In vivo evaluation of rotator cuff internal impingement during scapular plane abduction in asymptomatic individuals

Internal impingement-or entrapment of the undersurface of the rotator cuff tendon against the glenoid during overhead activities-is believed to contribute to articular-sided tears. However, little is known about internal impingement outside athletic populations. Therefore, the objectives of this study were to (1) describe glenoid-to-footprint distances and proximity centers during dynamic, in vivo motion in asymptomatic individuals, and (2) determine the extent to which these measures differed between individuals with and without a rotator cuff tear. Shoulder kinematics were assessed in 37 asymptomatic individuals during scapular plane abduction using a high-speed biplane radiographic system. Glenoid-to-footprint distances and proximity center locations were calculated by combining the kinematics with computerized tomography-derived bone models. Glenoid-to-footprint contact was presumed to occur when the minimum distance was less than the estimated labral thickness. The condition of the supraspinatus tendon (intact, torn) was assessed using ultrasound. Minimum distances and proximity centers were compared over humerothoracic elevation angles (90°, 110°, 130°, 150°) and between supraspinatus pathology groups using two-factor mixed model analysis of variances. Glenoid-to-footprint minimum distances decreased consistently across elevation angles (p < 0.01) without a significant difference between groups. Contact was estimated to occur in all participants. Proximity centers were generally located on the anterior half of the rotator cuff footprint and on the posterosuperior glenoid. Statement of Clinical Significance: Internal impingement during overhead motions may be a prevalent mechanism of rotator cuff pathology as contact appears to be common and involves the region of the rotator cuff footprint where degenerative rotator cuff tears are thought to originate.

1019 Quantified Learning Curves for Robotic Gastrointestinal Surgery

Aim

Robotic techniques are increasingly being adopted by gastrointestinal surgeons. It is important to understand the learning curves (LCs) for robotic surgery, to protect patients from harm caused by surgeon inexperience.

The aim of this study was to summarise reports of the LC for three robotic gastrointestinal procedures: cholecystectomy, oesophagectomy and Roux-en-Y gastric bypass (RYGB).

Method

Three systematic reviews were conducted by the trainee led RoboSurg Collaborative. Systematic searches identified reports of primary clinical research involving robotic cholecystectomy, oesophagectomy and RYGB. Articles were screened in duplicate by title, abstract and then full text. References to the LC were extracted and coded. Quantifications of the learning curve were summarised using descriptive statistics.

Results

259 articles were identified: 56 measured the LC, with 23 (9%) of these calculating the number of cases required to complete the LC. The mean reported number of cases at which the LC plateaued was: 16 for oesophagectomy (N = 6, SD = 3.7), 18 for cholecystectomy (N = 5, SD = 15.1), 34 for RYGB (N = 12, SD = 24.6). The reported LCs often incorporated equipment setup times, and so represents learning of the team as well as the surgeon. These values represent points on the LC that authors deemed their surgeons to have ‘completed’ learning. Definitions for when these points occurred varied greatly but largely fell in to two categories: ‘plateau of operative time’ or ‘matching operating time of laparoscopic control procedure’.

Conclusions

The heterogeneity in how LCs are defined, measured, and reported highlights the need for a more standardised approach when evaluating novel techniques such as robotics.

1028 How Has the Learning Curve Been Measured in Robotic Gastrointestinal Surgery?

Aim

Robotic surgery is increasingly being adopted by gastrointestinal surgeons. The IDEAL Collaboration has recommended evaluation of the learning curve (LC) for such surgical innovations. It is not known how learning curves have been reported for robotic gastrointestinal procedures. The aim of this study was to summarise how the LCs were measured for three robotic gastrointestinal procedures: cholecystectomy, oesophagectomy and Roux-en-Y gastric bypass (RYGB).

Method

Three systematic reviews conducted by the trainee led RoboSurg Collaborative identified primary clinical research involving robotic cholecystectomy, oesophagectomy and RYGB. Articles were screened in duplicate by title, abstract and then full text. References to the LC were extracted and coded. The techniques used to measure the LC were summarised using descriptive statistics.

Results

259 articles were identified, of which 56 (22%) actively measured the LC. The commonest surrogate marker for performance was operative time (N = 34, 63%). Several evaluated performances using the cumulative sum of the operative times (N = 8, 14%). Complications (N = 5, 8%) and time to complete a specific surgical step (N = 4, 7%) were also used. Some authors used multiple markers (N = 4, 7%). Cases were reported individually in 48 (81%) of the LCs, whereas they were grouped in 11 (19%). 19 authors (34%) provided graphical representation of the LC.

Conclusions

The reporting of LCs for robotic gastrointestinal surgery was heterogeneous and lacked standardisation. There was variation in choice of surrogate markers for performance, individual versus grouped case reporting, and graphical representations. To improve the utility of LC reports, the recommendations of the IDEAL Collaboration should be implemented.

Postmortem Analyses in a Patient With Succinic Semialdehyde Dehydrogenase Deficiency (SSADHD): II. Histological, Lipid, and Gene Expression Outcomes in Regional Brain Tissue

This study has extended previous metabolic measures in postmortem tissues (frontal and parietal lobes, pons, cerebellum, hippocampus, and cerebral cortex) obtained from a 37-year-old male patient with succinic semialdehyde dehydrogenase deficiency (SSADHD) who expired from SUDEP (sudden unexplained death in epilepsy). Histopathologic characterization of fixed cortex and hippocampus revealed mild to moderate astrogliosis, especially in white matter. Analysis of total phospholipid mass in all sections of the patient revealed a 61% increase in cortex and 51% decrease in hippocampus as compared to (n = 2-4) approximately age-matched controls. Examination of mass and molar composition of major phospholipid classes showed decreases in phospholipids enriched in myelin, such as phosphatidylserine, sphingomyelin, and ethanolamine plasmalogen. Evaluation of gene expression (RT² Profiler PCR Arrays, GABA, glutamate; Qiagen) revealed dysregulation in 14/15 GABA_A receptor subunits in cerebellum, parietal, and frontal lobes with the most significant downregulation in ∊, θ, ρ1, and ρ2 subunits (7.7-9.9-fold). GABA_B receptor subunits were largely unaffected, as were ionotropic glutamate receptors. The metabotropic glutamate receptor 6 was consistently downregulated (maximum 5.9-fold) as was the neurotransmitter transporter (GABA), member 13 (maximum 7.3-fold). For other genes, consistent dysregulation was seen for interleukin 1β (maximum downregulation 9.9-fold) and synuclein α (maximal upregulation 6.5-fold). Our data provide unique insight into SSADHD brain function, confirming astrogliosis and lipid abnormalities previously observed in the null mouse model while highlighting long-term effects on GABAergic/glutamatergic gene expression in this disorder.

Exploring the utility of neuro-monitoring in neurosurgery: The users' perspective in a single center

Background:

The purpose of intraoperative neuro-monitoring (IONM) is to minimize injury to eloquent neural structures and optimize tumor resection.

Method:

We explored the utility of IONM using a qualitative approach in a single center. Eight experienced users of its use in spinal and cranial surgery in adults and children were the informants. Using a constant comparative method, the findings were collated by thematic analysis.

Results:

The user perspective is that of caution to minimize adverse effects whilst empowering the need for formal training to enhance its efficacy. The process of IONM needs standardization as practices vary amongst users. Most users expressed limited trust on its current capabilities but hoped for its advancement to achieve higher sensitivity and specificity. None were however prepared to abandon its use.

Conclusion:

IONM needs optimization. Its utility depends on user vigilance, multi-disciplinary validation, and individual expertise. This study draws out key issues from the user perspective that need to be addressed in order to enhance the utility of IONM.

Systematic review to determine which validated measurement tools can be used to assess risk of problematic analgesic use in patients with chronic pain

Background

Misuse of prescription opioids, and other drugs prescribed for chronic pain, has increased, with major concerns about harm. This review was undertaken to identify validated measurement tools for risk assessment and monitoring of chronic non-cancer pain patients being considered for, or currently prescribed, analgesic drugs with abuse potential.

Methods

Selected databases (Embase, Medline, Cochrane library/CENTRAL, PsycINFO, PubMed, CINAHL) were systematically searched for studies evaluating tools for risk of analgesic misuse, either before, or during, analgesic therapy for chronic pain, using predetermined inclusion/exclusion criteria. Two independent reviewers assessed abstracts, selected full texts, extracted data and assessed quality.

Results

30 studies from 1844 met inclusion criteria, including three systematic reviews, with an additional four studies from bibliography review. The studies covered 14 tools pertaining to opioid use, with none for non-opioid analgesics.

Conclusions

For predicting prescription opioid misuse, the pain medication questionnaire (PMQ) and the screener and opioid assessment for patients with pain (SOAPP) had the best evidence; both developed and validated in five separate studies (four each of acceptable quality). The current opioid misuse measure (COMM) performed best screening for current misuse, developed and validated in three studies of acceptable quality. A small number of tools may accurately predict, or identify, opioid misuse. There are none for non-opioid analgesics, where there is a potential need.

Abstract OT3-02-08: Open label, phase 2 safety, efficacy, and pharmacokinetic study of pre-surgical intramuscular and intraductal fulvestrant in women with invasive breast cancer or DCIS undergoing mastectomy or lumpectomy

BACKGROUND: Breast cancer (BC) is the leading cause of cancer in women in the United States and the second leading cause of cancer-related death. Currently available options for prevention are oophorectomy, bilateral mastectomy, or medical therapy, such as tamoxifen, raloxifene or aromatase inhibitors. None of these options for prevention are without significant side effects with low patient uptake. This study proposes fulvestrant instilled directly into the breast via the nipple orifices as intraductal therapy. Providing a local therapy into the ducts could reduce the morbidity associated with prevention while potentially better targeting the carcinoma cell. Building on prior studies with cytotoxic agents, this study utilizes the pure anti-estrogen fulvestrant to be injected in up to 5 ducts to determine its effect on BC as well as the safety of this method of administration.

TRIAL DESIGN: An open-label, non-randomized PK study of pre-surgical fulvestrant in women scheduled for mastectomy or lumpectomy. Eligible subjects will be undergoing mastectomy or lumpectomy. The first 6 subjects will be treated with the standard dose of 500 mg intramuscular fulvestrant to establish the reference PK curve. The subsequent 24 subjects will receive fulvestrant by intraductal instillation. Subjects where at least 1 suitable duct is identified will undergo nipple aspiration in order to facilitate duct identification and intraductal infusion of a fulvestrant. A maximum of 5 ducts will receive intraductal infusion of fulvestrant. Across all ducts, the total dose will not exceed 500 mg (10 mL). Subsequent to mastectomy or lumpectomy subjects will undergo serial blood draws to determine fulvestrant blood concentration levels and tissue drug levels.

ELIGIBILITY: Female, age &gt; 18, mastectomy/lumpectomy scheduled within 30 days, Stage 1/2, ER+ low grade invasive BC or DCIS, ECOG scale 0-1.

Primary Objective: The safety and tolerability of intraductal administration of fulvestrant in women with Stage 1 or 2 invasive ductal carcinoma or DCIS, prior to mastectomy or lumpectomy.

Secondary Objectives: The pathological effects, specifically changes in Ki67, ER/PgR expression between pre-fulvestrant biopsy and post-fulvestrant surgical specimen.

STATISTICAL METHODS: Aim of this study is to assess safety and tolerability in subjects receiving intraductal fulvestrant. In addition this trial aims to characterize the PK of this alternative route of administration, and compare the intraductal PK profile to that of standard intramuscular administration. Finally, the 6 study subjects who receive intramuscular fulvestrant will be qualitatively compared with the main study cohort of 24 subjects who receive intraductal fulvestrant. Change in Ki67 labeling index will be compared between the two time points (baseline or time of diagnostic biopsy v. time of the surgically excised specimen collection).

CONTACT INFO: Sheldon Marc Feldman MD Columbia University Medical Center sf2388@cumc.columbia.edu 212-305-9676.

Citation Format: Feldman S, Gomberawalla A, Alonso A, Rea J, Quay S, Lawrence R. Open label, phase 2 safety, efficacy, and pharmacokinetic study of pre-surgical intramuscular and intraductal fulvestrant in women with invasive breast cancer or DCIS undergoing mastectomy or lumpectomy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr OT3-02-08.

Analgesic drugs and the gut - a reciprocal relationship

Analgesic drugs, as well as providing pain relief, can cause a range of other symptoms and side effects, most notably on the gastrointestinal system. Conversely, gastrointestinal disease will often require analgesia, and this can be complicated by the fact that the gut is the site of absorption of oral drugs. This paper discusses some of the effects of common oral analgesic drugs on the gastrointestinal tract and their role in managing some of the most common, nonmalignant, chronic gastrointestinal disorders in adults.

Persistent Mycobacterium bovis-BCG is resistant to glutathione induced reductive stress killing

This study focuses on the redox stress response in mycobacteria elicited by a host-derived, thiol-based detoxification molecule, glutathione (GSH). Although the growth and viability of Mycobacterium bovis-BCG (BCG) was hampered by exposure to 8 mM GSH, oxygen depleted, persistent BCG (NRP BCG) resisted GSH-mediated killing. Fast growing mycobacteria also resisted GSH-mediated killing. To determine the mechanisms behind these observations, we evaluated the levels of intracellular ATP in both BCG and NRP BCG exposed to 8 mM GSH. Intracellular ATP levels increased from 0.13 to 2.3 μM in BCG upon exposure to GSH. The levels of ATP remained low and unchanged when NRP BCG was exposed to GSH. Using both HPLC and a cell-based thiol detection assay, it was determined that GSH stimulates the production of mycothiol (MSH) by BCG approximately 5.7 fold. The levels of MSH did not change upon exposure of NRP BCG to GSH. MSH is an alternative, thiol-based detoxification molecule employed by mycobacteria. Changes in the cytoplasmic concentrations of this molecule are suggestive of redox imbalances. Together, GSH and MSH may introduce excess reducing equivalents into the mycobacterial cytoplasm; leading to reductive stress. The modulation of NAD(+) levels through alterations in ATP metabolism can enhance the cells ability to bind excess reducing equivalents and serve as a mechanism to restore the cellular redox balance when cells experience reductive stress. These data suggest that killing of BCG by GSH may result from reductive stress that cannot be controlled. NRP BCG appears to be resistant to GSH-induced reductive stress.

Controversies in the management of sudden sensorineural hearing loss: an evidence-based review

BACKGROUND

Sudden sensorineural hearing loss (SSNHL) is considered an otological emergency. It may present as an isolated condition or be the presenting feature of a systemic disease process. Idiopathic sudden sensorineural hearing loss (ISSNHL) is diagnosed when an underlying cause or condition cannot be identified.

OBJECTIVE OF REVIEW

To review the current literature on SSNHL and propose a treatment algorithm based on the highest quality evidence.

SEARCH STRATEGY AND TYPE OF REVIEW

An evidence-based literature review using medline (search terms 'sudden sensorineural hearing loss' and 'acute sensorineural hearing loss').

RESULTS

(i) Baseline Investigations: All patients should be assessed with a thorough history and examination. This should include a pure tone audiogram (PTA) where possible. Baseline and targeted laboratory tests should be carried out to diagnose specific conditions. (ii) Imaging: MRI should be carried out in all cases of ISSNHL. If MRI imaging is contraindicated either CT or auditory brainstem response (ABR) testing should be performed. (iii) Medical Management: If a specific cause for a SSNHL is found, the patient should be managed accordingly. If idiopathic in nature, patients may be offered a course of oral steroid. If systemic steroids are contraindicated and/or there is no improvement with initial oral therapy, intratympanic steroids (IT) as either primary or salvage therapy may be considered. (iv) Further Management: There is no evidence to support the routine use of antiviral therapy. The cost, limited availability and lack of strong evidence for hyperbaric oxygen therapy (HBOT) make it impractical at present. Due to the variability in the vasodilator and vasoactive agents used, there is insufficient evidence to support the routine use of these agents. Consideration should be given to both temporary and permanent hearing amplification when required.

CONCLUSIONS

SSNHL is an important condition that can have a significant impact on quality of life. Some patients respond spontaneously without intervention; however, evidence tells us that certain interventions such as corticosteroid treatment may improve outcomes. Further high-quality research is required. Meanwhile, an interim indicative treatment algorithm for SSNHL based on the current best evidence available is outlined.

Leiomyosarcoma of the inguinal canal

We describe a rare case of a leiomyosarcoma in the inguinal canal in a patient presenting clinically with an inguinal hernia. The clinical details, histological findings and surgical management are reviewed.

Examining the overlap between genome-wide rare variant association signals and linkage peaks in rheumatoid arthritis

OBJECTIVE

With the exception of the major histocompatibility complex (MHC) and STAT4, no other rheumatoid arthritis (RA) linkage peak has been successfully fine-mapped to date. This apparent failure to identify association under peaks of linkage could be ascribed to the examination of common variation, when linkage is likely to be driven by rare variants. The purpose of this study was to investigate the overlap between genome-wide rare variant RA association signals observed in the Wellcome Trust Case Control Consortium (WTCCC) study and 11 replicating RA linkage peaks, defined as regions with evidence for linkage in >1 study.

METHODS

The WTCCC data set contained 40,482 variants with minor allele frequency of ≤0.05 in 1,860 RA patients and 2,938 controls. Genotypes of all rare variants within a given gene region were collapsed into a single locus and a global P value was calculated per gene.

RESULTS

The distribution of rare variant signals (association P≤10(-5)) was found to differ significantly between regions with and without linkage evidence (P=2×10(-17) by Fisher's exact test). No significant difference was observed after data from the MHC region were removed or when the effect of the HLA-DRB1 locus was accounted for.

CONCLUSION

The results suggest that rare variant association signals are significantly overrepresented under linkage peaks in RA, but the effect is driven by the MHC. This is the first study to examine the overlap between linkage peaks and rare variant association signals genome-wide in a complex disease.

Case-Based Subgoaling in Real-Time Heuristic Search for Video Game Pathfinding

Real-time heuristic search algorithms satisfy a constant bound on the amount of planning per action, independent of problem size. As a result, they scale up well as problems become larger. This property would make them well suited for video games where Artificial Intelligence controlled agents must react quickly to user commands and to other agents' actions. On the downside, real-time search algorithms employ learning methods that frequently lead to poor solution quality and cause the agent to appear irrational by re-visiting the same problem states repeatedly. The situation changed recently with a new algorithm, D LRTA*, which attempted to eliminate learning by automatically selecting subgoals. D LRTA* is well poised for video games, except it has a complex and memory-demanding pre-computation phase during which it builds a database of subgoals. In this paper, we propose a simpler and more memory-efficient way of pre-computing subgoals thereby eliminating the main obstacle to applying state-of-the-art real-time search methods in video games. The new algorithm solves a number of randomly chosen problems off-line, compresses the solutions into a series of subgoals and stores them in a database. When presented with a novel problem on-line, it queries the database for the most similar previously solved case and uses its subgoals to solve the problem. In the domain of pathfinding on four large video game maps, the new algorithm delivers solutions eight times better while using 57 times less memory and requiring 14% less pre-computation time.

Effect of shade on body temperature and performance of feedlot steers

A 120-d feedlot study using 164 Angus steers (BW = 396.7 ± 7.0 kg) was undertaken in Queensland Australia (24°84' S, 149°78' N) to determine the effect of shade on body temperature (T(B)) and performance. Cattle were allocated to 20 pens: 16 with an area of 144 m(2) (8 steers/pen) and 4 with an area of 168 m(2) (9 steers/pen). Treatments (10 pens/treatment) were unshaded (NS) vs. shaded (SH). Shade (3.3 m(2)/steer) was provided by 80% solar block shade cloth. Before the study (d -31), 63 steers were implanted (between the internal abdominal muscle and the peritoneum at the right side flank) with a T(B) transmitter. Within each pen, 3 steers had a T(B) transmitter. Individual T(B) was obtained every 30 min. The cattle were fed a feedlot diet and had ad libitum access to water. Water usage and DMI were recorded daily on a pen basis. Average daily gain and G:F were calculated on a pen basis. Climatic variables were obtained from an on-site weather station every 30 min. Individual panting scores (PS) were obtained daily at 0600, 1200, and 1600 h. From these, mean PS (MPS) were calculated for each pen. At slaughter (d 121), individual HCW, loin muscle area (LMA), rump fat depth (P8), 12th-rib fat depth, and marbling score were obtained. Mean T(B) was not affected (P > 0.05) by treatment (SH = 39.58°C; NS = 39.60°C). However, during a 21-d heat wave when cattle were exposed to a mean ambient temperature (T(AM)) > 30°C for 8 h each d (T(AM) between 0800 and 1800 h = 29.7°C, and 23.4°C between 1830 and 0730 h), the T(B) of SH steers (40.41 ± 0.10°C) was less (P < 0.01) than the T(B) of NS steers (41.14 ± 0.10°C). During this period, pen-MPS were greater (P < 0.05) for the NS cattle at all observation times. Over the first 6 d of the heat wave, MPS of NS steers at 1200 h was 2.47 (P < 0.01) vs. 1.39 for SH steers. Hip height, DMI, ADG, and G:F were greater (P < 0.05) for SH cattle. Exit BW (final BW) of SH steers (596.1 kg) was greater (P < 0.05) when compared with NS steers (578.6 kg). During the heat wave, DMI was 51% less for NS steers and 39% less for SH steers when compared with the pre-heat wave period (P < 0.01). The HCW of SH steers (315.4 ± 0.8 kg) was greater (P < 0.05) than for NS steers (321.4 ± 0.8 kg). No treatment differences (P > 0.05) were found for LMA, P8, or marbling score. Access to shade improved (P < 0.05) ADG and G:F, increased HCW, and decreased MPS; however, shade did not completely eliminate the impact of high heat load.

Group cognitive behavioural therapy for schizophrenia: a systematic review of the literature

There are a growing number of studies which have evaluated group-based cognitive behavioural therapy (CBGT) for individuals with psychosis. This is at least partly driven by the need to maximize access to this evidence-based treatment which has still to be widely disseminated. In this paper we present a systematic review of trials which have evaluated the efficacy CBGT. Five controlled trials were identified, the results showed some improvements in specific areas of symptomatology such as social phobia and depression. However, methodological weaknesses of the studies compromised the confidence with which a cause and effect relationship can be established. CBGT may enable a greater number of individuals to be seen by a small group of trained therapists but whether this is an effective treatment remains to be established. In addition, whether therapists delivering cognitive behavioural therapy in a group format require a higher level of skill than those facilitating the intervention on an individual basis remains an empirical question. The finding that a short psycho-education group treatment reduced positive and negative symptoms is also worthy of further investigation given the difficulties reported in disseminating evidence-based psychosocial interventions for this client group.

Limits on gravitational-wave emission from selected pulsars using LIGO data

We place direct upper limits on the amplitude of gravitational waves from 28 isolated radio pulsars by a coherent multidetector analysis of the data collected during the second science run of the LIGO interferometric detectors. These are the first direct upper limits for 26 of the 28 pulsars. We use coordinated radio observations for the first time to build radio-guided phase templates for the expected gravitational-wave signals. The unprecedented sensitivity of the detectors allows us to set strain upper limits as low as a few times 10(-24). These strain limits translate into limits on the equatorial ellipticities of the pulsars, which are smaller than 10(-5) for the four closest pulsars.

Submucous lipoma of the ileocaecal valve presenting as caecal volvulus

Caecal volvulus is a well described but unusual condition. We report here, a case of caecal volvulus in a 53-year-old Caucasian woman associated with intussuscepted submucous lipoma of the ileocaecal region. The imaging and pathology are presented. Submucous lipoma of the ileocaecal region is uncommon but well described. It can be mistaken as carcinoma of the ascending colon on barium enema and on computed tomography scan. The combination with caecal volvulus is a rare occurrence.

Chromosome-wide distribution of haplotype blocks and the role of recombination hot spots

Recent studies of human populations suggest that the genome consists of chromosome segments that are ancestrally conserved ('haplotype blocks'; refs. 1-3) and have discrete boundaries defined by recombination hot spots. Using publicly available genetic markers, we have constructed a first-generation haplotype map of chromosome 19. As expected for this marker density, approximately one-third of the chromosome is encompassed within haplotype blocks. Evolutionary modeling of the data indicates that recombination hot spots are not required to explain most of the observed blocks, providing that marker ascertainment and the observed marker spacing are considered. In contrast, several long blocks are inconsistent with our evolutionary models, and different mechanisms could explain their origins.

A case of neurosyphilis with a florid Jarisch-Herxheimer reaction

A 37 year old man with a 2 year history of progressive cognitive decline, unilateral tinnitus and deafness presented with complex partial seizures and a fever. On examination there was a sluggish right pupillary response but no other abnormal findings. Serum and CSF syphilis serology were both strongly positive. High dose intravenous penicillin therapy was complicated by a severe Jarisch-Herxheimer reaction (JHR) characterised by fever, obtundation, fluctuating upper motor neuron signs and complex visual and auditory hallucinations. These symptoms resolved over three days and the course of penicillin was completed. At discharge the patient's cognitive functioning was unchanged from the pretreatment state. He made gradual improvement over the following months but remains unable to live alone or work. Clinical, pathologic and radiologic findings of neurosyphilis are reviewed, as is the JHR, a self-limiting, systemic febrile response related to massive cytokine release that can occur in response to treatment of a number of bacterial infections. The similarities in pathophysiology of the JHR and the Septic Shock Syndrome are discussed, with particular reference to use of the JHR as a potential model for therapeutic agents in the treatment of septic shock.

6-O-sulfotransferase-1 represents a critical enzyme in the anticoagulant heparan sulfate biosynthetic pathway

Using recombinant retroviral transduction, we have introduced the heparin/heparan sulfate (HS) 3-O-sulfotransferase 1 (3-OST-1) gene into Chinese hamster ovary (CHO) cells. Expression of 3-OST-1 confers upon CHO cells the ability to produce anticoagulantly active HS (HS(act)). To understand how 6-OST and other proteins regulate HS(act) biosynthesis, a CHO cell clone with three copies of 3-OST-1 was chemically mutagenized. Resulting mutants that make HS but are defective in generating HS(act) were single-cell-cloned. One cell mutant makes fewer 6-O-sulfated residues. Modification of HS chains from the mutant with pure 6-OST-1 and 3'-phosphoadenosine 5'-phosphosulfate increased HS(act) from 7% to 51%. Transfection of this mutant with 6-OST-1 created a CHO cell line that makes HS, 50% of which is HS(act). We discovered in this study that (i) 6-OST-1 is a limiting enzyme in the HS(act) biosynthetic pathway in vivo when the limiting nature of 3-OST-1 is removed; (ii) HS chains from the mutant cells serve as an excellent substrate for demonstrating that 6-OST-1 is the limiting factor for HS(act) generation in vitro; (iii) in contradiction to the literature, 6-OST-1 can add 6-O-sulfate to GlcNAc residues, especially the critical 6-O-sulfate in the antithrombin binding motif; (iv) both 3-O- and 6-O-sulfation can be the final step in HS(act) biosynthesis in contrast to prior publications that concluded 3-O-sulfation is the final step in HS(act) biosynthesis; (v), in the presence of HS interacting protein peptide, 3-O-sulfate-containing sugars can be degraded into disaccharides by heparitinase digestion as demonstrated by capillary high performance liquid chromatography coupled with mass spectrometry.

Gene polymorphism in Netherton and common atopic disease

Atopic dermatitis (AD) and asthma are characterized by IgE-mediated atopic (allergic) responses to common proteins (allergens), many of which are proteinases. Loci influencing atopy have been localized to a number of chromosomal regions, including the chromosome 5q31 cytokine cluster. Netherton disease is a rare recessive skin disorder in which atopy is a universal accompaniment. The gene underlying Netherton disease (SPINK5) encodes a 15-domain serine proteinase inhibitor (LEKTI) which is expressed in epithelial and mucosal surfaces and in the thymus. We have identified six coding polymorphisms in SPINK5 (Table 1) and found that a Glu420-->Lys variant shows significant association with atopy and AD in two independent panels of families. Our results implicate a previously unrecognized pathway for the development of common allergic illnesses.

The effect of precursor structures on the action of glucosaminyl 3-O-sulfotransferase-1 and the biosynthesis of anticoagulant heparan sulfate

To understand how 2-O-sulfation of uronic acid residues influences the biosynthesis of anticoagulant heparan sulfate, the cDNA encoding glucosaminyl 3-O-sulfotransferase-1 (3-OST-1) was introduced into wild-type Chinese hamster ovary cells and mutant pgsF-17 cells, which are defective in 2-O-sulfation. 3-OST-1-transduced cells gained the ability to bind to antithrombin. Structural analysis of the heparan sulfate chains showed that 3-OST-1 generates sequences containing GlcUA-GlcN(SO(3))3(SO(3)) and GlcUA-GlcN(SO(3))3(SO(3))6(SO(3)) in both wild-type and mutant cells. In addition, IdoUA-GlcN(SO(3))3(SO(3)) and IdoUA-GlcN(SO(3))3(SO(3))6(SO(3)) accumulate in the mutant chain. These disaccharides were also observed by tagging [6-(3)H]GlcN-labeled pgsF-17 heparan sulfate in vitro with [(35)S]PAPs and purified 3-OST-1. Heparan sulfate derived from the transduced mutant also had approximately 2-fold higher affinity for antithrombin than heparan sulfate derived from the transduced wild-type cells, and it inactivated factor Xa more efficiently. This study demonstrates for the first time that (i) 3-O-sulfation by 3-OST-1 can occur independently of the 2-O-sulfation of uronic acids, (ii) 2-O-sulfation usually occurs before 3-O-sulfation, (iii) 2-O-sulfation blocks the action of 3-OST-1 at glucosamine residues located to the reducing side of IdoUA units, and (iv) that alternative antithrombin-binding structures can be made in the absence of 2-O-sulfation.

Exploring the mechanisms of action of FB642 at the cellular level

FB642(methyl-2-benzimidazolecarbamate, carbendazim) is a systemic fungicide belonging to the benzimidazole family with antitumor activity against a broad spectrum of tumors both in vitro and in vivo such as pancreas, prostate, colon, and breast. Although the preclinical antitumor activity of FB642 has been well explored, its mechanism of action has not been as well delineated. Previous studies indicate that FB642 may interfere with mitosis and thus may disrupt or inhibit microtubule function resulting in apoptosis. This study seeks to determine if FB642 is a sufficiently novel agent worthy of further development by examining the effect of FB642 on apoptosis, the cell cycle, p53-positive and -negative tumors, and drug-resistant and MDR cell lines. The results of this present study indicate that FB642 increases the degree of apoptosis in all examined tumor cell lines, may induce G2/M uncoupling, may selectively kill p53 abnormal cells, and exhibits antitumor activity in drug- and multidrug-resistant cell lines. The induction of apoptosis by FB642, particularly in p53-deficient cells, its impressive in vivo activity against a broad spectrum of murine and human tumors, as well as an acceptable toxicity profile in animals, make FB642 an excellent candidate for further evaluation in clinical trials in cancer patients.

Genetic linkage of childhood atopic dermatitis to psoriasis susceptibility loci

We have carried out a genome screen for atopic dermatitis (AD) and have identified linkage to AD on chromosomes 1q21, 17q25 and 20p. These regions correspond closely with known psoriasis loci, as does a previously identified AD locus on chromosome 3q21. The results indicate that AD is influenced by genes with general effects on dermal inflammation and immunity.