Clinical and medico-legal considerations in endodontics

Endodontic treatment can be challenging for a number of reasons, including the microscopic nature of the clinical environment, reliance on tactile sensation and lack of direct visualization of the work being performed. Commonly, endodontic patients present with pain and distress, which can exacerbate an already difficult clinical situation. Complications may might arise prior to, or during treatment, despite practising with the utmost care and skill. Preventing and managing these complications can take considerable time and energy, and oftentimes assistance from or referral to more experienced colleagues is required. The aim of this review is to discuss medico-legal considerations in endodontics, with clinical correlations and a focus on the Australian legal landscape. [Correction added on 18 October 2023, after first online publication: The abstract was amended from a structured to an unstructured abstract.].

Creating a Digital Psychoeducation Programme for bipolar disorder in the COVID-19 pandemic

Introduction

The Covid-19 pandemic profoundly affected delivery and accessibility of mental health care services at a time when most needed. The OPTIMA Mood Disorder Service, a specialist bipolar disorder service, adapted group psychoeducation programme for delivery on-line.

Objectives

We report the feasibility of creating a digital psychoeducation programme.

Methods

The OPTIMA ten session group psychoeducation programme was converted into a ‘Digital’ intervention using video-conferencing. Sessions offered a range of key topics, derived from the initial Barcelona Group Psychoeducation Programme. At the time of writing, OPTIMA had fully completed two 10 session digital courses.

Results

A total of 12 people (6 in each group) consented to be part of a service evaluation of the digital groups. Just over half of the participants were women (7/12; 58.3%) and one identified as being non-binary (8.3); remaining participants were men. Age of participants ranged from 25 years to 65 years (Mean=42.3; SD=13.1). Data showed a high level of engagement (77%) All participants reported some improvement with a mean Bipolar Self-Efficacy scale (BPSES) post-group score of 105.6 (SD=14.8). At group level, this change was not statistically significant (F (1, 15) = 0.71, p=0.41). At an individual level, two out of five showed a reliable change index >1.96.

Conclusions

Delivering a ‘digital’ group psychoeducation programme was possible due to careful planning and programme development. There was good uptake from service users suggesting it is a feasible approach with preliminary evidence of clinical benefit.

Disclosure

No significant relationships.

Prescribing drugs of dependence in dentistry: a review of␣legal and regulatory considerations

The misuse of drugs of dependence is a major public health issue in Australia, and prescribing of these medications by dentists has increased in recent years. While there has been much focus on the appropriate indications and clinical use of these medicines in dental practice, the legal requirements of prescribing are equally important. Dental practitioners need to be aware of their legal obligations, as inappropriate prescription practices may lead to regulatory or criminal prosecution. Although dentists hold registration through the National Scheme␣and there is nationally standardised scheduling of drugs in Australia, the legislation governing drug laws differs for each state and territory, especially when prescribing drugs of dependence. This article summarises the legislation governing the prescription of drugs of dependence in Australia that is relevant to dental practice, providing insights into how dentists might contribute to the appropriate, safe and legal use and management of these medications.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

Comparing complex perspectives on obesity drivers: action-driven communities and evidence-oriented experts

INTRODUCTION

The Foresight obesity map represents an expert-developed systems map describing the complex drivers of obesity. Recently, community-led causal loop diagrams have been developed to support community-based obesity prevention interventions. This paper presents a quantitative comparison between the Foresight obesity systems map and a community-developed map of the drivers of obesity.

METHODS

Variables from a community-developed map were coded against the thematic clusters defined in the Foresight map to allow comparison of their sizes and strength of adjoining causal relationships. Central variables were identified using techniques from network analysis. These properties were compared to understand the similarities and differences between the systems as defined by the two groups.

RESULTS

The community map focused on environmental influences, such as built physical activity environment (18% of variables) and social psychology (38%). The Foresight map's largest cluster was physiology (23%), a minimal focus in the community map (2%). Network analysis highlighted media and available time within both maps, but variables related to school and sporting club environments were unique to the community map.

CONCLUSION

Community stakeholders focus on modifiable social and environmental drivers of obesity. Capturing local perspectives is critical when using systems maps to guide community-based obesity prevention.

Length of Variable Numbers of Tandem Repeats in the Carboxyl Ester Lipase (CEL) Gene May Confer Susceptibility to Alcoholic Liver Cirrhosis but Not Alcoholic Chronic Pancreatitis

BACKGROUND

Carboxyl-ester lipase (CEL) contributes to fatty acid ethyl ester metabolism, which is implicated in alcoholic pancreatitis. The CEL gene harbours a variable number of tandem repeats (VNTR) region in exon 11. Variation in this VNTR has been linked to monogenic pancreatic disease, while conflicting results were reported for chronic pancreatitis (CP). Here, we aimed to investigate a potential association of CEL VNTR lengths with alcoholic CP.

METHODS

Overall, 395 alcoholic CP patients, 218 patients with alcoholic liver cirrhosis (ALC) serving as controls with a comparable amount of alcohol consumed, and 327 healthy controls from Germany and the United Kingdom (UK) were analysed by determination of fragment lengths by capillary electrophoresis. Allele frequencies and genotypes of different VNTR categories were compared between the groups.

RESULTS

Twelve repeats were overrepresented in UK ACP patients (P = 0.04) compared to controls, whereas twelve repeats were enriched in German ALC compared to alcoholic CP patients (P = 0.03). Frequencies of CEL VNTR lengths of 14 and 15 repeats differed between German ALC patients and healthy controls (P = 0.03 and 0.008, respectively). However, in the genotype and pooled analysis of VNTR lengths no statistical significant association was depicted. Additionally, the 16-16 genotype as well as 16 repeats were more frequent in UK ALC than in alcoholic CP patients (P = 0.034 and 0.02, respectively). In all other calculations, including pooled German and UK data, allele frequencies and genotype distributions did not differ significantly between patients and controls or between alcoholic CP and ALC.

CONCLUSIONS

We did not obtain evidence that CEL VNTR lengths are associated with alcoholic CP. However, our results suggest that CEL VNTR lengths might associate with ALC, a finding that needs to be clarified in larger cohorts.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Postoperative pulmonary complications following major elective abdominal surgery: a cohort study

Background

Postoperative pulmonary complications (PPC) are an under-reported but major cause of perioperative morbidity and mortality. The aim of this prospective, contemporary, multicentre cohort study of unselected patients undergoing major elective abdominal surgery was to determine the incidence and effects of PPC.

Methods

Data on all major elective abdominal operations performed over a 2-week period in December 2014 were collected in six hospitals. The primary outcome measure of PPC at 7 days was used. Univariate and multivariate analyses were performed to investigate how different factors were associated with PPC and the effects of such complications.

Results

Two hundred sixty-eight major elective abdominal operations were performed, and the internal validation showed that the data set was 99 % accurate. Thirty-two (11.9 %) PPC were reported at 7 days. PPC was more common in patients with a history of chronic obstructive pulmonary disease compared to those with no history (26.7 vs. 10.2 %, p < 0.001). PPC was not associated with other patient factors (e.g. age, gender, body mass index or other comorbidities), type/method of operation or postoperative analgesia. The risk of PPC appeared to increase with every additional minute of operating time independent of other factors (odds ratio 1.01 (95 % confidence intervals 1.00–1.02), p = 0.007). PPC significantly increase the length of hospital stay (10 vs. 3 days). Attendance to the emergency department within 30 days (27.3 vs. 10.6 %), 30-day readmission (21.7 vs. 9.9 %) and 30-day mortality (12.5 vs. 0.0 %) was higher in those with PPC.

Conclusions

PPC are common and have profound effects on outcomes. Strategies need to be considered to reduce PPC.

Electronic supplementary material

The online version of this article (doi:10.1186/s13741-016-0037-0) contains supplementary material, which is available to authorized users.

Endodontics and the ageing patient

Patients are living longer and the rate of edentulism is decreasing. Endodontic treatment is an essential part of maintaining the health and well-being of the elderly. Retention of natural teeth improves the quality of life and the overall health and longevity of ageing patients. Also, teeth that might be otherwise extracted may be strategically valuable to retain a prosthesis, and elderly patients are more likely to have medical complications that may prevent dental extractions from being safely performed. The technical goals of endodontic treatment in the elderly are the same as those for younger patients. However, the pulpo-dentinal complex undergoes calcific changes over time, which may pose challenges for the clinician. The purposes of this review are to discuss age changes in the pulp and the challenges posed by diagnosing, treatment planning and treating the elderly endodontic patient.

Incidence of post-ERCP pancreatitis from direct pancreatic juice collection in hereditary pancreatitis and familial pancreatic cancer before and after the introduction of prophylactic pancreatic stents and rectal diclofenac

OBJECTIVES

Individuals from hereditary pancreatitis (HP) and familial pancreatic cancer (FPC) kindreds are at increased risk of developing pancreatic cancer. Premalignant molecular changes may be detected in pancreatic juice collected by endoscopic retrograde cholangiopancreatography (ERCP). The objective was to determine the risk of post-ERCP pancreatitis (PEP).

METHODS

A prospective study (1999-2013) was undertaken of 80 ERCPs (24 in HP and 56 in FPC) from 60 individuals and the impact of PEP prophylaxis using a self-expelling pancreatic stent and 50 mg diclofenac per rectum from 2008.

RESULTS

There was no PEP in the HP cohort and 13 (23.2%) PEP from 56 procedures in the FPC cohort (P = 0.0077). Up to 2008 PEP had occurred in 7 (43.8%) of 16 procedures in FPC individuals versus none of 18 procedures in HP individuals (P = 0.0021). After the introduction of prophylaxis, the incidence of PEP fell to 6 (15.0%) of 40 procedures in FPC individuals (P = 0.0347).The odds ratio (95% confidence interval) was 0.23 (0.06-0.84) in favor of prophylaxis (0.035).

CONCLUSIONS

Individuals with HP are at minimal risk for PEP. Although the risk of PEP in individuals with FPC can be reduced by using prophylactic self-expelling stents and diclofenac, it remains too high for routine screening.

Protocol for a multicentre, prospective, population-based cohort study of variation in practice of cholecystectomy and surgical outcomes (The CholeS study)

INTRODUCTION

Cholecystectomy is one of the most common general surgical operations performed. Despite level one evidence supporting the role of cholecystectomy in the management of specific gallbladder diseases, practice varies between surgeons and hospitals. It is unknown whether these variations account for the differences in surgical outcomes seen in population-level retrospective data sets. This study aims to investigate surgical outcomes following acute, elective and delayed cholecystectomies in a multicentre, contemporary, prospective, population-based cohort.

METHODS AND ANALYSIS

UK and Irish hospitals performing cholecystectomies will be recruited utilising trainee-led research collaboratives. Two months of consecutive, adult patient data will be included. The primary outcome measure of all-cause 30-day readmission rate will be used in this study. Thirty-day complication rates, bile leak rate, common bile duct injury, conversion to open surgery, duration of surgery and length of stay will be measured as secondary outcomes. Prospective data on over 8000 procedures is anticipated. Individual hospitals will be surveyed to determine local policies and service provision. Variations in outcomes will be investigated using regression modelling to adjust for confounders.

ETHICS AND DISSEMINATION

Research ethics approval is not required for this study and has been confirmed by the online National Research Ethics Service (NRES) decision tool. This novel study will investigate how hospital-level surgical provision can affect patient outcomes, using a cross-sectional methodology. The results are essential to inform commissioning groups and implement changes within the National Health Service (NHS). Dissemination of the study protocol is primarily through the trainee-led research collaboratives and the Association of Upper Gastrointestinal Surgeons (AUGIS). Individual centres will have access to their own results and the collective results of the study will be published in peer-reviewed journals and presented at relevant surgical conferences.

Carcinoma showing thymus-like elements of the thyroid gland: report of three cases including one case with breast cancer history

Carcinoma showing thymus-like elements (CASTLE) is a rare malignant tumor of the thyroid or adjacent neck soft tissues, whose histogenesis is still debated. It may resemble other primary or metastatic poorly differentiated tumors histologically and the differential diagnosis is crucial for CASTLE has a better prognosis. However, CASTLE as a second primary tumor has not been reported in the literature. We report three cases of thyroid CASTLE, including a unique tumor following breast-conserving surgery for early-stage breast invasive carcinoma. There were two female and one male. All three tumors were located in the right lobe of the thyroid, and one tumor showed extension into the surrounding soft tissue. Histologically, all tumors showed expansive growth and consisted of cords, nests or sheets of epithelial cells divided into irregularly shaped lobules by fibrous connective tissue with lymphoplasmacytic infiltration. Focal squamous differentiation resembling Hassall's corpuscles were observed. All cases stained positively for CD5, CD117, high molecular weight cytokeratin, cytokeratin, P63, carcinoembryonic antigen and epithelial membrane antigen. Positive staining for Bcl-2 in two cases and chromogranin A in one case was noted. Ki-67 expression ranged from 15 to 25%. Thyroid transcription factor and CD3 were negative. There was no evidence of recurrent or metastatic disease at following surgery. These features demonstrated CASTLE may arise from branchial pouch remnants, the thyroid solid cell nests. CASTLE is a rare entity, awareness of its occurrence as a second primary tumor is important to avoid overtreatment because it is associated with a favorable prognosis.

The impact of timing of cholecystectomy following gallstone pancreatitis

INTRODUCTION

Current guidelines for the management of acute gallstone pancreatitis recommend cholecystectomy as definitive treatment during primary admission or within 2 weeks of discharge, with the aim of preventing recurrent pancreatitis. However, cholecystectomy during the inflammatory phase may increase surgical complication rates. This study aimed to determine whether adherence to the guidelines prevents recurrent pancreatitis while minimising surgical complications.

METHODS

Multi-centre review of seven UK hospitals, indentifying patients presenting with their first episode of gallstone pancreatitis between 2006 and 2008.

RESULTS

A total of 523 patients with gallstone pancreatitis were identified, of which 363 (69%) underwent cholecystectomy (72 during the primary admission or within 2 weeks of discharge; 291 following this). Overall, 7% of patients had a complication related to cholecystectomy of which a greater proportion occurred when cholecystectomy was performed within guideline parameters (13% vs 6%; p = 0.07). 11% of patients were readmitted with recurrent pancreatitis prior to surgery, with those undergoing cholecystectomy outside guideline parameters being most at risk (p = 0.006).

CONCLUSION

This study suggests cholecystectomy within guideline parameters significantly reduces recurrence of pancreatitis but may increase the risk of surgical complications. A prospective randomised study to assess the associated morbidity is required to inform future guidelines.

Prediction of the severity of acute pancreatitis on admission by urinary trypsinogen activation peptide: A meta-analysis

AIM: To undertake a meta-analysis on the value of urinary trypsinogen activation peptide (uTAP) in predicting severity of acute pancreatitis on admission.

METHODS: Major databases including Medline, Embase, Science Citation Index Expanded and the Cochrane Central Register of Controlled Trials in the Cochrane Library were searched to identify all relevant studies from January 1990 to January 2013. Pooled sensitivity, specificity and the diagnostic odds ratios (DORs) with 95%CI were calculated for each study and were compared to other systems/biomarkers if mentioned within the same study. Summary receiver-operating curves were conducted and the area under the curve (AUC) was evaluated.

RESULTS: In total, six studies of uTAP with a cut-off value of 35 nmol/L were included in this meta-analysis. Overall, the pooled sensitivity and specificity of uTAP for predicting severity of acute pancreatitis, at time of admission, was 71% and 75%, respectively (AUC = 0.83, DOR = 8.67, 95%CI: 3.70-20.33). When uTAP was compared with plasma C-reactive protein, the pooled sensitivity, specificity, AUC and DOR were 0.64 vs 0.67, 0.77 vs 0.75, 0.82 vs 0.79 and 6.27 vs 6.32, respectively. Similarly, the pooled sensitivity, specificity, AUC and DOR of uTAP vs Acute Physiology and Chronic Health Evaluation II within the first 48 h of admission were found to be 0.64 vs 0.69, 0.77 vs 0.61, 0.82 vs 0.73 and 6.27 vs 4.61, respectively.

CONCLUSION: uTAP has the potential to act as a stratification marker on admission for differentiating disease severity of acute pancreatitis.

Endoscopic ultrasound-guided choledoco-duodenostomy as an alternative to percutaneous trans-hepatic cholangiography

BACKGROUND

Endoscopic ultrasonography (EUS)-guided choledochoduodenostomy (CDS) is an alternative to percutaneous transhepatic cholangiography (PTC) drainage in patients with an obstructed biliary system where conventional endoscopic retrograde biliary drainage (ERBD) has been unsuccessful.

METHODS

Five EUS-CDS procedures were reviewed to assess whether successful decompression was achieved and maintained.

RESULTS

There was technical success in each instance with no immediate complications. There was a significant fall in the median bilirubin of 164 mmol/l. The median follow-up was 44 days. In one patient the stent migrated with no adverse outcome.

CONCLUSION

EUS-CDS is a viable alternative to PTC with fewer complications and comparable success rates. EUS-CDS may offer a future route for novel therapeutic advances.

Noncontact all-optical measurement of corneal elasticity

We report on a noninvasive and noncontact all-optical method to measure the elasticity of the cornea. We use a pulsed laser to excite surface acoustic waves (SAW) that propagate on the corneal surface, then use a phase-sensitive optical coherence tomography system to remotely record the SAWs from which the corneal elasticity is estimated. In addition, the system is able to provide real-time tomographic images of the cornea being examined, an important consideration for clinical studies. While precisely maintaining a range of intraocular pressures (IOP), a series of measurements is performed on ex vivo intact primate eyes. The measurement results not only demonstrate the feasibility of the proposed system to remotely measure the corneal elasticity, but also suggest a strong correlation between the corneal stiffness and the true IOP.

Mirtazapine: a solution for postoperative gastroparesis?

This report describes the case of a 52-year-old man with an obstructed para-oesophageal hiatus hernia who required a gastropexy, who postoperatively developed gastroparesis which inadequately responded to conventional prokinetics including erythromycin, metoclopramide, ondansetron, and domperidone. The patient's symptoms were relieved rapidly with a trial of mirtazapine. A review of related literature is presented.

A pilot randomized controlled crossover study comparing regional heparinization to regional citrate anticoagulation for continuous venovenous hemofiltration

OBJECTIVE

To evaluate the efficacy and safety of a regional heparinization and a regional citrate method of anticoagulation in CVVH.

DESIGN

Randomized controlled cross-over study.

SUBJECTS

Ten critically ill patients with acute renal failure.

SETTING

ICU of tertiary hospital.

INTERVENTION

CVVH was performed with pre-filter fluid replacement at 2000 ml/h and a blood flow rate of 150 ml/min. Regional heparinization was by the administration of heparin pre-filter at 1500 IU/h and protamine post-filter at 15 mg/h. Regional citrate anticoagulation was by means of a citrate-based replacement fluid (14 mmol/L) administered pre-dilution.

RESULTS

We studied nine males and one female. The mean age and APACHE II score were 70.5 and 17 respectively. Median circuit life was 13 hours (IQR 9.28) for the regional heparinization method compared to 17 hours (IQR 12,19.5) for the regional citrate method (p=0.77). There were no episodes of bleeding in either group.

CONCLUSION

Regional heparinization and regional citrate anticoagulation achieve similar circuit life in critically ill patients receiving CVVH.

What is the normal heart rate of a term fetus?

There is controversy about the value of continuous versus intermittent auscultation of the fetal heart during labour, but there is no agreement on what constitutes normal heart rate of a term fetus. There are variations between the definitions adopted by different countries, and even within a single country. We propose 110-160 beats per minute for clinical use.

Net Carbon Gain and Growth of Bell Peppers, Capsicum annuum 'Cubico', Following Root Infection by Pythium aphanidermatum

ABSTRACT The first characterization of alterations in whole-plant photosynthetic rate and carbon assimilation of bell peppers associated with infection by Pythium aphanidermatum is described. Relationships of root disease caused by P. aphanidermatum to whole-plant net carbon exchange rate (NCER), total carbon accumulation, dark respiration rates, water loss, and destructive growth parameters were quantified in vegetative, hydroponically grown pepper plants (Capsicum annuum 'Cubico'). Inoculated plants displayed lower whole-plant NCER. This translated into a loss of 28% in cumulative C gain during 7 days after inoculation and occurred before visible shoot symptoms developed. Leaf area and dry weight of shoots and roots were significantly decreased and the shoot/root ratio was higher in inoculated plants than in noninoculated plants. We propose that reduced NCER in inoculated plants was mainly due to restricted development of leaf area, because no differences in NCER and evapotranspiration were observed between control and inoculated plants when expressed based on leaf area and root dry mass, respectively. These findings indicate that Pythium infection did not affect the photosynthetic apparatus directly and that the reductions in photosynthesis and growth were not caused by inefficient water transport by diseased roots. These results enlarge on the understanding of physiological responses of host plants to early stages of root disease.

Thyroglobulin monitoring after treatment of well-differentiated thyroid cancer

AIMS

The prognosis for well-differentiated thyroid carcinomas is favourable after treatment, but the rate of recurrence is around 20%. Cervical ultrasonography, radio-iodine scans, and monitoring of serum thyroglobulin (Tg) levels allow these recurrences to be diagnosed. The management of patients with isolated elevated Tg levels is controversial in the presence of negative radio-iodine scans.

METHODS

The records of 57 patients diagnosed with recurrence of well-differentiated thyroid cancer were reviewed. Serum Tg was not evaluated in 31 of these patients (group 1) and measured in the other 26 cases (group 2).

RESULTS

Forty-three recurrence sites were found; four deposits in the thyroid bed and 39 cervical metastatic nodes, with an average of five nodes per patient. The radio-iodine scan was accurate in detecting 10/24 of cases, radiology in 9/17, and elevated Tg levels in 20/25. Thirteen patients with recurrences diagnosed on the basis of Tg levels had negative radio-iodine scans. After surgery, Tg levels were normal in 10 patients from group 1 and 16 patients from group 2 (p=0.0078).

CONCLUSIONS

Elevated Tg levels are indicative of disease progression or recurrence in patients who have previously been operated on for well-differentiated thyroid cancer. Even when the radiological study or radio-iodine scan is normal, surgical re-exploration of the neck, with total thyroidectomy and lymphadenectomy, is advisable.

Radon in the workplace: implications of studies of post-remediation monitoring

Radon gas has been shown to cause an increased incidence of lung cancer. In affected areas, levels in the overground workplace can be sufficiently high to be a health risk and remediation is required. In the UK, the workplace Action Level is 400 Bq m(-3). The variation of radon levels in the workplace was studied both before and after remediation. In most rooms, remediation resulted in a greater reduction at night than during the working day. The dose reduction, and therefore the health benefit, to workers is less than that predicted by the drop in radon averaged over 24 h. In order to obtain a health benefit to 75% of workers in our series, the 24 h average radon level in each room must be reduced to <225 Bq m(-3). It is recommended that UK Regulatory Agencies adopt a post-remediation workplace Action Level of 225 Bq m(-3).

Urban squatting and migration in Peninsular Malaysia

"This article examines some of the links between the phenomena of urban migration and squatter settlements in the Third World city. This will be done by demonstrating that both are outcomes of fundamental social and political forces that have operated on these societies. Migration and squatting are placed in a context of the historical processes that led to the uneven development of Malaysia. The article offers some explanation for the origin of the inequalities observed in spatial structures--in this case urban housing--by focusing on one of the contributory factors, namely migration."

Glaucoma laser treatment parameters and practices of ASCRS members--1999 survey. American Society of Cataract and Refractive Surgery

A survey of glaucoma laser parameters and practices was mailed to all United States members of the American Society of Cataract and Refractive Surgery (ASCRS) in March 1999. Approximately 19% (947) of the 5100 surveys were returned. The survey assessed parameters used for laser trabeculoplasty, laser iridotomy, and gonioplasty. Respondents also answered questions about the application of these laser therapies in a wide variety of clinical situations. The results were cross-tabulated by age, number of laser trabeculoplasties performed per month, fellowship training in glaucoma, and geographic location.

A central role for astrocytes in the inflammatory response to beta-amyloid; chemokines, cytokines and reactive oxygen species are produced

Alzheimer's disease (AD) is the commonest form of adult onset dementia and is characterised neuropathologically by the accumulation of plaques containing beta-amyloid (A beta) fibrils, reactive astrocytes, activated microglia, and leukocytes. A beta plays a role in the pathology of AD by directly causing neuronal cytotoxicity and stimulating microglia to secrete cytokines and reactive oxygen species (ROS) which also damage neurons. Here, we demonstrate that A beta activates astrocytes and oligodendrocytes (the most common cell types in the brain) to produce chemokines, in particular MCP-1 and RANTES, which serve as potent in vitro microglial and macrophage chemoattractants. Furthermore, we have shown that A beta activates astrocytes to upregulate pro-inflammatory cytokine expression and enhances the production of ROS. We propose therefore that A beta-mediated astrocyte activation initiates an inflammatory cascade which could be targeted for therapeutic intervention in AD.

Medical treatment patterns of ASCRS members for primary open-angle glaucoma--1998 survey

A survey of medical treatment patterns for primary open-angle glaucoma (POAG) was mailed to all United States members of the American Society of Cataract and Refractive Surgery (ASCRS) in March 1998; 21.2% responded. Demographic information pertinent to glaucoma care was also obtained. The use of diagnostic ancillary tests, as well as the sequential order of preferred therapy, in 3 hypothetical patient populations was analyzed: patients with mild, moderate, and advanced POAG. Preferred medical therapy was cross-tabulated with number of years in practice, fellowship training in glaucoma, and geographic location.

Flu-like symptoms and hyperechoic foetal bowel

Images

Localisation of microtubule-associated protein 1B phosphorylation sites recognised by monoclonal antibody SMI-31

MAP 1B is a microtubule-associated phosphoprotein that is expressed early in neurons and plays a role in axon growth. MAP 1B has two types of phospho-isoforms, one of which is developmentally down-regulated after neuronal maturation and one of which persists into adulthood. Because phosphorylation regulates MAP 1B binding activity, characterisation of the phosphorylation sites and identification of the corresponding kinases/phosphatases are important goals. We have characterised the developmentally down-regulated phosphorylation sites recognised by monoclonal antibody (mAb) SMI-31. We purified MAP 1B from neonatal rat brain and mapped the mAb SMI-31 sites to specific MAP 1B fragments after chemical cleavage. We then developed an in vitro kinase assay by using a high-speed spin supernatant from neonatal rat brain in the presence of ATP and recombinant proteins encoding selective regions of the MAP 1B molecule. Phosphorylation of the recombinant protein was detected on western blots using mAb SMI-31. This analysis showed that mAb SMI-31 recognises two recombinant proteins corresponding to residues 1,109-1,360 and 1,836-2,076 of rat MAP 1B after in vitro phosphorylation. The former phosphorylation site was further defined in the in vitro kinase assay by inhibition with peptides and antibodies from candidate regions of the MAP 1B sequence. This approach identified a region of 20 amino acids, from 1,244 to 1,264, characterised by a high concentration of serines immediately upstream of prolines, indicating that the kinase responsible is a proline-directed serine kinase.

The neurofilament antibody RT97 recognises a developmentally regulated phosphorylation epitope on microtubule-associated protein 1B

Microtubules are important for the growth and maintenance of stable neuronal processes and their organisation is controlled partly by microtubule-associated proteins (MAPs). MAP 1B is the first MAP to be expressed in neurons and plays an important role in neurite outgrowth. MAP 1B is phosphorylated at multiple sites and it is believed that the function of the protein is regulated by its phosphorylation state. We have shown that the monoclonal antibody (mAb) RT97, which recognises phosphorylated epitopes on neurofilament proteins, fetal tau, and on Alzheimer's paired helical filament-tau, also recognises a developmentally regulated phosphorylation epitope on MAP 1B. In the rat cerebellum, Western blot analysis shows that mAb RT97 recognises the upper band of the MAP 1B doublet and that the amount of this epitope peaks very early postnatally and decreases with increasing age so that it is absent in the adult, despite the continued expression of MAP 1B in the adult. We confirmed that mAb RT97 binds to MAP 1B by showing that it recognises MAP 1B immunoprecipitated from postnatal rat cerebellum using polyclonal antibodies to recombinant MAP 1B proteins. We established that the RT97 epitope on MAP 1B is phosphorylated by showing that antibody binding was abolished by alkaline phosphatase treatment of immunoblots. Epitope mapping experiments suggest that the mAb RT97 site on MAP 1B is near the N-terminus of the molecule. Despite our immunoblotting data, immunostaining of sections of postnatal rat cerebellum with mAb RT97 shows a staining pattern typical of neurofilaments with no apparent staining of MAP 1B. For instance, basket cell axons and axons in the granule cell layer and white matter stained, whereas parallel fibres did not. These results suggest that the MAP 1B epitope is masked or lost under the immunocytochemical conditions in which the cerebellar sections are prepared. The upper band of the MAP 1B doublet is believed to be predominantly phosphorylated by proline-directed protein kinases (PDPKs). PDPKs are also good candidates for phosphorylating neurofilament proteins and tau and therefore we postulate that the sites recognised by RT97 on these neuronal cytoskeletal proteins may be phosphorylated by similar kinases. Important goals are to determine the precise location of the RT97 epitope on MAP 1B and the kinase responsible.

Comparative anatomy of the cardiac foramen ovale in cats (Felidae), dogs (Canidae), bears (Ursidae) and hyaenas (Hyaenidae)

The structure of the foramen ovale from 16 species representing 4 carnivore families, the Felidae, Canidae, Ursidae and Hyaenidae, was studied using the scanning electron microscope. The Felidae were represented by 9 domestic cat fetuses (Felis catus), 2 snow leopard neonates (Uncia uncia), an ocelot neonate (Leopardus pardalis), 2 lion neonates (Panthera leo), a panther neonate (Panthera pardus) and 3 tigers (Neofelis tigris), comprising 2 fetuses and a neonate. The Canidae were represented by a golden jackal neonate (Canis aureus), a newborn wolf (Canis lupus), 8 domestic dog fetuses (Canis familiaris), 3 red fox neonates (Vulpes vulpes) and a dhole neonate (Cuon alpinus). The Ursidae were represented by a brown bear neonate (Ursus arctos), a day-old grizzly bear cub (Ursus arctos horribilis), a polar bear neonate (Ursus maritimus), and 2 additional bear fetuses (species unknown). The Hyaenidae were represented by a striped hyaena neonate (Hyaena hyaena). In each species, the foramen ovale, when viewed from the terminal part of the caudal vena cava, had the appearance of a short tunnel. A thin fold of tissue, the developed remains of the embryonic septum primum, extended from the distal end of the caudal vena cava for a variable distance into the lumen of the left atrium and contributed towards the 'tunnel' appearance in all specimens. It constituted a large proportion of the tube, and its distal end was straight-edged. There was fibrous material underlying the endothelium of the flap, the apparent morphology of which suggested that it comprised cardiac muscle.(ABSTRACT TRUNCATED AT 250 WORDS)

Children visiting members of their family receiving treatment in ICUs: a literature review

Occasionally people ask if children can visit members of their family who are patients in our intensive care unit (ICU). To allow us to devise a unit policy based on research, the author felt it necessary to review literature concerning child visitors to ICUs, more specifically the reasons why they should or should not be allowed to visit. Unfortunately very little has been written about the effects of visits to ICU on children; so it was felt that it would be beneficial to review the literature concerning child visitors to wards other than ICUs, as well, and also review the reasons behind hospital visiting policies for adults. The literature reviewed suggested that no reasons have been found not to allow children to visit but that advice should be given to the parents allowing them to come to the final decision. If the parents then decide to allow the child to visit, further support for all the family should be given.

Platelet-bound prekallikrein promotes pro-urokinase-induced clot lysis: a mechanism for targeting the factor XII dependent intrinsic pathway of fibrinolysis

Clots formed from platelet rich plasma were found to be lysed more readily by low concentrations of pro-urokinase (pro-UK) than clots formed from platelet poor plasma. This was not a non-specific effect since the reverse occurred with tissue plasminogen activator. A mechanical explanation due to platelet-mediated clot retraction was excluded by experiments in which retraction was inhibited with cytochalasin B. Therefore, a platelet-mediated enzymatic mechanism was postulated to explain the promotion of fibrinolysis. Casein autography of isolated platelets revealed a approximately 90 kDa band of activity which comigrated with plasma prekallikrein (PK)/kallikrein, a known activator of pro-UK. Furthermore, treatment of platelets with plasma PK activator (PPA), consisting essentially of factor XIIa, induced activation of pro-UK and of chromogenic substrate for kallikrein (S-2302). This activity corresponded to approximately 40-200 pM kallikrein per 10(8) washed and gel filtered platelets per ml. The activation of pro-UK by PPA-pretreated platelets was dose-dependent and inhibited by soybean trypsin inhibitor but not by bdellin, a specific inhibitor of plasmin, nor by the corn inhibitor of factor XIIa. Kinetic analysis of pro-UK activation by kallikrein showed promotion of the reaction by platelets. The KM of the reaction was reduced by platelets by approximately 7-fold, while the kcat was essentially unchanged. In conclusion, PK was shown to be tightly associated with platelets where it can be activated by factor XIIa during clotting. The activation of pro-UK by platelet-bound kallikrein provides an explanation for the observed platelet mediated promotion of pro-UK-induced clot lysis.(ABSTRACT TRUNCATED AT 250 WORDS)

A phosphorylation epitope on MAP 1B that is transiently expressed in growing axons in the developing rat nervous system

We have isolated a monoclonal antibody (150) that recognizes a phosphorylation epitope on the microtubule-associated protein (MAP) 1B. Immunoblot analysis of the developing rat central nervous system shows that monoclonal antibody 150 is directed against a protein of approximately 325 kDa (MAP 1B) that copolymerizes with microtubules through successive cycles of temperature-dependent assembly and disassembly. Furthermore, immunoprecipitated MAP 1B contains the epitope recognized by monoclonal antibody 150. Removal of phosphate from blotted proteins using alkaline phosphatase abolishes the binding of monoclonal antibody 150 to MAP 1B, indicating that the epitope is phosphorylated. In the developing rat nervous system, immunohistochemistry with monoclonal antibody 150 shows that the phosphorylation epitope on MAP 1B is transiently expressed in growing axons but not in dendrites. For instance, in the neonatal rat cerebellum, the parallel fibres of granule cells are stained only during elongation and not after synaptogenesis. The monoclonal antibody 150 epitope is also transiently expressed in radial glial fibres and in certain cell nuclei. All immunostaining of sections with monoclonal antibody 150 was completely abolished by alkaline phosphatase treatment. These observations and previous ones made by us in cell culture (Mansfield et al., J. Neurocytol., 20, 654-666, 1991) suggest that the phosphorylation epitope on MAP 1B recognized by monoclonal antibody 150, which has not been previously detected in vivo, may be important in axonogenesis.

Pro-urokinase and prekallikrein are both associated with platelets. Implications for the intrinsic pathway of fibrinolysis and for therapeutic thrombolysis

The contact-dependent intrinsic pathway of fibrinolysis involving factor XII, prekallikrein (PK) and pro-urokinase (pro-UK) remains poorly understood. Casein autography of washed, intact platelets revealed both PK and pro-UK. Accordingly, platelets may mediate physiological thrombolysis by this pathway since factor XIIa activates PK and kallikrein activates pro-UK. Acid washing dissociated PK but not pro-UK from platelets. Exogenous pro-UK was specifically incorporated by platelets from the ambient fluid and similarly could not be dissociated from intact platelets. Therefore, platelets may also mediate an effect from therapeutically administered pro-UK by prolonging its half-life.

Exercise-induced myocardial ischemia in a cold environment. Effect of antianginal medications

The influence of cold on the threshold for myocardial ischemia and the efficacy of antianginal drugs in a cold environment were assessed in 24 patients with stable angina and exercise-induced ST depression. Treadmill exercise tests were done according to a randomized double-blind protocol 90 minutes after administration of placebo, 80 mg propranolol, or 120 mg diltiazem, each at both -8 degrees and 20 degrees C. Eight of the patients were classified by history as cold-sensitive before the study. For the entire group, none of the exercise end points differed significantly between cold and normal temperatures with placebo. However, cold-sensitive patients developed 1 mm ST depression 30% sooner (169 +/- 41 versus 244 +/- 38 seconds, p less than 0.01) at -8 degrees C compared with 20 degrees C. At the onset of ischemia, rate-pressure product was lower in the cold (19.8 +/- 1.0 versus 22.0 +/- 1.6 x 10(-3), p less than 0.05). Both propranolol and diltiazem prolonged time to onset of 1 mm ST depression at both temperatures. The magnitude of improvement at -8 degrees C was equal to that at 20 degrees C, and differences between the two drugs were not statistically significant. Only diltiazem prolonged total exercise duration. Thus, as assessed by exercise testing, cold does not worsen ischemic threshold in most stable angina patients. However, in a subgroup identifiable by history, ischemic threshold is lower in the cold. Propranolol and diltiazem are as effective for exercise-induced ischemia in a cold environment as at normal temperatures.

Recurrent giant hypogastric artery aneurysms--a case report

Aneurysms of the hypogastric artery are rare occurrences that are frequently asymptomatic until the time of rupture. When signs and symptoms are present, a pulsatile pelvic mass, frequently detected by rectal or vaginal examination, may produce compression symptoms with urologic, gastrointestinal, and neurologic manifestations. In addition to classical invasive methods of detection such as angiography, newer noninvasive imaging techniques, including ultrasonography, computerized tomography, and magnetic resonance imaging, may be employed to establish the diagnosis. Proximal ligation of the hypogastric artery is the usual method of treatment. A case of bilateral, giant hypogastric artery aneurysms with successful surgical management is reported.