surfaces of tight-junction RBEC (grown on matrigel-coated transwells) when exposed to cytokines from either the luminal (upper well) or the abluminal (lower well) surface. Luminal stimulation produced an early upregulation of ICAM-1 not only on the luminal surface of the endothelial cells but also on the lateral surface below the tight junctions and on the abluminal surface. Peak expression on the abluminal surface of the monolayer occurred at the time of maximal "trapping" of lymphocytes seen during an in vitro migration assay. This suggests that the in vitro trapping, as well as the in vivo trapping described by others, may have its basis in a receptor-ligand interaction. We also demonstrate that when the monolayer is stimulated with cytokine from the abluminal surface there is a delayed but preferential upregulation of ICAM-1 on the luminal surface.

Mechanical manipulation of bone and cartilage cells with 'optical tweezers'

The single beam optical gradient trap (optical tweezers) uses a single beam of laser light to non-invasively manipulate microscopic particles. Optical tweezers exerting a force of approximately 7 pN were applied to single bone and cartilage derived cells in culture and changes in intracellular calcium levels were observed using Fluo-3 labelling. Human derived osteoblasts responded to optical tweezers with an immediate increase in [Ca2+]i that was inhibited by the addition of a calcium channel blocker nifedipine. Force applied to different regions of cells resulted in a variable response. [Ca2+]i elevation in response to load was lower in rat femur derived osteoblasts, and not apparent in primary chondrocytes and the osteocytic cell line (MLO Y4).

Microvascular involvement in cardiac pathology

Abnormalities of the microvasculature are centrally involved in the pathogenesis of some forms of heart disease, but in others are consequences of it. Microvascular abnormalities may contribute to the progression of viral myocarditis and Chagas' disease. Focal abnormalities may occur early in some cardiomyopathies and do occur later in most types of myocarditis. The thickening of arteriolar walls in chronic hypertension is likely to contribute significantly to the impairment of coronary haemodynamics associated with adaptive ventricular hypertrophy and the consequent diminution of coronary reserve, increasing diffusion distances and failure of angiogenesis to compensate. However, the resulting myocyte necrosis stimulates inflammatory angiogenesis. When ischemic myocyte injury becomes irreversible there is a concomitant loss of capacity for reperfusion, the no-reflow phenomenon. Less severe temporary ischemia reduces the proportion of functional capillaries. Multiple mechanisms are involved in this microvascular stunning, including: reperfusion injury; leukocyte activation; adhesion and accumulation; and impaired endothelium-dependent vasodilation. Many of the microvascular changes are those of the inflammatory response to cell death and form part of a final common pathway in myocarditis, cardiomyopathy, cardiac hypertrophy and failure, and ischemic heart disease. Stimulation of angiogenesis prior to myocyte necrosis in hypertrophy and control of leukocyte activity in ischemic heart disease could minimize myocyte loss.

Gene therapy of diabetes: glucose-stimulated insulin secretion in a human hepatoma cell line (HEP G2ins/g)

In order to design a feasible somatic cell gene delivery system for the treatment of type I diabetes, a suitable cell type needs to be determined. We have previously shown that the stable transfection of the full-length insulin cDNA into the human liver cell line, (HEP G2ins) resulted in synthesis, storage and acute regulated release of insulin to analogues of cAMP, but not to the physiological stimulus glucose. In attempting to explain the lack of glucose responsiveness of the HEP G2ins cells we have stably transfected these cells with the human islet glucose transporter GLUT 2 (HEP, G2ins/g cells). The HEP G2ins/g cell clones exhibit glucose-stimulated insulin secretion and glucose potentiation of the secretory response to nonglucose secretagogues. While glucose responsiveness commenced at a lower concentration than normal islets, a secretion curve approaching normal physiological conditions was generated. Immunoelectron microscopy revealed the presence of insulin-containing granules, similar in size and appearance to those of the normal beta cell. These results demonstrate that while it is most likely that the HEP G2ins/g cell line predominantly secretes insulin via the constitutive pathway, significant acute regulated release was seen in response to glucose, and thus represents significant progress in the creation of a genetically engineered 'artificial beta cell' from a human hepatocyte cell line.

A confocal microscopic survey of serotoninergic axons in the lumbar spinal cord of the rat: co-localization with glutamate decarboxylase and neuropeptides

Patterns of co-localization of serotonin with glutamate decarboxylase (the synthetic enzyme for GABA) or each one of eight neuropeptides (calcitonin gene-related peptide, dynorphin, enkephalin, galanin, neuropeptide Y, neurotensin, substance P and somatostatin) were investigated with dual-colour confocal laser scanning microscopy in the lumbar spinal cords of three adult rats. Four regions of the gray matter were studied (laminae I-II, V, IX and X). The extent of co-localization was estimated by direct assessment of merged pairs of optical sections and by automated image analysis. Co-localization of serotonin and glutamate decarboxylase was found only in a few axons of laminae I-II but was not detected in other laminae. Peptides were not co-localized with serotonin in the superficial dorsal horn but considerable co-localization was found in motor nuclei and sparse co-localization was found in laminae V and X. Galanin and substance P frequently co-existed with serotonin in lamina IX but some co-localization with dynorphin, somatostatin, [Met]enkephalin and neuropeptide Y was also detected. Galanin, substance P and dynorphin were also co-localized with serotonin in a few axons of the deep dorsal horn and in the gray matter around the central canal. Neurotensin and calcitonin gene-related compound did not co-exist with serotonin in any of the laminae investigated. This evidence suggests that different populations of serotoninergic axons project to different regions of the spinal gray matter. Those containing glutamate decarboxylase terminate in the superficial dorsal horn and are likely to be involved in antinociception, whereas those containing peptides terminate principally in motor nuclei and are likely to modulate motor activity.

Invasive intestinal spirochetosis: a report of three cases

We here report on three patients with gastrointestinal symptoms in whom spirochetes were found in colonic biopsies. The patients, heterosexual adults, were not immunocompromised. Electron microscopy was performed on colonic biopsies from each of the three patients. Apart from the basophilic band consisting of spirochetes, the mucosa was normal in two patients on light microscopy and showed mild inflammation in the other one. However on electron microscopy there was invasion of the colonic epithelial cells, macrophages, goblet cells and Schwann cells by spirochetes, and stunting of the microvilli. The spirochetes conformed to the morphology of Brachyspira aalborgi, and no other infective etiology or pathology could be identified in these patients to account for their symptoms. Since the clinical significance of intestinal spirochetosis is uncertain, antibiotics were not administered to any of the three patients and all three improved symptomatically with non-specific treatment. Intestinal spirochetosis, previously thought to be non-invasive and non-pathogenic in humans, may be invasive and may be the cause of gastrointestinal symptoms in some patients.

Distribution of human colonic dendritic cells and macrophages

To define the phenotype of intestinal dendritic cells and macrophages, resected colonic specimens were used to obtain lamina propria cell suspensions by EDTA treatment, then enzymatic digestion. The phenotype of dendritic cell-enriched suspensions was compared with that of macrophage-enriched populations by immunocytochemistry using the avidin-biotin-peroxidase (ABC) system and immunoelectron microscopy. Dendritic cells expressed HLA-DR (L243) and HLA-DQ-associated (RFD) antigens and CD68 in a perinuclear distribution. Staining for S100 was weak or absent. Macrophages also expressed HLA markers (L243 and RFD1) and CD68. The 25F9 antigen was expressed strongly, whilst CD14 was absent from cells isolated from noninflamed tissues. To determine their anatomic distribution, immunohistochemistry was performed using single- and double-labelling techniques (ABC +or- alkaline phosphatase anti-alkaline phosphatase method). Mutually exclusive subsets of 25F9+ and S100+ cells were seen: 25F9+ macrophages were concentrated in a band immediately beneath the luminal epithelium; S100+/HLA-DR+ dendritic cells formed a reticular network throughout the lamina propria and beneath the basement membrane of the crypts. This distribution suggests that macrophages may help regulate intestinal responses by acting as the first line of defence against the entry of luminal antigens. A breach of the macrophage 'barrier' by invading antigens may necessitate the recruitment of T cell responses by immunostimulatory dendritic cells.

Harlequin ichthyosis--a case report

The Harlequin infant represents the most severe form of nonbullous ichthyosis. Although the clinical features of infants with Harlequin ichthyosis are generally similar, histological, ultrastructural, and biochemical analyses have not shown consistent findings. An unexpected case of Harlequin ichthyosis in a female infant born at 35 wks gestation is presented. Light microscopic and ultrastructural investigations of skin biopsies are detailed. The presence of extracellular lipid material in the stratum corneum has not been described in the previously reported cases of Harlequin ichthyosis.

A new ureteral anastomotic device: the Unilink system. A pilot study using the porcine model

OBJECTIVE

Ureteral injury is a complication of gynecologic surgery in approximately 1% of all cases. The anatomic site of the injury determines the type of operative repair. When an end-to-end ureteral anastomosis is required, interrupted sutures are usually used. A prospective, randomized animal study was performed to determine the efficacy of a new microvascular anastomotic device, the Unilink system, in repairing transected ureters.

STUDY DESIGN

Nineteen pigs underwent randomized anastomosis with the Unilink system on one side and traditional anastomosis with suture on the contralateral side. A postoperative intravenous pyelogram was performed immediately and 2 weeks later, before the anastomotic site at a second laparotomy was harvested. Patency rates for each type of anastomosis were compared microscopically, and the degree of hydronephrosis was compared grossly and radiographically.

RESULTS AND CONCLUSION

The anastomotic repair with the Unilink system did not significantly differ structurally or functionally from traditional suture repair.

The augmentation of leucocyte adhesion to endothelium by therapeutic ultrasound

To determine the effects of exposure of endothelial cells to therapeutic ultrasound on leucocyte adhesion to these cells, confluent cultures of bovine aortic endothelial cells in tissue culture flasks and on collagen coated coverslips were exposed to a maximum of 1.6 W/cm2 1 MHz continuous ultrasound for 15 min, then incubated with neutrophil-rich suspensions containing a known number of viable human leucocytes for intervals from 1 to 240 min. After incubation, nonadherent cells were decanted, the number of leucocytes in the eluted suspension determined and the percentage of adhered cells calculated. Endothelial cell viability was not significantly reduced by ultrasound or by incubation with leucocytes. Whereas untreated endothelial cells were flattened and had surface microvilli, those exposed to ultrasound were plump, rounded and more widely separated along their borders. The percentage of leucocytes that adhered to sonicated endothelium was significantly higher, and this proportion increased with the duration of incubation. Thus, exposure of endothelial cells to ultrasound in vitro can cause intercellular separation and increase the adhesion to leucocytes. If such changes were also to occur in vivo, therapeutic ultrasound would potentiate the inflammatory response.

Improvement of doxorubicin induced cardiomyopathy in rats treated with insulin-like growth factor I

OBJECTIVES

This study was designed to assess the effects of treatment with insulin-like growth factor-I (IGF-I) on cardiac function and structure in rats with an established cardiomyopathy.

METHODS

Adult male Wistar rats were injected with doxorubicin (2 mg.kg-1 subcutaneously) weekly for 12 weeks and either rhIGF-I (0.8 mg.kg-1.day-1; n = 16, D-I group) or saline (n = 25, D-S group) subcutaneously via an osmotic pump from weeks 9 to 12. A non-doxorubicin injected control group was also studied. After 12 weeks survivors were anaesthetised and cardiac output determined with radiolabelled microspheres. At postmortem pleural effusion and ascitic volumes were measured and the heart was removed for histological examination by light and transmission electron microscopy.

RESULTS

Doxorubicin treated animals showed less mean weight gain from week 2 than the untreated control group. Animals treated with IGF-I from week 9 showed a significant (p < 0.05) but non-sustained increase in weight. Survival to 12 weeks was 56% in the D-I group and 44% in the D-S group (p = 0.2). Evidence of cardiac failure was seen in the D-I and the D-S groups, but there was a tendency (p = 0.06) for less ascites in the D-I group (21 (SEM 8) ml) than in the D-S group (46 (10) ml). Cardiac output was significantly higher in the D-I than in the D-S group (132 (7.2) v 91.4 (6.4) ml.min-1, p < 0.01), as was stroke volume (0.323 (0.03) v 0.226 (0.02) ml, p < 0.01). There was focal cardiac damage in both D-I and D-S animals. Scattered groups of myocytes showed prominent vacuolation of the nuclear envelope, sarcoplasmic reticulum, and t tubular system, mild to severe mitochondrial swelling, and loss of orientation and definition of myofibrils. No clear morphological differences were evident between the two groups.

CONCLUSIONS

Administration of IGF-I may improve the function of damaged myocardium, although the mechanisms are unclear. Further studies with earlier coadministration of IGF-I, quantitative histological analysis, and with other models of cardiac injury are indicated.

The myocardial vasculature during ischemia and reperfusion: a target for injury and protection

Ischemia and reperfusion may result in injury to one or more of the cellular components of the heart. In addition to damaging myocytes and their contractile capability, ischemia and reperfusion may inflict early and severe injury on the vasculature which, in turn, may further jeopardize the survival of the myocytes. While ischemia is known to cause progressive injury to endothelium and vascular smooth muscle it now appears that reperfusion can inflict additional, possibly severe, injury on the microcirculation which may compromise the return of normal coronary perfusion. This post-ischemic/reperfusion microvascular incompetence ranges from a transient exacerbation of the increase in vascular resistance initiated during ischemia, to a sustained loss of competent capillaries and eventually to the "no reflow" phenomenon which is characterized by the total inability of the affected tissue to be reperfused. Whereas "no reflow" may be of little importance if it occurs in already infarcted tissue, post-ischemic microvascular incompetence in potentially salvable myocardium could be of considerable significance. Evidence is presented that the vascular endothelium, and its ability to regulate coronary vascular tone, play a central and early role in the pathogenesis of myocardial injury. Mechanisms underlying microvascular injury have been identified and pharmacological strategies now exist for the effective manipulation of this injury--a prospect that is of considerable importance in the light of the widespread use of thrombolytic procedures for the reperfusion of the human myocardium.

Endothelin-3-induced microvascular incompetence and mitochondrial damage in rat myocardium

1. To determine the possible role of an endothelin in the development of postischaemic microvascular incompetence, isolated buffer-perfused rat hearts were perfused with endothelin-3 (ET-3) in phosphate buffer. 2. ET-3 produced a reduction in coronary flow rate, heart rate and arrhythmia. There was a marked reduction in the density of competent capillaries, and the myocytes showed vacuolation and mitochondrial damage in regions where microvascular incompetence was most severe. 3. These results indicate that ET-3 can substantially reduce microvascular perfusion in the heart and can also cause damage to the myocyte.