Integrated omics analysis unveils a DNA damage response to neurogenic injury

Spinal cord injury (SCI) evokes profound bladder dysfunction. Current treatments are limited by a lack of molecular data to inform novel therapeutic avenues. Previously, we showed systemic inosine treatment improved bladder function following SCI in rats. Here, we applied multi-omics analysis to explore molecular alterations in the bladder and their sensitivity to inosine following SCI. Canonical pathways regulated by SCI included those associated with protein synthesis, neuroplasticity, wound healing, and neurotransmitter degradation. Upstream regulator analysis identified MYC as a key regulator, whereas causal network analysis predicted multiple regulators of DNA damage response signaling following injury, including PARP-1. Staining for both DNA damage (γH2AX) and PARP activity (poly-ADP-ribose) markers in the bladder was increased following SCI, and attenuated in inosine-treated tissues. Proteomics analysis suggested that SCI induced changes in protein synthesis-, neuroplasticity-, and oxidative stress-associated pathways, a subset of which were shown in transcriptomics data to be inosine-sensitive. These findings provide novel insights into the molecular landscape of the bladder following SCI, and highlight a potential role for PARP inhibition to treat neurogenic bladder dysfunction.

Vascular smooth muscle-derived Trpv1+ progenitors are a source of cold-induced thermogenic adipocytes

Brown adipose tissue (BAT) and beige fat function in energy expenditure in part due to their role in thermoregulation, making these tissues attractive targets for treating obesity and metabolic disorders. While prolonged cold exposure promotes de novo recruitment of brown adipocytes, the exact sources of cold-induced thermogenic adipocytes are not completely understood. Here, we identify transient receptor potential cation channel subfamily V member 1 (Trpv1)⁺ vascular smooth muscle (VSM) cells as previously unidentified thermogenic adipocyte progenitors. Single-cell RNA sequencing analysis of interscapular brown adipose depots reveals, in addition to the previously known platelet-derived growth factor receptor (Pdgfr)α-expressing mesenchymal progenitors, a population of VSM-derived adipocyte progenitor cells (VSM-APC) expressing the temperature-sensitive cation channel Trpv1. We demonstrate that cold exposure induces the proliferation of Trpv1⁺ VSM-APCs and enahnces their differentiation to highly thermogenic adipocytes. Together, these findings illustrate the landscape of the thermogenic adipose niche at single-cell resolution and identify a new cellular origin for the development of brown and beige adipocytes.

Nrf2 overexpression rescues the RPE in mouse models of retinitis pigmentosa

Nrf2, a transcription factor that regulates the response to oxidative stress, has been shown to rescue cone photoreceptors and slow vision loss in mouse models of retinal degeneration (rd). The retinal pigment epithelium (RPE) is damaged in these models, but whether it also could be rescued by Nrf2 has not been previously examined. We used an adeno-associated virus (AAV) with an RPE-specific (Best1) promoter to overexpress Nrf2 in the RPE of rd mice. Control rd mice showed disruption of the regular array of the RPE, as well as loss of RPE cells. Cones were lost in circumscribed regions within the cone photoreceptor layer. Overexpression of Nrf2 specifically in the RPE was sufficient to rescue the RPE, as well as the disruptions in the cone photoreceptor layer. Electron microscopy showed compromised apical microvilli in control rd mice but showed preserved microvilli in Best1-Nrf2–treated mice. The rd mice treated with Best1-Nrf2 had slightly better visual acuity. Transcriptome profiling showed that Nrf2 upregulates multiple oxidative defense pathways, reversing declines seen in the glutathione pathway in control rd mice. In summary, Nrf2 overexpression in the RPE preserves RPE morphology and survival in rd mice, and it is a potential therapeutic for diseases involving RPE degeneration, including age-related macular degeneration (AMD).

Dementia and mild cognitive impairment in prisoners aged over 50 years in England and Wales: a mixed-methods study

Background

People aged ≥ 50 years constitute the fastest-growing group in the prison population of England and Wales. This population has complex health and social care needs. There is currently no national strategy to guide the development of the many-faceted services required for this vulnerable population; therefore, prisons are responding to the issue with a range of local initiatives that are untested and often susceptible to failure if they are not fully embedded in and securely funded as part of commissioned services.

Objectives

The objectives were to establish the prevalence of dementia and mild cognitive impairment in prisoners in England and Wales and their health and social care needs; validate the six-item cognitive impairment test for routine use in prisons to aid early and consistent identification of older prisoners with possible dementia or mild cognitive impairment; identify gaps in current service provision; understand the first-hand experiences of prisoners living with dementia and mild cognitive impairment; develop a care pathway for prisoners with dementia and mild cognitive impairment; develop dementia and mild cognitive impairment training packages for staff and prisoners; and produce health economic costings for the care pathway and training packages.

Design

This was a mixed-methods study.

Setting

The study setting was prisons in England and Wales.

Participants

Prisoners aged ≥ 50 years and multiagency staff working in prison discipline and health and social care services took part.

Results

Quantitative research estimated that the prevalence rate of suspected dementia and mild cognitive impairment in the prison population of England and Wales is 8%. This equates to 1090 individuals. Only two people (3%) in our sample had a relevant diagnosis in their health-care notes, suggesting current under-recognition of these conditions. The prevalence rate in prisons was approximately two times higher among individuals aged 60–69 years and four times higher among those aged ≥ 70 years than among those in the same age groups living in the community. The Montreal Cognitive Assessment screening test was found to be more effective than the six-item cognitive impairment test assessment in the older prisoner population. Qualitative research determined that staff and prisoners lacked training in knowledge and awareness of dementia and mild cognitive impairment, and this leads to problematic behaviour being viewed as a disciplinary issue rather than a health issue. Local initiatives to improve the lives of prisoners with dementia and mild cognitive impairment are often disadvantaged by not being part of commissioned services, making them difficult to sustain. Multidisciplinary working is hampered by agencies continuing to work in silos, with inadequate communication across professional boundaries. A step-by-step care pathway for prisoners with dementia and mild cognitive impairment was developed, and two tiers of training materials were produced for staff and prisoners.

Limitations

Our prevalence rate was based on the results of a standardised assessment tool, rather than on clinical diagnosis by a mental health professional, and therefore it may represent an overestimation. Furthermore, we were unable to distinguish subcategories of dementia. We were also unable to distinguish between a likely diagnosis of dementia and other conditions presenting with mild cognitive impairment, including learning disability, severe depression and hearing impairment. Questionnaires regarding current service provision were collected over an extended period of time, so they do not reflect a ‘snapshot’ of service provision at a particular point.

Conclusions

We hypothesise that implementing the step-by-step care pathway and the training resources developed in this study will improve the care of older prisoners with dementia and mild cognitive impairment.

Future work

The care pathway and training materials should be evaluated in situ. Alternatives to prison for those with dementia or mild cognitive impairment should be developed and evaluated.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 27. See the NIHR Journals Library website for further project information.

Linking indirect effects of cytomegalovirus in transplantation to modulation of monocyte innate immune function

Cytomegalovirus (CMV) is an important cause of morbidity and mortality in the immunocompromised host. In transplant recipients, a variety of clinically important "indirect effects" are attributed to immune modulation by CMV, including increased mortality from fungal disease, allograft dysfunction and rejection in solid organ transplantation, and graft-versus-host-disease in stem cell transplantation. Monocytes, key cellular targets of CMV, are permissive to primary, latent and reactivated CMV infection. Here, pairing unbiased bulk and single cell transcriptomics with functional analyses we demonstrate that human monocytes infected with CMV do not effectively phagocytose fungal pathogens, a functional deficit which occurs with decreased expression of fungal recognition receptors. Simultaneously, CMV-infected monocytes upregulate antiviral, pro-inflammatory chemokine, and inflammasome responses associated with allograft rejection and graft-versus-host disease. Our study demonstrates that CMV modulates both immunosuppressive and immunostimulatory monocyte phenotypes, explaining in part, its paradoxical "indirect effects" in transplantation. These data could provide innate immune targets for the stratification and treatment of CMV disease.

Prison healthcare services: the need for political courage

SummaryPrisons in England and Wales have reached a low point in service delivery. Despite initial improvements after National Health Service transfer in 2006, it has deteriorated since 2010, with numerous reports giving cause for concern. Improvements are now urgently required, and political courage and a revised national programme of expenditure are necessary.Declaration of interestNone.

Abstract P1-15-15: Accuracy of MRI after neoadjuvant therapy for invasive lobular carcinoma of the breast

Background: Invasive lobular carcinoma of the breast (ILC) has higher rates of false negative imaging than invasive ductal carcinoma, and lower rates of neoadjuvant therapy (NAT) use. We evaluated the accuracy of Breast Imaging Reporting And Data System (BIRADS) findings on magnetic resonance imaging (MRI) after either neoadjuvant chemotherapy or endocrine therapy, and determined whether imaging change correlates with disease free survival.

Methods: We queried a database of 674 ILC cases treated at UCSF from 1981-2017 and identified all patients treated with NAT. We reviewed MRI reports and recorded BIRADS descriptors of findings, maximal tumor diameter for mass or non-mass enhancement (NME), and subjective radiologist comments on progression or improvement. We used the t-test, chi-squared test, Pearson's correlation, and Kaplan Meier survival estimates to evaluate the accuracy of MRI after NAT compared to true tumor size on pathology, and the relationship between imaging change and disease free interval in Stata 14.2.

Results: Of 136 patients with ILC treated with NAT, we included 101 women who had a post-treatment breast MRI report available. Of these, 58.4% received neoadjuvant chemotherapy, and 41.6% neoadjuvant endocrine therapy. After NAT, MRI findings were mass only in 43%, both mass/NME in 33%, NME only in 18%, and neither in 5%. Maximal diameter of mass on post-treatment MRI underestimated true size by a mean of 3.3 cm (range -3.6 to 15.3 cm). NME size on post-treatment MRI underestimated true size by a mean of 1.87 cm (range -7.2 to 9.7 cm). Mass size on MRI underestimated true size by ≥1 cm in 61.5% of cases; this size discrepancy was associated with increased positive margins (46.4% versus 20%, p=0.011). NME size on MRI underestimated true size by at ≥1 cm in 65.6%. The correlation coefficient between mass size on MRI and true size was 0.34 (p=0.0041), which increased to 0.67 (p<0.0001) when excluding those with associated NME. The correlation coefficient between NME size on MRI and true size was 0.28 (p=0.1239). Subjective progression on post-treatment MRI was associated with increased recurrence rates (80% versus 18.3%, p=0.001). In those with subjective improvement on MRI, there was a trend towards longer disease free interval (89% versus 73% disease free at 4 years, p=0.13).

Table 1.Patient and tumor characteristics. Neoadjuvant chemotherapy (n=59)Neoadjuvant endocrine therapy (n=42)P valueMean age (yrs, 95% CI)53.6 (50.9-56.3)61.3 (58.4-64.1)0.0002Subtype  0.105ER+ PR+ HER2-29 (53.7%)23 (62.16%) ER+ PR- HER2-14 (25.9%)13 (35.14%) ER- PR- HER2-1 (1.85%)0 HER2+10 (18.5%)1 (2.7%) Grade  0.076114 (25%)16 (38.1%) 237 (66.1%)26 (61.9%) 35 (8.93%)0 Surgical stage  <0.001I17 (28.81%)28 (66.67%) II26 (44.07%)6 (14.29%) III16 (27.12%)8 (19.1%) Mean follow-up time (yrs, 95% CI)5.6 (4.53-6.75)5.1 (3.84-6.27)0.48

Conclusions: Maximal tumor diameter on MRI after NAT in ILC vastly underestimates true tumor size. While these findings suggest using caution when using an MRI for surgical planning in patients with ILC, particularly if there is associated NME, the trend towards improved disease free survival in those with a subjective improvement is intriguing and suggests that MRI changes could become an early predictor of outcomes.

Citation Format: Fahrner-Scott KE, Wong JM, Piper M, Ewing C, Alvarado M, Esserman LJ, Hylton N, Mukhtar RA. Accuracy of MRI after neoadjuvant therapy for invasive lobular carcinoma of the breast [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-15.

A strain-specific multiplex RT-PCR for Australian rabbit haemorrhagic disease viruses uncovers a new recombinant virus variant in rabbits and hares

Rabbit haemorrhagic disease virus (RHDV, or GI.1) is a calicivirus in the genus Lagovirus that has been widely utilized in Australia as a biological control agent for the management of overabundant wild European rabbit (Oryctolagus cuniculus) populations since 1996. Recently, two exotic incursions of pathogenic lagoviruses have been reported in Australia; GI.1a-Aus, previously called RHDVa-Aus, is a GI.1a virus detected in January 2014, and the novel lagovirus GI.2 (previously known as RHDV2). Furthermore, an additional GI.1a strain, GI.1a-K5 (also known as 08Q712), was released nationwide in March 2017 as a supplementary tool for wild rabbit management. To discriminate between these lagoviruses, a highly sensitive strain-specific multiplex RT-PCR assay was developed, which allows fast, cost-effective and sensitive detection of the four pathogenic lagoviruses currently known to be circulating in Australia. In addition, we developed a universal RT-qPCR assay to be used in conjunction with the multiplex assay that broadly detects all four viruses and facilitates quantification of viral RNA load in samples. These assays enable rapid detection, identification and quantification of pathogenic lagoviruses in the Australian context. Using these assays, a novel recombinant lagovirus was detected in rabbit tissue samples, which contained the non-structural genes of GI.1a-Aus and the structural genes of GI.2. This variant was also recovered from the liver of a European brown hare (Lepus europaeus). The impact of this novel recombinant on Australian wild lagomorph populations and its competitiveness in relation to circulating field strains, particularly GI.2, requires further studies.

Prevention of Suicidal Behavior in Prisons

BACKGROUND

Worldwide, prisoners are at high risk of suicide. Research on near-lethal suicide attempts can provide important insights into risk and protective factors, and inform suicide prevention initiatives in prison.

AIMS

To synthesize findings of research on near-lethal attempts in prisons, and consider their implications for suicide prevention policies and practice, in the context of other research in custody and other settings.

METHOD

We searched two bibliographic indexes for studies in any language on near-lethal and severe self-harm in prisoners, supplemented by targeted searches over the period 2000-2014. We extracted information on risk factors descriptively. Data were not meta-analyzed owing to heterogeneity of samples and methods.

RESULTS

We identified eight studies reporting associations between prisoner near-lethal attempts and specific factors. The latter included historical, prison-related, and clinical factors, including psychiatric morbidity and comorbidity, trauma, social isolation, and bullying. These factors were also identified as important in prisoners' own accounts of what may have contributed to their attempts (presented in four studies).

CONCLUSION

Factors associated with prisoners' severe suicide attempts include a range of potentially modifiable clinical, psychosocial, and environmental factors. We make recommendations to address these factors in order to improve detection, management, and prevention of suicide risk in prisoners.

Suicide by people in a community justice pathway: population-based nested case-control study

The elevated risk of suicide in prison and after release is a well-recognised and serious problem. Despite this, evidence concerning community-based offenders' suicide risk is sparse. We conducted a population-based nested case-control study of all people in a community justice pathway in England and Wales. Our data show 13% of general population suicides were in community justice pathways before death. Suicide risks were highest among individuals receiving police cautions, and those having recent, or impending prosecution for sexual offences. Findings have implications for the training and practice of clinicians identifying and assessing suicidality, and offering support to those at elevated risk.

Induction therapy by anti-thymocyte globulin (rabbit) versus basiliximab in deceased donor renal transplants and the effect on delayed graft function and outcomes

The use of induction therapy significantly reduces the incidence of acute rejection (AR) episodes posttransplantation and prevents delayed graft function (DGF). In our program, all adult deceased donor kidney transplant (DDKT) recipients receive immunosuppression induction therapy with either basiliximab (anti-CD25 Ab) or rabbit anti-thymocyte globulin (RATG). Our protocol is risk adjusted such that patients who are at a higher risk for DGF or AR received RATG and all other patients receive anti-CD25 Ab. We hypothesized that treating our higher-risk patients with RATG induction at the time of transplantation would lead to a lower rate of DGF and better outcomes. From August 1, 2005 through August 31, 2010, 116 consecutive adult patients received a DDKT in a single academic transplantation center. All DDKT patients received induction with RATG or anti-CD25 Ab. The induction decision was made prior to transplantation based on donor and recipient risk factors for AR and DGF. Transplants that were deemed at higher risk for DGF or AR based on donor factors or recipient factors received RATG. Medical records and patient databases were reviewed retrospectively. The use of RATG in higher-risk recipients for DGF and AR did not significantly reduce the DGF rate. At 6 months the function of the allograft function measured as creatinine clearance or serum creatinine was lower in the RATG group than the patients who received anti-CD25 Ab induction. The choice of induction therapy did not improve outcomes in high-risk patients in this short-term study.

Characteristics of and trends in subgroups of prisoner suicides in England and Wales

BACKGROUND

The suicide rate is higher in prisoners compared with the general population. The aim was to describe the characteristics of and longitudinal trends in prisoner suicides in England and Wales.

METHOD

A case series was ascertained from the Safer Custody and Offender Policy Group at the Ministry of Justice and included a 9-year (1999-2007) national census of prisoner suicides. Questionnaires were completed by prison staff on sociodemographic, custodial, clinical and service-level characteristics of the suicides.

RESULTS

There was a fall in the number of prison suicides and a decline in the proportion of young prisoner (18-20 years) suicides over time. Females were over-represented. Upward trends were found in prisoners with a history of violence and with previous mental health service contact. A downward trend was found in those with a primary psychiatric diagnosis of drug dependence. Drug dependence was found to be significant in explaining suicides within the first week of custody.

CONCLUSIONS

The findings provide an important insight to aid a target set in the National Suicide Prevention Strategy in England to reduce suicides in the prisoner population by 20% and highlight an important area for policy development in mental health services. Examining trends identified subgroups that may require improved mental healthcare and recognized those that appeared to be having their treatment needs more adequately met. Evidence suggests that targeted suicide prevention strategies for subgroups of prisoners are required.

Surgically placed wound catheters (SPWC) and local anaesthetic infusion in breast surgery: efficacy and safety analysis

BACKGROUND

The effectiveness of surgically placed wound catheters (SPWC) and local anaesthetic infusion in the management of post-operative pain following breast surgery is controversial. This meta-analysis was performed to assess efficacy SPWC compared to other techniques of pain management.

MATERIAL AND METHODS

The meta-analysis included randomised control trials that compared SPWC with other forms of pain control. Post-operative opioid requirements and pain measured in visual analogue scale (VAS) were analysed using Comprehensive Meta-analysis Software version 2. Literature was reviewed for the safety of the SPWC and local anaesthetic infusion.

RESULTS

Four randomised controlled trials evaluating 147 women were included in the final analysis. The overall standard difference in means was 0.094 and 0.033 for post-operative opioid requirement and pain respectively favouring the SPWC and local anaesthetic infusion group. It is a safe technique with no major adverse events as a result.

CONCLUSION

Surgically placed wound catheters and local anaesthetic infusion is clinically safe in a wide range of surgical procedures on the breast and there appears to be a trend towards improved post operative pain relief. The studies analyzed in this review have several important drawbacks such as inadequate power to detect significant differences (none of them included more than 50 patients). A well designed RCT of patients undergoing breast surgery with an adequate number is of patients required to emphatically demonstrate if the operative site infusion with local anaesthetic solution postoperatively is safe and efficacious compared to opioid based regimens alone for post operative pain relief.

Suicide in recently released prisoners: a case-control study

BACKGROUND

Recently released prisoners are at markedly higher risk of suicide than the general population. The aim of this study was to identify key risk factors for suicide by offenders released from prisons in England and Wales.

METHOD

All suicides committed by offenders within 12 months of their release from prison in England and Wales, between 2000 and 2002, were identified. One control matched on gender and date of release from prison was recruited for each case. Univariate and multivariate logistic regression modelling identified key independent risk factors for suicide.

RESULTS

Of 256 920 released prisoners, 384 suicides occurred within a year of release. Factors significantly associated with post-release suicide were increasing age over 25 years, released from a local prison, a history of alcohol misuse or self-harm, a psychiatric diagnosis, and requiring Community Mental Health Services (CMHS) follow-up after release from prison. Non-white ethnicity and a history of previous imprisonment were protective factors.

CONCLUSIONS

There is a need to improve the continuity of care for people who are released from prison and for community health, offender and social care agencies to coordinate care for these vulnerable individuals.

Erythropoietin or darbepoetin for patients with cancer

BACKGROUND

Anaemia associated with cancer and cancer therapy is an important clinical factor in the treatment of malignant diseases. Therapeutic alternatives are recombinant human erythropoietin (Epo), darbepoetin (Darbepo) and red blood cell transfusions.

OBJECTIVES

The aim of this systematic review was to assess the effects of Epo or Darbepo to either prevent or treat anaemia in cancer patients.

SEARCH STRATEGY

We searched the Central Register of Controlled Trials, MEDLINE and EMBASE and other data bases. Searches were done for the periods 01/1985 to 12/2001 for the first review and 1/2002 to 04/2005 for the update. We also contacted experts in the field and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials on managing anaemia in cancer patients that compared the use of Epo/Darbepo (plus transfusion if needed) with observation until red blood cell transfusion was required.

DATA COLLECTION AND ANALYSIS

Several reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

This update of the systematic review included a total of 57 trials with 9,353 patients. Of these, 27 trials with 3,287 adults were also included in the first Cochrane Review. Thirty trials with 6,066 patients were added during the update process. Use of Epo/Darbepo significantly reduced the relative risk of red blood cell transfusions (RR 0.64; 95% CI 0.60 to 0.68, 42 trials, n = 6,510). On average participants in the Epo/Darbepo group received one unit of blood less than the control group (WMD -1.05; 95% CI -1.32 to -0.78, 14 trials, n = 2,353). For participants with baseline haemoglobin below 12 g/dL haematological response was observed more often in participants receiving Epo/Darbepo (RR 3.43; 95% CI 3.07 to 3.84, 22 trials, n = 4,307). There was suggestive evidence that Epo/Darbepo may improve Quality of Life (QoL). The relative risk for thrombo embolic complications was increased in patients receiving Epo/Darbepo compared to controls (RR 1.67, 95% CI 1.35 to 2.06; 35 trials, n = 6,769). Uncertainties remain whether and how Epo/Darbepo effects tumour response (fixed effect RR 1.12; 95% CI 1.01 to 1.23, 13 trials, n = 2,833; random effects: RR 1.09; 95% CI 0.94 to 1.26) or overall survival (unadjusted and adjusted data: HR 1.08; 95% CI 0.99 to 1.18; 42 trials, n = 8,167).

AUTHORS' CONCLUSIONS

There is consistent evidence that administration of Epo/Darbepo reduces the relative risk for blood transfusions and the number of units transfused in cancer patients. For patients with baseline haemoglobin below 12 g/dL (mild anaemia) there is strong evidence that Epo/Darbepo improves haematological response. There is suggestive evidence that Epo/Darbepo may improve QoL. However, there is strong evidence that Epo/Darbepo increases the relative risk for thrombo embolic complications. Whether and how Epo/Darbepo effects tumour response and overall survival remains uncertain.

Suicide in recently released prisoners: a population-based cohort study

BACKGROUND

Several studies have been undertaken on suicide in custody, but few on suicide after the release from prison. We undertook a population-based cohort study to investigate suicide rates in recently released prisoners in England and Wales.

METHODS

We used the database of the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness for England and Wales to identify all individuals who died by suicide or who received an open verdict at the coroner's inquest between 2000 and 2002. These records were linked to a Home Office register to identify all such deaths in people within 1 year of release from prison in England and Wales. We compared suicide rates per 100,000 person-years in these released prisoners with rates in the general population by using the indirectly age-standardised mortality ratio.

FINDINGS

We identified 382 suicides occurring in 244 988 individuals within 1 year of release from prison; a suicide rate of 156 per 100 000 person-years. 79 (21%) suicides occurred within the first 28 days after release. In all age groups, suicide rates were higher in recently released prisoners than in the general population. The overall age-standardised mortality ratio for recently released prisoners was 8.3 (95% CI 7.5-9.3) for men and 35.8 (25.4-50.2) for women.

INTERPRETATION

Recently released prisoners are at a much greater risk of suicide than the general population, especially in the first few weeks after release. The risk of suicide in recently released prisoners is approaching that seen in discharged psychiatric patients. A shared responsibility lies with the prison, probation, health, and social services to develop more collaborative practices in providing services for this high-risk group.

Modelling the hepatitis B vaccination programme in prisons

A vaccination programme offering hepatitis B (HBV) vaccine at reception into prison has been introduced into selected prisons in England and Wales. Over the coming years it is anticipated this vaccination programme will be extended. A model has been developed to assess the potential impact of the programme on the vaccination coverage of prisoners, ex-prisoners, and injecting drug users (IDUs). Under a range of coverage scenarios, the model predicts the change over time in the vaccination status of new entrants to prison, current prisoners and IDUs in the community. The model predicts that at baseline in 2012 57% of the IDU population will be vaccinated with up to 72% being vaccinated depending on the vaccination scenario implemented. These results are sensitive to the size of the IDU population in England and Wales and the average time served by an IDU during each prison visit. IDUs that do not receive HBV vaccine in the community are at increased risk from HBV infection. The HBV vaccination programme in prisons is an effective way of vaccinating this hard-to-reach population although vaccination coverage on prison reception must be increased to achieve this.

Hepatitis A vaccination--a prison-based solution for a community-based outbreak?

In December 2001, an increase in cases of hepatitis A was observed in South Yorkshire. Cases were predominantly young males who reported injecting drug use. A community-based vaccination programme was introduced in November 2002, but new cases continued to occur. In March 2003, a vaccination campaign was implemented in the local prison for a four-week period. One thousand two hundred and thirty-six (91%) prisoners were vaccinated. Two thirds (895/1,363) of the prisoners came from the area affected by the outbreak and 52% (465/895) reported injecting drugs. The median age of injectors was 25 years. Notifications of cases of hepatitis A from South Yorkshire ceased in August 2003. Although on this occasion the prison vaccination campaign was probably implemented too late to have had a significant impact on the local outbreak, a large number of young male injectors from the local area were successfully vaccinated. This suggests that a prison-based intervention offers a potentially effective way of immunising the IDU population and interrupting a community-based outbreak.

Increasing hepatitis B vaccine coverage in prisons in England and Wales

The most frequently reported risk factor for hepatitis B infection in England and Wales is injecting drug use (38%). Since approximately 61% of injecting drug users (IDUs) had been imprisoned and less than 40% had received hepatitis B vaccine, a prison based hepatitis B vaccination programme was set up in 2001. At the 42 establishments participating in this study, all prisoners were offered vaccine at reception. Prisoners over 18 years were vaccinated using the 0, 7 and 21 days schedule and those under 18 years, using the 0, 1 and 2 months schedule. As far as possible a fourth dose was given to all after 12 months. In 2003, 14,163 prisoners received at least one dose of vaccine and altogether 26,265 doses were administered. A further 1111 prisoners reported they had already been vaccinated against hepatitis B. The median vaccine coverage rate was 17% (range 0-94%). Despite low coverage levels, the vaccination programme in prisons can be said to have vaccinated a sizable number of young, male prisoners, a group that have previously been shown to be at high risk of infection. The prisons which achieved vaccine coverage levels over 50% had designated nursing staff who ran the vaccination clinics.

Outbreak of isoniazid resistant tuberculosis in north London

BACKGROUND

A description is given of a major outbreak of isoniazid monoresistant tuberculosis (TB) chiefly in north London, including prisons. The earliest case was diagnosed in 1995 with most cases appearing after 1999.

METHODS

Confirmation of a local cluster of cases was confirmed by restriction fragment length polymorphism (RFLP IS6110) typing or "rapid epidemiological typing" (RAPET). Further cases were found by retrospective analysis of existing databases, prospective screening of new isolates, and targeted epidemiological case detection including questionnaire analysis.

RESULTS

By the end of 2001, 70 confirmed cases in London had been linked with a further 13 clinical cases in contacts and nine epidemiologically linked cases outside London. The epidemic curve suggests that the peak of the outbreak has not yet been reached. Cases in the outbreak largely belong to a social group of young adults of mixed ethnic backgrounds including several individuals from professional/business backgrounds. Compared with other cases of TB reported to the enhanced surveillance scheme in London during 1999-2001, the cases are more likely to be of white (26/70 (37%) v 1308/7666 (17%)) or black Caribbean ethnicity (17/70 (24%) v 312/7666 (4%)), born in the UK (41/70 (59%) v 1335/7666 (17%)), and male (52/70 (74%) v 4195/7666 (55%)). Drug misuse and/or prison detention are factors common to many cases.

CONCLUSIONS

The investigation of the outbreak revealed significant problems on an individual patient and population based level including difficulties with contact tracing, compliance, and the risk of developing multidrug resistance. This incident has demonstrated the value of molecular strain typing in investigating an extensive outbreak of TB. This is the first documented outbreak involving a UK prison.

Erythropoietin for patients with malignant disease

BACKGROUND

Anaemia associated with cancer and cancer therapy is an important clinical factor in the treatment of malignant diseases. Therapeutic alternatives are recombinant human erythropoietin (EPO) and red blood cell transfusions.

OBJECTIVES

The aim of this systematic review was to assess the effect of erythropoietin to either prevent or treat anaemia in cancer patients.

SEARCH STRATEGY

We searched the Central Register of Controlled Trials, MEDLINE (01/1985 to 12/2001), EMBASE (01/1985 to 12/2001), other databases and reference lists of articles. We also contacted experts in the field and pharmaceutical companies.

SELECTION CRITERIA

Randomised controlled trials comparing the use of recombinant human erythropoietin (plus transfusion if needed) with red blood cell transfusions alone for the treatment or prevention of anaemia in cancer patients.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. All authors from included studies were contacted for additional information.

MAIN RESULTS

Twenty seven trials with 3,287 adults were included. Use of erythropoietin significantly reduced the relative risk of red blood cell transfusions (RR 0.67; 95% CI 0.62 to 0.73, 25 trials, n = 3,069). On average participants in the erythropoietin group received one unit of blood less than the control group (WMD -1.00; 95% CI-1.31 to -0.70, 13 trials, n = 2,056). For participants with baseline haemoglobin below 10 g/dL haematological response was observed more often in participants receiving EPO (RR 3.60; 95% CI 3.07 to 4.23, 14 trials, n = 2,347). There was inconclusive evidence whether EPO improves tumour response (fixed effect RR 1.36; 95% CI 1.07 to 1.72, seven trials, n = 1,150; random effects: RR 1.21; 95% CI 0.92 to 1.59) and overall survival (adjusted data: HR 0.81; 95% CI 0.67 to 0.99; unadjusted data: HR 0.84; 95% CI 0.69 to 1.02, 19 trials, n = 2,865). There were no statistically significant adverse effects. Evidence was inconclusive with respect to quality of life and fatigue.

REVIEWERS' CONCLUSIONS

There is consistent evidence that the administration of erythropoietin reduces the risk for blood transfusions and the number of units transfused in cancer patients. For patients with baseline haemoglobin below 10 g/dL there is strong evidence that erythropoietin improves haematological response. There is inconclusive evidence whether erythropoietin improves tumour response and overall survival. Research on side effects is inconclusive.

Erythropoietin: a paradigm for the development of practice guidelines

Erythropoietin (EPO) is an endogenous hormone produced in the kidney that regulates red blood cell production within the body. Since the cloning and first clinical introduction of recombinant erythropoietin (epoetin) in the late 1980s indications and usage of epoetin have expanded significantly. It is estimated that as many as one third of patients with substantial anemia (hemoglobin less than 10.0 g/dL) resulting from chemotherapy for cancer are treated with epoetin. Though use of epoetin may avoid the inconvenience and infectious risk of blood transfusions, it is expensive and its benefit in some clinical scenarios has been modest. Like many new technologies, strong evidence suggesting situations where the benefit is high has lagged behind its adoption by patients and practitioners. As well, epoetin is expensive and third party payers do not always reimburse it. Research suggests there is considerable variation in epoetin usage in practice. To provide guidance to hematology/oncology specialists regarding use of epoetin, the American Society of Hematology (ASH) and the American Society of Clinical Oncology (ASCO) proposed that the Agency for Healthcare Research and Quality (AHRQ) fund an evidence review by one of the Evidence-based Practice Centers (EPC) that would be used to develop evidence-based guidelines for members of the society. This review highlights principles of evidence-based medicine, distills and appraises the evidence in the published literature that supports the use of epoetin, and presents evidence-based recommendations for use of epoetin in situations where benefit is substantiated by high-quality studies. As well, this review addresses some of the difficulties of performing clinical research in this area, provocative research findings that will require further study, and suggestions regarding epoetin in those areas where further strong evidence has yet to be developed.

Health of elderly male prisoners: worse than the general population, worse than younger prisoners

BACKGROUND

Assessment of the health of men aged 60 and over in English and Welsh prisons.

METHODS

203 men were interviewed from 15 prisons, comprising one-fifth of all sentenced men in this age group in England and Wales. Assessment included semi-structured interviews covering chronic and acute health problems, and recording of major illnesses from the medical notes and prison reception health screen.

RESULTS

85% of the elderly prisoners had one or more major illnesses reported in their medical records, and 83% reported at least one chronic illness on interview. The most common illnesses were psychiatric, cardiovascular, musculoskeletal and respiratory.

CONCLUSION

The rates of illness in elderly prisoners are higher than those reported in other studies of younger prisoners and surveys of the general population of a similar age. The increasing number of elderly people in prison poses specific health challenges for prison health-care services.

Epoetin treatment of anemia associated with cancer therapy: a systematic review and meta-analysis of controlled clinical trials

Epoetin treatment offers an attractive but costly alternative to red blood cell transfusion for managing anemia associated with cancer therapy. The goal of this review is to facilitate more efficient use of epoetin by 1) quantifying the effects of epoetin on the likelihood of transfusion and on quality of life in patients with cancer treatment-related anemia and 2) evaluating whether outcomes are superior when epoetin treatment is initiated at higher hemoglobin thresholds. Two independent reviewers followed a prospective protocol for identifying studies. Outcomes data were combined with the use of a random-effects meta-analysis model. Double-blind, randomized, controlled trials that minimized patient exclusions were defined as higher quality for sensitivity analysis; randomized but unblinded trials and trials with excessive exclusions were included in the meta-analysis but were defined as lower quality. Twenty-two trials (n = 1927) met inclusion criteria, and 12 (n = 1390) could be combined for estimation of odds of transfusion. Epoetin decreased the percentage of patients transfused by 9%-45% in adults with mean baseline hemoglobin concentrations of 10 g/dL or less (seven trials; n = 1080), by 7%-47% in those with hemoglobin concentrations greater than 10 g/dL but less than 12 g/dL (seven trials; n = 431), and by 7%-39% in those with hemoglobin concentrations of 12 g/dL or higher (five trials; n = 308). In sensitivity analysis, the combined odds ratio for transfusion in epoetin-treated patients as compared with controls was 0.45 (95% confidence interval [CI] = 0.33 to 0.62) in higher quality studies and 0.14 (95% CI = 0.06 to 0.31) in lower quality studies. The number of patients needed to treat to prevent one transfusion is 4.4 for all studies, 5.2 for higher quality studies, and 2.6 for lower quality studies. Only studies with mean baseline hemoglobin concentrations of 10 g/dL or less reported statistically significant effects of epoetin treatment on quality of life; quality-of-life data were insufficient for meta-analysis. No studies addressed epoetin's effects on anemia-related symptoms. We conclude that epoetin reduces the odds of transfusion for cancer patients undergoing therapy. Evidence is insufficient to determine whether initiating epoetin earlier spares more patients from transfusion or results in better quality of life than waiting until hemoglobin concentrations decline to nearly 10 g/dL.

Dual trafficking of Slit3 to mitochondria and cell surface demonstrates novel localization for Slit protein

Drosophila slit is a secreted protein involved in midline patterning. Three vertebrate orthologs of the fly slit gene, Slit1, 2, and 3, have been isolated. Each displays overlapping, but distinct, patterns of expression in the developing vertebrate central nervous system, implying conservation of function. However, vertebrate Slit genes are also expressed in nonneuronal tissues where their cellular locations and functions are unknown. In this study, we characterized the cellular distribution and processing of mammalian Slit3 gene product, the least evolutionarily conserved of the vertebrate Slit genes, in kidney epithelial cells, using both cellular fractionation and immunolabeling. Slit3, but not Slit2, was predominantly localized within the mitochondria. This localization was confirmed using immunoelectron microscopy in cell lines and in mouse kidney proximal tubule cells. In confluent epithelial monolayers, Slit3 was also transported to the cell surface. However, we found no evidence of Slit3 proteolytic processing similar to that seen for Slit2. We demonstrated that Slit3 contains an NH(2)-terminal mitochondrial localization signal that can direct a reporter green fluorescent protein to the mitochondria. The equivalent region from Slit1 cannot elicit mitochondrial targeting. We conclude that Slit3 protein is targeted to and localized at two distinct sites within epithelial cells: the mitochondria, and then, in more confluent cells, the cell surface. Targeting to both locations is driven by specific NH(2)-terminal sequences. This is the first examination of Slit protein localization in nonneuronal cells, and this study implies that Slit3 has potentially unique functions not shared by other Slit proteins.

Race-specific results of Papanicolaou testing and the rate of cervical neoplasia in the National Breast and Cervical Cancer Early Detection Program, 1991-1998 (United States)

OBJECTIVE

To describe differences in cervical screening and biopsy results by race or ethnicity from women in the National Breast and Cervical Cancer Early Detection Program (NBCCEDP).

METHODS

We examined the percentage of abnormalities detected by Papanicolaou (Pap) tests and the rate of biopsy-diagnosed high-grade precancerous or cancerous lesions by racial or ethnic group.

RESULTS

Almost half the 628,085 women screened were members of racial or ethnic minority groups. American Indian or Alaska Native women were more likely than others to report never having had a prior Pap test. American Indian or Alaska Native women had the highest proportion of abnormal Pap tests for first program screens (4.4%), followed by blacks (3.2%), whites (3.0%), Hispanics (2.7%), and Asians or Pacific Islanders (1.9%). Whites had the highest biopsy detection rate of high-grade lesions for first program screens (9.9 per 1000 Pap tests), followed by Hispanics (7.6), blacks (7.1), American Indians or Alaska Natives (6.7), and Asians or Pacific Islanders (5.4).

CONCLUSIONS

This program provides important data on the prevalence of cervical neoplasia among diverse populations. Our findings that black women with a high-grade Pap test were less likely to get a work-up are disconcerting and merit further study and ultimate correction.

Expression of the vertebrate Slit gene family and their putative receptors, the Robo genes, in the developing murine kidney

The slit (sli) gene, encoding a secreted glycoprotein, has been demonstrated to play a vital role in axonal guidance in Drosophila melanogaster by acting as a signalling ligand for the robo receptor (Rothberg, J.M., Jacobs, J.R., Goodman, C.S., Artavanis-Tsakonas, S., 1990. slit: an extracellular protein necessary for development of midline glia and commissural axon pathways contains both EGF and LRR domains. Genes Dev. 4, 2169-2187; Kidd, T., Bland, K.S., Goodman, C. S., 1999. Slit is the midline repellent for the robo receptor in Drosophila. Cell 96, 785-794). Multiple homologs of both sli and robo have been identified in vertebrates and are thought to play similar roles to their fly counterparts in neural development (Brose, K., Bland, K.S., Wang, K.H., Arnott, D., Henzel, W., Goodman, C.S., Tessier-Lavigne, M., Kidd, T., 1999. Slit proteins bind Robo receptors and have an evolutionarily conserved role in repulsive axon guidance. Cell 96, 795-806). Slit2 has been shown to bind Robo1, mediating both neuronal and axonal guidance in the developing central nervous system (CNS), (Brose et al., 1999; Hu, H., 1999. Chemorepulsion of neuronal migration by Slit2 in the developing mammalian forebrain. Neuron 23, 703-711). Importantly, both gene families display distinct expression patterns outside the CNS (Holmes, G.P., Negus, K., Burridge, L., Raman, S., Algar, E., Yamada, T., Little, M.H., 1998. Distinct but overlapping expression patterns of two vertebrate slit homologs implies functional roles in CNS development and organogenesis. Mech. Dev. 79, 57-72; Yuan, W., Zhou, L., Chen, J.H., Wu, J.Y., Rao, Y., Ornitz, D.M., 1999. The mouse SLIT family: secreted ligands for ROBO expressed in patterns that suggest a role in morphogenesis and axon guidance. Dev. Biol. 212, 290-306). Using in situ hybridization on metanephric explant cultures and urogenital tract sections, the expression patterns of Slit1, 2, 3 and Robo1 and 2 were investigated during murine metanephric development. Slit1 was expressed in the metanephric mesenchyme (MM) surrounding the invading ureteric tree (UT). Slit2 was expressed at the tips of the UT and both Slit2 and Slit3 were expressed at the far proximal end of the comma shaped and S-shaped bodies. Expression of Robo1 was initially diffuse throughout the MM, then upregulated in the pretubular aggregates, and maintained at the distal end of the comma and S-shaped bodies. Robo2 was detected in the induced MM surrounding the arborizing UT tips and later in the proximal end of the S-shaped bodies. Coincident expression of Robo1 with Slit1 in the metanephric mesenchyme and Robo2, Slit2 and Slit3 in the far proximal end of the S-shaped bodies was observed during metanephric development.

Protective effect of HOE642, a selective blocker of Na+-H+ exchange, against the development of rigor contracture in rat ventricular myocytes

The objective of this study was to investigate the effect of Na+-H+ exchange (NHE) and HCO3--Na+ symport inhibition on the development of rigor contracture. Freshly isolated adult rat cardiomyocytes were subjected to 60 min metabolic inhibition (MI) and 5 min re-energization (Rx). The effects of perfusion of HCO3- or HCO3--free buffer with or without the NHE inhibitor HOE642 (7 microM) were investigated during MI and Rx. In HCO3--free conditions, HOE642 reduced the percentage of cells developing rigor during MI from 79 +/- 1% to 40 +/- 4% (P < 0.001) without modifying the time at which rigor appeared. This resulted in a 30% reduction of hypercontracture during Rx (P < 0.01). The presence of HCO3- abolished the protective effect of HOE642 against rigor. Cells that had developed rigor underwent hypercontracture during Rx independently of treatment allocation. Ratiofluorescence measurement demonstrated that the rise in cytosolic Ca2+ (fura-2) occurred only after the onset of rigor, and was not influenced by HOE642. NHE inhibition did not modify Na+ rise (SBFI) during MI, but exaggerated the initial fall of intracellular pH (BCEFC). In conclusion, HOE642 has a protective effect against rigor during energy deprivation, but only when HCO3--dependent transporters are inhibited. This effect is independent of changes in cytosolic Na+ or Ca2+ concentrations.

Alterations in skeletal muscle gene expression of ob/ob mice by mRNA differential display

To identify molecules that contribute to insulin resistance, we compared the patterns of gene expression in skeletal muscle of the obese ob/ob mouse, a genetic model of obesity and severe insulin resistance, with that of its thin littermate (ob/+) using the mRNA differential display method. From about 9,000 cDNAs displayed, we found 12 differentially expressed in ob/ob mice skeletal muscle that could be recovered from the differential display gels and confirmed by Northern blot analysis and sequenced. Eight mRNAs were overexpressed in ob/ob muscle: Id2 (a negative regulator of the basic helix-loop-helix family of transcription factors), fast skeletal muscle troponin T, ribosomal protein L3, the integral protein of the peroxisomal membrane 22PMP, the mammalian homolog of geranylgeranyl pyrophosphate synthase, an mRNA related to phosphatidylinositol-glycan-specific phospholipase D, and two unknown mRNAs. The level of overexpression of these mRNAs in skeletal muscle varied from a 500% increase to as little as a 25% increase. Two mRNAs were underexpressed 20-35%, including the f-subunit of mitochondrial ATP synthase and a retrovirus-related DNA. Two proteins with multiple transcripts, skeletal muscle alpha-tropomyosin and one for a repetitive sequence, showed a change in mRNA pattern of expression in the muscle of the ob/ob mouse. Because the primary genetic defect in the ob/ob mouse is known to be in the leptin gene, these data indicate how acquired alterations in gene expression of multiple classes of proteins may play a role in the complex pathogenesis of insulin resistance in obesity and diabetes.

Genomic and functional map of the chromosome 14 t(12;14) breakpoint cluster region in uterine leiomyoma

A translocation involving chromosomes 12 and 14 [t(12;14)(q15;24.1)] is commonly seen in benign smooth muscle tumor as uterine leiomyoma (UL). A contig of P1-derived artificial chromosome and bacterial artificial chromosome clones on chromosome 14, encompassing a t(12;14) breakpoint cluster region (BCR) in UL, was generated principally using the recently developed HAPPY map of chromosome 14 as a framework (P. H. Dear et al., 1998, Genomics 48: 232-241). Three UL t(12;14) breakpoints have been localized within this contig, showing that a BCR of at least 400 kb exists on chromosome 14. Other studies of tumors with t(12;14) rearrangements similarly show breakpoints within a 475-kb multiple aberration region on chromosome 12. Thus t(12;14) is an example of a translocation in which the breakpoints are located within a BCR on both chromosome 12 and chromosome 14, justifying the identification of expressed sequences that are altered in these BCR regions. A total of four expressed sequences were identified in the BCR on chromosome 14. Two of these were novel cDNAs (D14S1460E and D14S1461E). The chromosome 14 cDNAs were expressed in multiple adult tissues. The identification of a large breakpoint cluster region on chromosome 14 suggests that translocations in this region mediate their effects at a distance and also that elements that predispose this region to recurrent chromosomal translocation may be widely distributed.