Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation

Background

The effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse is poorly evidenced. A UK-based multicenter randomized controlled trial was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up.

Methods

The randomized controlled trial was conducted from March 1, 2015 TO January 31, 2019. A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR (controls) with those who had undergone surgery. Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to three arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was defined as ≥ 1.0-point reduction in Patient Assessment of Constipation-Quality of Life and/or Symptoms (PAC-QOL and/or PAC-SYM) scores at 24 weeks. Secondary outcome measures included 14-day diary data, the Generalized Anxiety Disorder scale (GAD-7), the Patient Health Questionnaire-9 (PHQ-9), St Marks incontinence score, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12), the chronic constipation Behavioral Response to Illness Questionnaire (CC-BRQ), and the Brief Illness Perception Questionnaire (BIPQ).

Results

Of a calculated sample size of 114, only 28 patients (100% female) were randomized from 6 institutions (due mainly to national pause on mesh-related surgery). Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the three arms. Compared to baseline, significant reduction (improvement) in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (– 1.09 [95% CI – 1.76, – 0.41], p = 0.0019, and – 0.92 [– 1.52, – 0.32], p = 0.0029, respectively) in the 19 patients available for analysis (9 were excluded for dropout [n = 2] or missing primary outcome [n = 7]). There was a clinically significant long-term reduction in PAC-QOL scores (− 1.38 [− 2.94, 0.19], p = 0.0840 at 72 weeks). Statistically significant improvements in PAC-SYM scores persisted to 72 weeks (− 1.51 [− 2.87, − 0.16], p = 0.0289). Compared to baseline, no differences were found in secondary outcomes, except for significant improvements at 24 and 48 weeks on CC-BRQ avoidance behavior (− 14.3 [95% CI − 23.3, − 5.4], and − 0.92 [− 1.52, − 0.32], respectively), CC-BRQ safety behavior (− 13.7 [95% CI − 20.5, − 7.0], and − 13.0 [− 19.8, − 6.1], respectively), and BIPQ negative perceptions (− 16.3 [95% CI − 23.5, − 9.0], and − 10.5 [− 17.9, − 3.2], respectively).

Conclusions

With the caveat of under-powering due to poor recruitment, the study presents the first randomized trial evidence of short-term benefit of LVMR for internal rectal prolapse.

Trial registration

ISRCTN Registry (ISRCTN11747152).

Supplementary Information

The online version contains supplementary material available at 10.1007/s10151-022-02633-w.

Next Generation Sequencing of Renal Medullary Carcinoma Diagnosed Concurrently with Sickle Cell Trait: A Case Report and Literature Review

Casestudy

We present a 33-year-old African American male with 4 months of intermittent right flank pain and gross hematuria with hypermetabolic retroperitoneal lymphadenopathy, persistent right-sided hydronephrosis, perinephric fat stranding and a 5.5-cm hypermetabolic right lower pole mass demonstrated on imaging.

Results

Core needle biopsies of the mass contained atypical glands composed of epithelioid cells with pleomorphic nuclei, prominent nucleoli, eosinophilic cytoplasm and abundant mitoses infiltrating through desmoplastic stroma.

Immunohistochemical staining demonstrated CK7 and PAX8 reactivity of the tumor cells, and negative staining for CK20, WT1, PSA, PLAP and CD10. The patient underwent a radical right nephrectomy; microscopic examination illustrated invasion of the renal sinus, perirenal fat, and lymphovascular space by the neoplastic glands and sickling erythrocytes in the vasculature. Further IHC staining revealed intact mismatch repair proteins (MLH1, PMS2, MSH2, and MSH6) and a loss in expression of INI1 (SMARCB1), leading to the concurrent diagnoses of renal medullary carcinoma and sickle cell trait (confirmed with hemoglobin fractionation). Next generation sequencing of 144 clinically significant genes detected no mutations.

Conclusion

Renal medullary carcinoma is a rare, aggressive neoplasm that accounts for less than 0.5% of all renal cell carcinomas and presents at an advanced stage. Patients are usually young males who are of African or Mediterranean descent with comorbid sickling disease. Although loss of SMARCB1/INI-1 gene expression is associated with this neoplasm, no effective therapeutic targets have yet been established. Renal medullary carcinomas are usually resistant to chemotherapy and radiotherapy, making the identification of an immunotherapy target paramount. With a median survival of four months from diagnosis, additional genetic studies of these malignancies may identify an effective treatment option for renal medullary carcinoma.

Tumor RIPK1 signaling mediates intrinsic and extrinsic mechanisms of resistance to immune checkpoint blockade therapy

Immune checkpoint blockade (ICB) therapy can result in impressive clinical responses of multiple cancer types, however resistance is common. Mechanisms of resistance include both tumor intrinsic evasion of immune mediated killing and tumor extrinsic features in the immune-microenvironment, such as poor infiltration of tumor reactive T cells and accumulation of immunosuppressive cells. By examining transcriptomic features associated with response or resistance to ICB, we found the expression of Receptor Interacting Protein Kinase 1 (RIPK1), a critical regulator of inflammation and cell death, is significantly higher in ICB resistant murine tumor cells. We hypothesized that RIPK1 expression in the tumor cells may influence both intrinsic and extrinsic mechanisms regulating response to ICB. To test this hypothesis, we genetically deleted RIPK1 in murine tumor cell lines and found improved overall survival upon treatment compared to tumors expressing RIPK1. Mechanistically, deletion of RIPK1 in the tumor cells results in favorable changes in the tumor microenvironment, including an increased frequency of effector T cells, a decreased frequency of immunosuppressive myeloid cells, and changes in inflammatory cytokine secretion that can impact these changes in immune infiltrate. Further, deletion of the apoptosis effector Caspase 8 reversed RIPK1 KO tumor sensitization to ICB, suggesting that tumor sensitization to cell death also contributes to improved response to ICB upon RIPK1 deletion. In conclusion, RIPK1 is an important regulator at the intersection of tumor intrinsic and extrinsic pathways governing response to ICB, and therefore is a potential target for combinatorial therapies to improve patient response to ICB.

Runx1 negatively regulates inflammatory cytokine production by neutrophils in response to Toll-like receptor signaling

RUNX1 is frequently mutated in myeloid and lymphoid malignancies. It has been shown to negatively regulate Toll-like receptor 4 (TLR4) signaling through nuclear factor κB (NF-κB) in lung epithelial cells. Here we show that RUNX1 regulates TLR1/2 and TLR4 signaling and inflammatory cytokine production by neutrophils. Hematopoietic-specific RUNX1 loss increased the production of proinflammatory mediators, including tumor necrosis factor-α (TNF-α), by bone marrow neutrophils in response to TLR1/2 and TLR4 agonists. Hematopoietic RUNX1 loss also resulted in profound damage to the lung parenchyma following inhalation of the TLR4 ligand lipopolysaccharide (LPS). However, neutrophils with neutrophil-specific RUNX1 loss lacked the inflammatory phenotype caused by pan-hematopoietic RUNX1 loss, indicating that dysregulated TLR4 signaling is not due to loss of RUNX1 in neutrophils per se. Rather, single-cell RNA sequencing indicates the dysregulation originates in a neutrophil precursor. Enhanced inflammatory cytokine production by neutrophils following pan-hematopoietic RUNX1 loss correlated with increased degradation of the inhibitor of NF-κB signaling, and RUNX1-deficient neutrophils displayed broad transcriptional upregulation of many of the core components of the TLR4 signaling pathway. Hence, early, pan-hematopoietic RUNX1 loss de-represses an innate immune signaling transcriptional program that is maintained in terminally differentiated neutrophils, resulting in their hyperinflammatory state. We hypothesize that inflammatory cytokine production by neutrophils may contribute to leukemia associated with inherited RUNX1 mutations.

ITK signaling differentiates GVT and GVHD after allogeneic bone marrow transplantation by regulating IRF-4, JAK/STAT and Eomesodermin expression

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective therapy for patients with hematologic malignancies. Donor T cells contained within the graft prevent tumor recurrence by exhibiting graft-versus-tumor (GVT) effects but also cause graft-versus-host disease (GVHD); therefore, novel treatment strategies are needed to maintain GVT while suppressing GVHD. We investigated the role of TCR-mediated ITK activation in mediating GVT vs. GVHD effects after allo-HSCT. We discovered that T cells from ITK−/−mice display a CD62Lhi CD122+ CD44hi Innate Lymphoid Cell-Like (ILCL) functional phenotype, and higher Eomes but not T bet expression compared to WT. We showed that T cells from ITK−/−mice reduced IRF-4, JAK1 and JAK2 and STAT3. T cells from ITK−/− mice displayed reduced cytokine production but showed preserved cytotoxicity after allo-HSCT. These cells also showed defective upregulation of the chemokine receptors CX3CR3, CXCR1, and CXCR6, which correlated with their reduced migration into GVHD target organs. The defective migration of ITK deficient T cells into GVHD target organs contributed to separation of GVHD and GVT effects, since ITK deficeint T cells cleared intravenously injected but not subcutaneously injected tumor cells in allo-HSCT mice. Moreover, pharmacological ITK inhibition attenuated GVHD and preserved GVT function by wild type CD8+ T cells. Together, our data suggest that ITK inhibition could be used as therapy after allo-HSCT to reduce GVHD while preserving the beneficial GVT effects by donor T cells

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

INTERCOMPARISON OF EYE LENS DOSEMETERS

An intercomparison of eye lens dosemeters has been conducted in terms of the quantity Hp(3). For the first time, besides photon radiation also beta radiation qualities were included. Three dosemeter types designed for the quantity Hp(3) and ten for Hp(0.07) took part in the intercomparison. As shown in a previous intercomparison for photon radiation only, the dosemeters designed for Hp(0.07) and calibrated in terms of Hp(3) performed well in photon radiation fields. But for beta radiation, it turned out that Hp(0.07) dosemeters over-responded up to a factor of 5 000 (with respect to the true Hp(3) dose) in the medium beta energy range (85Kr with a beta endpoint energy of 0.69 MeV), while some Hp(3) dosemeters performed quite well. For medium (57 keV) and high (662 keV) energy photon radiation, all dosemeter types showed response values well within the trumpet curve according to the current draft of ISO 14146.

[Proximal corrective osteotomy : Correction of hallux valgus deformity]

Severe symptomatic hallux valgus deformities are usually not treatable with conservative methods in the long-term. Surgical treatment currently aims for mechanical restitution of the first ray with preserved mobility of the first metatarsophalangeal (MTP 1) joint and with low risk of recurrence after surgery. Keeping these aims in mind the surgical methods consist of osteotomy at the proximal part of the first metatarsal bone with a high potential for correction of the deformity. Surgical interventions at the midshaft level of the first metatarsal are only useful if the anatomical shape of the metatarsal shows a wide shaft, which allows a large shift in the osteotomy. In all other cases of severe hallux valgus deformity two different surgical principles are currently used and recommended: 1. proximal or basal osteotomy of the first metatarsal bone in all cases with a preserved MTP 1 and tarsometatarsal (TMT-1) joint without signs of instability. 2. Arthrodesis of the TMT-1 joint in all cases of instability or degenerative changes with an intact MTP 1 joint, the so-called Lapidus arthrodesis. This article gives an overview over the most important and widely used surgical techniques for correction of severe hallux valgus deformities. Emphasis is placed on the different osteosynthesis techniques and the recommended postoperative regimens. The advantages and disadvantages of the most frequently employed osteotomy techniques are discussed based on the current literature and the authors own experience.

[Arthroscopic treatment of chondral lesions of the ankle joint. Evidence-based therapy]

Ankle sprains are the most relevant injuries of the lower extremities and can lead to damage to ligaments and osteochondral lesions. Up to 50 % of patients with a sprained ankle later develop a lesion of the cartilage in the ankle joint or an osteochondral lesion of the talus. This can lead to osteoarthritis of the injured ankle joint. Spontaneous healing is possible in all age groups in cases of a bone bruise in the subchondral bone but in isolated chondral injuries is only useful in pediatric patients. In many cases chondral and osteochondral injuries lead to increasing demarcation of the affected area and can result in progressive degeneration of the joint if not recognized in time. There also exist a certain number of osteochondral changes of the articular surface of the talus without any history of relevant trauma, which are collectively grouped under the term osteochondrosis dissecans. Perfusion disorders are discussed as one of many possible causes of these alterations. Nowadays, chondral and osteochondral defects can be treated earlier due to detection using very sensitive magnetic resonance imaging (MRI) and computed tomography (CT) techniques. The use of conservative treatment only has a chance of healing in pediatric patients. Conservative measures for adults should only be considered as adjuvant treatment to surgery.Based on a comprehensive analysis of the current literature, this article gives an overview and critical analysis of the current concepts for treatment of chondral and osteochondral injuries and lesions of the talus. With arthroscopic therapy curettage and microfracture of talar lesions are the predominant approaches or retrograde drilling of the defect is another option when the chondral coating is retained. Implantation of autologous chondral cells or homologous juvenile cartilage tissue is also possible with arthroscopic techniques. Osteochondral fractures (flake fracture) are usually performed as a mini-open procedure supported by arthroscopy. The use of the osteochondral autograft transfer system (OATS), implantation of membranes with or without autologous bone marrow transfer and possibly with growth factors or implantation of stem cells are carried out in combination with arthroscopic mini-open procedures. The results from the literature are discussed and compared with own results after arthroscopic treatment of chondral lesions of the talus.

Case report: A rare case of eosinophilic cholecystitis presenting after talc pleurodesis for recurrent pneumothorax

Eosinophilic cholecystitis (EC) is a rare inflammatory condition of the gallbladder, confirmed by a cellular infiltrate comprised of more than 90% eosinophils in the gallbladder wall on histological examination. Although the etiology of EC is largely unknown, local autoimmune reactions within the gallbladder wall to inflammatory mediators from distal sites of inflammation have been hypothesized. Talc pleurodesis (TP) is a common clinical procedure used within respiratory medicine. However, it is associated with activation of systemic acute inflammatory responses including an increase in serum interleukin-8 (IL-8), which is a potent mediator of eosinophil chemotaxis. We report a case of EC following a TP procedure for persistent, secondary pneumothorax.

User-centered design and usability testing of an innovative health-related quality of life module

OBJECTIVES

Various computerized health risk appraisals (HRAs) are available, but few of them assess health-related quality of life (HRQoL) in a goal-directed framework. This study describes the user-centered development and usability testing of an innovative HRQoL module that extends a validated HRA tool in primary care settings.

METHODS

Systematic user-centered design, usability testing, and qualitative methods were used to develop the HRQoL module in primary care practices. Twenty two patients and 5 clinicians participated in two rounds of interactive technology think-out-loud sessions (TOLs) and semi-structured interviews (SSIs) to iteratively develop a four-step, computerized process that collects information on patient goals for meaningful life activities and current level of disability and presents a personalized and prioritized list of preventive recommendations linked to online resources.

RESULTS

Analysis of TOLs and SSIs generated 5 categories and 11 sub-categories related to facilitators and barriers to usability and human-technology interaction. The categories included: Understanding the Purpose, Usability, Perceived Value, Literacy, and Participant Motivation. Some categories were inter-connected. The technology was continually and iteratively improved between sessions until saturation of positive feedback was achieved in 4 categories (addressing motivation will require more research). Usability of all screen units of the module was improved substantially. Clinician feedback emphasized the importance of the module's ability to translate the patient-centered HRQoL Report into actionable items for clinicians to facilitate shared decision-making. Complete integration of the HRQoL module into the existing HRA will require further development and testing.

CONCLUSIONS

Systematic application of user-centered design and human factors principles in technology development and testing may significantly improve the usability and clinical value of health information systems. This more sophisticated approach helped us translate complex clinical concepts, goal-setting steps, and decision-support processes into an accepted and value-added technology.

Albedo neutron dosimetry in Germany: regulations and performance

Personal neutron dosimetry has been performed in Germany using albedo dosemeters for >20 y. This paper describes the main principles, the national standards, regulations and recommendations, the quality management and the overall performance, giving some examples.

Efficacy and safety of fibrin glue and tranexamic acid to prevent postoperative blood loss in total knee arthroplasty: a randomized controlled clinical trial

BACKGROUND

Postoperative blood loss in patients after total knee arthroplasty may cause local and systemic complications and influence clinical outcome. The aim of this study was to assess whether fibrin glue or tranexamic acid reduced blood loss compared with routine hemostasis in patients undergoing total knee arthroplasty.

METHODS

A randomized, single-center, parallel, open clinical trial was performed in adult patients undergoing primary total knee arthroplasty. Patients were divided into four groups. Group 1 received fibrin glue manufactured by the Blood and Tissue Bank of Catalonia, Group 2 received Tissucol (fibrinogen and thrombin), Group 3 received intravenous tranexamic acid, and Group 4 (control) had no treatment other than routine hemostasis. The primary outcome was total blood loss collected in drains after surgery. Secondary outcomes were the calculated hidden blood loss, transfusion rate, preoperative and postoperative hemoglobin, number of blood units transfused, adverse events, and mortality.

RESULTS

One hundred and seventy-two patients were included. The mean total blood loss (and standard deviation) collected in drains was 553.9 ± 321.5 mL for Group 1, 567.8 ± 299.3 mL for Group 2, 244.1 ± 223.4 mL for Group 3, and 563.5 ± 269.7 mL for Group 4. In comparison with the control group, Group 3 had significantly lower total blood loss (p < 0.001), but it was not significantly lower in Groups 1 and 2. The overall rate of patients who had a blood transfusion was 21.1% (thirty-five of 166 patients analyzed per protocol). Two patients required transfusion in Group 3 compared with twelve patients in Group 4 (p = 0.015). No significant difference was observed between the two fibrin glue groups and the control group with regard to the need for transfusion. There was no difference between groups with regard to the percentage of adverse events.

CONCLUSIONS

Neither type of fibrin glue was more effective than routine hemostasis in reducing postoperative bleeding and transfusion requirements, and we no longer use them. However, this trial supports findings from previous studies showing that intravenous tranexamic acid can decrease postoperative blood loss.

Calcium phosphate transfection optimization for serum-free suspension culture

Aim of this study was to identify optimal conditions for suspension transfection in the absence of serum. Transfection parameters for suspension culture can be very different to ones in adherent cells. Most transfection protocols have been developed and optimizedfor adherent culture. Using green fluorescent protein (GFP) as reporter, FCS was eliminated from the transfection process by altering critical parameters and by substituting serum with albumin. Using standard phosphate and calcium concentrations for transfection in the absence of serum resulted in titers of only 1% of those observed in the presence of serum. A reduction of the calcium concentration from 250 mM to 100 mM, yielded a 25-fold increase in the expression of the recombinant protein compared to the serum-free standard conditions. Altering the phosphate concentration, 1.4 mM in the transfection buffer, did not improve the protein expression. Interestingly, reduction of DNA quantity by half to a concentration of 0.5 μg per milliliter of culture volume resulted in a two-fold increase of protein production. Addition of albumin to serum-free medium protected the cells against the toxicity of the calcium phosphate transfection particles (CaPi) yielding higher protein expression. All the experiments were executed in a shaken multi-well system, allowing high multiplicity parameter screening to speed up optimizations. The culture system is inexpensive, simple and efficient, minimizing costs for labor and consumables.

Interactions between animal cells and gas bubbles: The influence of serum and pluronic F68 on the physical properties of the bubble surface

We describe a method by which the degree of bubble saturation can be determined by measuring the velocity of single bubbles at different heights from the bubble source in pure water containing increasing concentrations of surfactants. The highest rising velocities were measured in pure water. Addition of surfactants caused a concentration-dependent and height-dependent decrease in bubble velocity; thus, bubbles are covered with surfactants as they rise, and the distance traveled until saturation is reached decreases with increased concentration of surfactant. Pluronic F68 is a potent effector of bubble saturation, 500 times more active than serum. At Pluronic F68 concentrations of 0.1% (w/v), bubbles are saturated essentially at their source. The effect of bubble saturation on the interactions between animal cells and gas bubbles was investigated by using light microscopy and a micromanipulator. In the absence of surfactants, bubbles had a killing effect on cells; hybridoma cells and Chinese hamster ovary (CHO) cells were ruptured when coming into contact with a bubble. Bubbles only partially covered by surfactants adsorbed the cells. The adsorbed cells were not damaged and they also could survive subsequent detachment. Saturated bubbles, on the other hand, did not show any interactions with cells. It is concluded that the protective effect of serum and Pluronic F68 in sparged cultivation systems is based on covering the medium-bubble interface with surfaceactive components and that cell death occurs either after contact of cells with an uncovered bubble or by adsorption of cells through partially saturated bubbles and subsequent transport of cells into the foam region. (c) 1994 John Wiley & Sons, Inc.

Extraction of plasmid DNA using reactor scale alkaline lysis and selective precipitation for scalable transient transfection

DNA extracted and purified for vaccination, gene therapy or transfection of cultured cells has to meet different criteria. We describe herein, a scalable process for the primary extraction of plasmid DNA suitable for transient expression of recombinant protein. We focus on the scale up of alkaline lysis for the extraction of plasmid DNA from Escherichia coli, and use a simple stirred tank reactor system to achieve this. By adding a series of three precipitations (including a selective precipitation step with ammonium acetate) we enrich very quickly the plasmid DNA content in the extract. The process has been thus far used to extract up to 100 mg of plasmid from 1.5 l of clarified lysate, corresponding to an E.coli bioreactor fermentation of 3 l.

Calcium-phosphate mediated DNA transfer into HEK-293 cells in suspension: control of physicochemical parameters allows transfection in stirred media. Transfection and protein expression in mammalian cells

This is the first report of transient transfection of suspended cells with purified plasmid DNA in bioreactors or spinner flasks. DNA/calcium phosphate complexes were pumped or injected directly into stirred cultures of the immortalized human embryo kidney cell line 293 (HEK-293) which had been adapted to growth in suspension. We identified culture conditions suitable for this approach and modified the protocol for the generation of precipitate complexes, based on our earlier work. In order to stabilize the 'DNA-vehicle'-complex in the culture medium, we identified pH ranges and ion-concentrations which prevent dissolution or aggregation of the precipitate particles. Such conditions maintained suspended fine particles in spinners or bioreactors for up to 6 hr. During that period, cells and precipitate complexes interacted sufficiently to allow DNA transfer and subsequent expression of recombinant protein. In a simple 5 day batch process, with a starting density of 0.3 × 10(6) cells mL(-1), about 0.5 mg L(-1) of a recombinant tissue plasminogen activator variant was observed.

Photonic wire bonding: a novel concept for chip-scale interconnects

Photonic integration requires a versatile packaging technology that enables low-loss interconnects between photonic chips in three-dimensional configurations. In this paper we introduce the concept of photonic wire bonding, where polymer waveguides with three-dimensional freeform geometries are used to bridge the gap between nanophotonic circuits located on different chips. In a proof-of-principle experiment, we demonstrate the fabrication of single-mode photonic wire bonds (PWB) by direct-write two-photon lithography. First-generation prototypes allow for efficient broadband coupling with average insertion losses of only 1.6 dB in the C-band and can carry wavelength-division multiplexing signals with multi-Tbit/s data rates. Photonic wire bonding is well suited for automated mass production, and we expect the technology to enable optical multi-chip systems with enhanced performance and flexibility.

Hp(0.07) photon dosemeters for eye lens dosimetry: calibration on a rod vs. a slab phantom

In recent years, several papers dealing with eye lens dosimetry have been published as epidemiological studies are implying that the induction of cataracts occurs even at eye lens doses of less than 500 mGy. For that reason, the necessity to monitor the eye lens may become more important than it was before. However, only few dosemeters for the appropriate quantity H(p)(3) are available. Partial-body dosemeters are usually designed to measure the quantity H(p)(0.07) calibrated on a rod phantom representing a finger while a slab phantom much better represents the head. Therefore, in this work it was investigated whether dosemeters designed for the quantity H(p)(0.07) calibrated on a rod phantom can also be worn on the head (close to the eyes) and still deliver correct results (H(p)(0.07) on a head). For that purpose, different types of partial-body dosemeters from routine use were irradiated at different photon energies on both a rod and a slab phantom. It turned out that their response values are within ±5% independent of the phantom if the quantity value for the respective phantom is used. Thus, partial-body dosemeters designed for the quantity H(p)(0.07) calibrated on a rod phantom may be worn on the head and used to monitor the eye lens dose due to photon radiation via the measurement of H(p)(0.07) on the head.

Cell-cell adhesion and aggregation: Influence on the growth behavior of CHO cells

The influence of cell-cell adhesion on the growth behavior of Chinese hamster ovary (CHO) cells in suspension culture was investigated. CHO cells form aggregates under suboptimal growth conditions. Clusters are formed around decaying and dead cells. The deoxyribonucleic acid (DNA) released from these cells was found to mediate the cells was found to mediate the cell-cell adhesion. Cluster formation dramatically influenced the growth behavior of the cells. First, cells within aggregates showed a strongly reduced specific proliferation rate, and second, shear forces exerted on large aggregates caused a considerable higher specific death rate than those exerted on single cells. These factors led to a reduction of the specific growth rate up to 50%. This decrease could be avoided by addition of DNase 1 to the medium. It is shown that the separate determination of the specific proliferation and death rates is not feasible with state-of-the-art methods. To achieve a more profound and precise description of the growth pattern of animal cells, we propose an extended Monod model and describe the relevant methods.

A series of 1, 2-coupled indane dimers with mast cell stabilisation and smooth muscle relaxation properties

Asthma is characterised by bronchoconstriction and inflammation, with infiltration and activation of inflammatory cells such as eosinophils and mast cells, and subsequent release of inflammatory mediators. Much of the therapy directed at the treatment of asthma is either to provide symptomatic relief through bronchodilation or to reduce inflammation to prevent or delay airway remodelling. In an attempt to address both of these issues, a novel series of 1,2-indane dimers has been synthesized and evaluated for smooth muscle relaxant and mast cell stabilising activities. We have identified two lead compounds, 5 and 15, which have substantial mast cell stabilisation activity.

Audit of the consultation process on general internal medicine services

OBJECTIVE

To determine the proportion of consultations requested by general internal medicine services that communicate key components of the consultation process to medical subspecialists.

DESIGN

Retrospective chart review by two researchers, using a standardised chart abstraction instrument (93.1% agreement, kappa 0.85).

SETTING

Calgary, Alberta, Canada.

SAMPLE

A random sample of medical consultations was selected from those generated on two medical teaching units (MTUs) from 2003 to 2004.

MEASUREMENTS

The primary measure of interest was whether a "clear clinical question" was posed to the subspecialist, a binary variable.

RESULTS

Two hundred consultations were sampled from the 2885 subspecialty consultations. Of the selected consultations, 94.0% (188/200) were available for review. A clear clinical question was posed in 69.7% (131/188) of consultations (CI 0.63 to 0.74). In a secondary analysis involving a larger sample permitting comparison across subspecialties, 95.1% (368/387) of the consultations, representative of the subspecialties, were available for review. An MTU member contacted the subspecialist for 74.2% of consultations. If a consultation was urgent, a member of the MTU contacted the subspecialist in 81.0% of consultations. Of these urgent consultations, 63.3% had a clear clinical question.

CONCLUSION

More than one in four consultations does not contain a clear clinical question, illustrating suboptimal communication between physicians. Innovative strategies that provide a sustainable solution for overcoming barriers to communication could have a significant impact on quality of care.

Different by Destruction: Unequal Inheritance of the Transcription Factor T-bet as a Mechanism to Diversify Daughter T Cell Fates (47.29)

We have previously suggested that asymmetric cell division might represent a mechanism to ensure that appropriate diversity of cell fate arises from the descendants of a single lymphocyte during an immune response. We now show that the fate-determining transcription factor T-bet is asymmetrically inherited by dividing CD4+ and CD8+ T cells recruited into an immune response. T-bet is induced in interphase T cells within hours of activation. During mitosis, T-bet undergoes proteasome-dependent degradation. Mitotic destruction is mediated by T cell receptor-induced tyrosine phosphorylation of T-bet. Unequal inheritance of T-bet is associated with asymmetric segregation of the proteasomal degradative machinery during mitosis and cytokinesis. Mutations of T-bet at the critical tyrosine and those disabling the T cell receptor-associated kinase, ITK, both result in symmetric inheritance of T-bet without affecting asymmetry of the proteasome. These results suggest that two experimentally distinct mechanisms promote the unequal inheritance of T-bet by initial daughter T cells: one signal that targets T-bet for mitotic destruction and another signal that renders inequality in the inheritance of the cellular machinery that destroys T-bet. These findings offer a new framework for understanding how signaling to a single T lymphocyte can result in unequal fate determination of its daughter cells.

Effect of cellulose wastes upon the growth of Phragmites australis

Growth responses of Phragmites australis (Cav.) Trin. Ex Steud, (reed grass), a helophyte species, were examined under in vitro and greenhouse conditions in the presence of various residues from a Kraft pulp mill. Plant tolerance to solid residues (ashes, dregs, flyashes, grits, primary sludge, and brown stock rejects) was tested in vitro. Solid residues were added separately up to 30% (w/v), as well a liquid residue up to 30% (v/v), to a Murashige and Skoog (1962) sucrose-free nutrient media with (5 mg l(-1)) 6-benzylaminopurine. After 2 mo in vitro, plantlets developed well in the presence of up to 10% solid or liquid wastes, but higher concentrations of either limited growth. This effect was mainly attributed to the plant's uptake and accumulation of various elements such as sodium, iron, copper, manganese, and boron, which are common to these waste types, thus showing an efficient phytoremediation potential. When added to MS media, the concentration of these elements generally decreased in the residual media after 2 mo of culture: the initial sodium, iron, and copper content in the growth media was reduced ca. 10-fold detected; a 5-fold reduction occurred for manganese and boron. In experiments under greenhouse conditions with in vitro propagated plantlets potted in mixtures of a commercial organic soil and residues, significant differences in plant development (plant size and fresh weight increase) were observed in the presence of ashes mixed at levels of 20% and 30%, compared to the control in organic soil. For other solid wastes, plant growth was inhibited as the concentration of each waste increased, causing chlorosis and/or plant necrosis.

A systematic review of the effects of casting on equinus in children with cerebral palsy: an evidence report of the AACPDM

This systematic review examines the effects of casting, either alone or in combination with botulinum toxin type A (BTX-A), on equinus in children with cerebral palsy (CP). Comparisons are made between casting alone and no treatment, between casting alone and BTX-A alone, between combined casting and BTX-A and each treatment by itself, and between casting followed by BTX-A and BTX-A followed by casting. A search of PUBMED, CINAHL, Proquest Health and Medical Complete, Cochrane Database of Systematic reviews, Physiotherapy Evidence Database (PEDro), OTseeker, Database of Reviews of Effectiveness (DARE), and Infotrieve yielded 184 citations. Articles were included in the review if they reported the effects of an intervention using casting for equinus in particpants with CP aged 20 or less, if they appeared in a peer-reviewed scholarly journal in 1970 or later, with no language restriction, and if casting was not used in conjunction with surgery. Twenty-two articles were selected, including seven randomized controlled trials (RCTs). There is little evidence that casting is superior to no casting, but the protocols of casting in current use have not been compared with no treatment in any RCT. There is no strong and consistent evidence that combining casting and BTX-A is superior to using either intervention alone, or that either casting or BTX-A is superior to the other immediately after treatment. Finally, there is no evidence that order of treatment (casting before BTX-A versus BTX-A before casting) affects outcome. Much of the evidence both for and against differences is weak, and results may be explained by methodological limitations. Future research needs to use adequate sample sizes, long-term follow-ups, and broader and more global measures.

Individualising drug dispensaries in a university hospital

BACKGROUND

In hospitals and other healthcare institutions drugs are routinely stored in designated satellite areas on the wards. Often ad hoc decisions are made by clinicians and nurses regarding drug type and quantity to be stored. As a result the number of different drugs and drug packages in storage tends to increase, which may lead to inefficient drug handling and become a potential risk factor in the medication control process. Based on an extended analysis of drug inventories on three different wards it was hypothesized that a ward-individualised formulary (WIF) can halve the number of different drugs and drug packages in a drug dispensary and hence reduce bound capital, money lost through expired drugs, and facilitate safer drug handling. The interdisciplinary intervention described here took place on three 40-bed wards in a 700-bed university hospital housing patients in general internal medicine, haematology, nephrology and oncology.

METHODS

A WIF was defined by including all drugs from the hospital formulary ordered at least three times in the past six months. A pharmacist, a nurse and a clinician reviewed the inclusion list of drugs and clinicians were strongly encouraged to prescribe drugs primarily from the WIF. Drugs excluded from the WIF were removed from the drug dispensaries and the number of included drug packages stored in the remote dispensaries was reduced according to their order history. Drug inventory on the wards was monitored from February 2004 to April 2006.

RESULTS

The initial drug dispensary inventories on wards A, B and C consisted of 2031, 1667 and 1536 packages with 943, 897 and 831 different drugs valued at h 83 931, h 44 590 and h 57 285. respectively. After adjusting the drug dispensaries according to the WIF drug dispensary inventories on wards A, B and C consisted of 808 (-60%), 600 (-64%) and 485 (-68%) packages with 415 (-56%), 334 (-63%) and 376 (-55%) different drugs valued euro 28 012 (-67%), euro 10 381 (-77%) an euro 17 898 (-69%). The overall reductions the number of packages, the different drugs and the drug value were comparable (>50%) and remained low during the entire observation time (A: 18 months, B: 13 months, C: 8 months).

CONCLUSION

Rearranging dispensaries by individualizing the drug inventory according to the needs of the ward by introducing a WIF is a valuable means to significantly (>50%) reduce [1] the number of drug packages, [2] the number of different drugs stored and [3] the capital bound drugs. The positive effects of the WIF are supported by the interdisciplinary interaction of the different professional groups involved in the medication process. The leaner drug dispensaries offer optimal basic conditions for introducing new IT-based systems to further increase the safety of the medication process.

Individualising drug dispensaries in a university hospital

BACKGROUND

In hospitals and other healthcare institutions drugs are routinely stored in designated satellite areas on the wards. Often ad hoc decisions are made by clinicians and nurses regarding drug type and quantity to be stored. As a result the number of different drugs and drug packages in storage tends to increase, which may lead to inefficient drug handling and become a potential risk factor in the medication control process. Based on an extended analysis of drug inventories on three different wards it was hypothesized that a ward-individualised formulary (WIF) can halve the number of different drugs and drug packages in a drug dispensary and hence reduce bound capital, money lost through expired drugs, and facilitate safer drug handling. The interdisciplinary intervention described here took place on three 40-bed wards in a 700-bed university hospital housing patients in general internal medicine, haematology, nephrology and oncology.

METHODS

A WIF was defined by including all drugs from the hospital formulary ordered at least three times in the past six months. A pharmacist, a nurse and a clinician reviewed the inclusion list of drugs and clinicians were strongly encouraged to prescribe drugs primarily from the WIF. Drugs excluded from the WIF were removed from the drug dispensaries and the number of included drug packages stored in the remote dispensaries was reduced according to their order history. Drug inventory on the wards was monitored from February 2004 to April 2006.

RESULTS

The initial drug dispensary inventories on wards A, B and C consisted of 2031, 1667 and 1536 packages with 943, 897 and 831 different drugs valued at h 83 931, h 44 590 and h 57 285. respectively. After adjusting the drug dispensaries according to the WIF drug dispensary inventories on wards A, B and C consisted of 808 (-60%), 600 (-64%) and 485 (-68%) packages with 415 (-56%), 334 (-63%) and 376 (-55%) different drugs valued euro 28 012 (-67%), euro 10 381 (-77%) an euro 17 898 (-69%). The overall reductions the number of packages, the different drugs and the drug value were comparable (>50%) and remained low during the entire observation time (A: 18 months, B: 13 months, C: 8 months).

CONCLUSION

Rearranging dispensaries by individualizing the drug inventory according to the needs of the ward by introducing a WIF is a valuable means to significantly (>50%) reduce [1] the number of drug packages, [2] the number of different drugs stored and [3] the capital bound drugs. The positive effects of the WIF are supported by the interdisciplinary interaction of the different professional groups involved in the medication process. The leaner drug dispensaries offer optimal basic conditions for introducing new IT-based systems to further increase the safety of the medication process.

Disruption of diacylglycerol metabolism impairs the induction of T cell anergy

Anergic T cells have altered diacylglycerol metabolism, but whether that altered metabolism has a causative function in the induction of T cell anergy is not apparent. To test the importance of diacylglycerol metabolism in T cell anergy, we manipulated diacylglycerol kinases (DGKs), which are enzymes that terminate diacylglycerol-dependent signaling. Overexpression of DGK-alpha resulted in a defect in T cell receptor signaling that is characteristic of anergy. We generated DGK-alpha-deficient mice and found that DGK-alpha-deficient T cells had more diacylglycerol-dependent T cell receptor signaling. In vivo anergy induction was impaired in DGK-alpha-deficient mice. When stimulated in anergy-producing conditions, T cells lacking DGK-alpha or DGK-zeta proliferated and produced interleukin 2. Pharmacological inhibition of DGK-alpha activity in DGK-zeta-deficient T cells that received an anergizing stimulus proliferated similarly to wild-type T cells that received CD28 costimulation and prevented anergy induction. Our findings suggest that regulation of diacylglycerol metabolism is critical in determining whether activation or anergy ensues after T cell receptor stimulation.

Epidemiologic investigation of lead poisoning in trumpeter and tundra swans in Washington State, USA, 2000-2002

An observational study was conducted to determine the proportionate mortality of wild trumpeter (Cygnus buccinator) and tundra (Cygnus columbianus columbianus) swans that died during the winters of 2000-02 in northwestern Washington State, USA. Among 400 swans necropsied, 81% were lead poisoned (302/365 trumpeter swans; 20/35 tundra swans). Mortality started in mid-November and peaked from late December through mid-February; swan mortality that was not associated with lead poisoning was uniformly lower throughout the winter months. Lead poisoning was 24 times more likely to be the cause of death in swans found in Whatcom County compared to swans found in other locations in northwestern Washington State (95% CI: 12.7, 47.0). Mortality attributable to lead poisoning was twice as likely in adults as in juveniles (95% CI: 1.0, 4.2). Aspergillosis was documented in 62 trumpeter and two tundra swans, including 37 swans in which mortality was caused by lead poisoning. Males were twice as likely as females to have aspergillosis (95% CI: 1.1, 3.8). Traumatic injuries were documented in 37 trumpeter and seven tundra swans, including seven trumpeter swans with concurrent lead poisoning. Dead swans found outside Whatcom County were four times more likely to have traumatic injuries compared to those found in Whatcom County (95% CI: 1.6, 10.0). Overall, lead-poisoned swans were significantly less likely to have concurrent aspergillosis or traumatic injuries. There was no apparent association between grit ingestion (total mass or mass categorized by size) and lead poisoning or number of lead shot. Not surprisingly, lead-poisoned swans were more likely to have one or more lead shot compared to swans that died from other causes (OR 294; 95% CI: 92, 1,005); lead-poisoned swans were also more likely to have one or more nontoxic shot compared to swans that were not poisoned (OR 63; 95% CI: 19, 318). The source(s) of shot are unknown but likely are in or near Whatcom County, Washington.