Börjeson-Forssman-Lehmann syndrome: delineating the clinical and allelic spectrum in 14 new families

Börjeson-Forssman-Lehmann syndrome (BFLS) is an X-linked intellectual disability syndrome caused by variants in the PHF6 gene. We ascertained 19 individuals from 15 families with likely pathogenic or pathogenic PHF6 variants (11 males and 8 females). One family had previously been reported. Six variants were novel. We analysed the clinical and genetic findings in our series and compared them with reported BFLS patients. Affected males had classic features of BFLS including intellectual disability, distinctive facies, large ears, gynaecomastia, hypogonadism and truncal obesity. Carrier female relatives of affected males were unaffected or had only mild symptoms. The phenotype of affected females with de novo variants overlapped with the males but included linear skin hyperpigmentation and a higher frequency of dental, retinal and cortical brain anomalies. Complications observed in our series included keloid scarring, digital fibromas, absent vaginal orifice, neuropathy, umbilical hernias, and talipes. Our analysis highlighted sex-specific differences in PHF6 variant types and locations. Affected males often have missense variants or small in-frame deletions while affected females tend to have truncating variants or large deletions/duplications. Missense variants were found in a minority of affected females and clustered in the highly constrained PHD2 domain of PHF6. We propose recommendations for the evaluation and management of BFLS patients. These results further delineate and extend the genetic and phenotypic spectrum of BFLS.

Genetic Differentiation of Five Sea Cucumber Species from the Red Sea, Hurghada, Egypt

This study aimed to assess the genetic differentiation and relationship among five sea cucumber species from the Red Sea in Egypt, namely Holothuria atra, H. impatiens, H. leucospilota, Actinopyga crassa and A. mauritiana, using Inter Simple Sequence Repeated (ISSR) and Start Codon Targeted (SCoT) markers. A collection of 100 specimens, with 20 individuals per species, was gathered for the analysis. With ten ISSR primers, 135 amplified bands were detected, including 11 distinct species-specific bands, indicating high-level polymorphism among species. Using ten SCoT primers, 151 amplicons were generated, including 30 species-specific bands, with 52% polymorphic bands indicating high-level polymorphism among species. The degree of genetic similarity (GS) among the different genotypes of species was calculated based on ISSR bands analysis, which ranged from 93% between H. atra and H. impatiens to 86% between H. atra and A. crassa. The highest genetic similarity was observed between H. atra and H. impatiens (90%), while the lowest was identified between A. crassa and A. mauritiana (75%) using SCoT bands. Notably, the ISSR and SCoT-based DNA analysis revealed similar genetic relationships between H. atra and H. impatiens compared to other sea cucumber species studied. This study provides new insights into the genetic diversity and relationship among sea cucumber species in the Red Sea, which could have implications for their conservation and management.

Effect of amla and ginger powders on quality criteria of African catfish (Clarias gariepinus) fingers

Catfish (Clarias gariepinus) meat isn't preferred by consumers in compared to other fish species meat, thus to enhance the use of catfish meat, ready to eat catfish fingers were prepared with some plants additives (amla and ginger powder). The mean objective of this study was to assess the impact of amla and ginger powder on catfish finger qualities in terms of physical, chemical, microbiological, and sensorial parameters under stored at a low temperature (5 ± 1 °C). The obtained results were compared with those of a control sample (basic formula) and a sample containing the synthetic antioxidant. During the storage period, the levels of pH, thiobarbituric acid, total volatile basic nitrogen, trimethylamine, total bacteria count, psychrophilic bacteria, molds and yeasts counts increased dramatically, although the values remained within acceptable ranges. The findings also revealed, that amla and ginger powder considerably (p < 0.05) reduced the changes in quality parameters, as well as there was a considerable increase in the quality parameter in all treated samples than in the control. Finally, amla and ginger powder can be a substitute for synthetic antioxidants and antimicrobials. These findings suggest that the powder of amla and ginger are suitable for use as a natural antioxidants and antimicrobials to extend the shelf-life of animal products.

Screening, assessment and management of perioperative malnutrition: a survey of UK practice

Background

Perioperative malnutrition is common and is associated with increased mortality, complications and healthcare costs. Patients having surgery for cancer and gastro-intestinal disease are at particular risk. It is a modifiable pre-operative risk factor and perioperative clinicians are well placed to identify those at risk and instigate interventions shown to improve outcome. Thus, we conducted a survey of Perioperative Medicine Leads with the aim of assessing the current provision of nutritional screening and intervention pathways in the UK.

Methods

Perioperative Medicine Leads registered with the Royal College of Anaesthetists were asked to complete an online survey exploring current practice in screening, assessment and management of malnutrition in the perioperative period. The survey included a mixture of open and closed questions, graded response questions and options for free text. Where a response was not received, departments were phoned directly and e-mails sent to non-responders.

Results

We received 121 completed questionnaires from 167 Perioperative Medicine Leads (response rate of 72.5%). Seventy respondents (57.9%) reported using the Malnutrition Universal Screening Tool to screen patients; however, only 61 (50.4%) referred patients at nutritional risk onto a dietitian. Sixty (49.6%) lacked confidence in local ability to identify and manage malnutrition perioperatively, with 28 (23.1%) reporting having a structured pathway for managing malnourished patients. One hundred eleven respondents (91.7%) agreed that malnutrition impacts on quality of life after surgery and 105 (86.8%) felt adopting a standard protocol would improve outcomes for patients. Those reporting a lack of confidence in dealing with malnutrition perioperatively cited a lack of organisational support, patients being seen too close to surgery and lack of clarity around responsibility as key reasons for difficulties in managing this group of patients.

Conclusions

Malnutrition in the perioperative period is a modifiable risk factor which is common and results in increased morbidity for patients and increased cost to healthcare systems. This survey highlights areas of practice where perioperative clinicians can improve the assessment and management of patients at nutritional risk prior to elective surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-021-00196-2.

Referral rates of patients with diabetes to secondary care are inversely related to the prevalence of diabetes in each primary care practice and confidence in treatment, not to HbA1c level

AIMS

To determine the factors affecting the referral rates of patients with diabetes from primary care to secondary care.

METHODS

A study based on 66 GP surgeries in the Cardiff and Vale University Health Board (population: 515,581) was conducted. We included patients who had an established clinical diagnosis of diabetes (type 1 and type 2) from September 2017 to September 2018. HbA1c outcome data of GP surgeries were obtained from the Quality and Outcomes Framework (QOF) database published for 2018. Referral rates were obtained from the electronic referral database of Cardiff and Vale University Health Board over the same period, and this was adjusted according to the number of patients with diabetes in each GP surgery. Confidence level on the treatment of diabetes among GPs was assessed as a sub-study conducted in nine GP surgeries in the same area, using a self-administered questionnaire. Linear regression was undertaken to assess the relationship between adjusted referral rate and key factors which might influence prescribing rate.

RESULTS

The average adjusted referral rate to secondary care in one year was 4.23% of patients with diabetes in each GP surgery, with a wide variation of 1.24% to 16.28%. The average percentage of patients with diabetes with HbA1c<59mmol/mol was 63.17% (range: 43.19-76.23%). The average confidence score of GPs in treating diabetes was 67% and ranged from 50-85% in the sub-study. Referral rates correlated inversely with the numbers of patients with diabetes in each practice β=-0.32; (95% CI -0.57, -0.08) p=0.01, but there was no significant correlation with the HbA1c outcome β=-0.13; (95% CI -0.39, 0.12); p=0.30. Borderline significant negative correlation was observed between referral rates and overall practice size β=-0.23; (95% CI -0.48, 0.02) p=0.07.

CONCLUSIONS

Referral rates of patients with diabetes to secondary care are determined by the number of patients with diabetes in each practice and confidence level in treatment, not by the overall practice size or HbA1c level. Ensuring quality training in diabetes care for primary care teams as well as the development of integrated diabetes care may be the best way to optimise the volume and appropriateness of referrals to secondary care.

Oesophageal cancer: The effect of early nutrition support on clinical outcomes

BACKGROUND AND AIMS

Malnutrition is prevalent in oesophageal cancer. Evidence for the use of nutrition support and prehabilitation in this cohort is variable. The aim of this study was to examine the effect of early nutrition support and functional measures of nutritional status on post-operative outcomes in adult patients with oesophageal cancer.

METHODS

Retrospective review of adults with oesophageal cancer undergoing oesophagectomy (n = 151). Early nutrition support was defined as: oral or enteral nutrition supplementation during neoadjuvant treatment. Late nutrition support defined as: oral or enteral nutrition supplementation prescribed post-operatively. Nutrition outcome measures were; percentage weight loss from 3 to 6 months prior to diagnosis, peri- and post-operatively, and pre-operative assessment of handgrip-strength (HGS).

RESULTS

Pre-operative weight loss ≥10% was a significant predictor of mortality at 1 year (OR 2.84, 95%CI 1.03-7.83, p = 0.04) independent of tumour stage, adjuvant treatment, age and gender. Adults prescribed early nutrition support during neoadjuvant treatment experienced less weight loss at 12-months post-oesophagectomy compared to adults prescribed late oral nutrition support (p=<0.05). Pre-operative HGS measurements were not a useful predictor of postoperative complications (p = 0.2), length of stay (p = 0.9) or 90-day mortality (p = 0.6).

CONCLUSIONS

Pre-operative weight loss ≥10% was associated with mortality. Early nutrition support was associated with less weight loss at 12-months post-operatively. Pre-operative HGS measures did not have prognostic value as a stand-alone measure. Future work should investigate the efficacy of early nutrition support in reducing both pre- and post-operative weight loss to improve nutritional status and surgical outcomes as part of a multimodal prehabilitation programme in adults with oesophageal cancer.

A comparison of different standard-setting methods for professional qualifying dental examination

BACKGROUND

The outcome of assessments is determined by the standard-setting method used. Standard setting is the process of deciding what is good enough. A cutoff score of 50% was commonly used in dental schools in Malaysia. This study aims to compare the conventional, norm-referenced, and modified-Angoff standard-setting methods.

METHODS

The norm-referenced method of standard setting was applied to the real scores of 40 final-year dental students on a multiple-choice question (MCQ), a short answer question (SAQ), and an objective structured clinical examination (OSCE). A panel of 10 judges set the standard using the modified-Angoff method for the same paper in one sitting. One judge set the passing score of 10 OSCE questions after 2 weeks. A comparison of the grades and pass/fail rates derived from the absolute standard, norm-referenced, and modified-Angoff methods was made. The intra-rater and inter-rater reliabilities of the modified-Angoff method were assessed.

RESULTS

The passing rate for the absolute standard was 100% (40/40), for the norm-referenced method it was 62.5% (25/40), and for the modified-Angoff method it was 80% (32/40). The modified-Angoff method had good inter-rater reliability of 0.876 and excellent test-retest reliability of 0.941.

CONCLUSION

There were significant differences in the outcomes of these three standard-setting methods, as shown by the difference in the proportion of candidates who passed and failed the assessment. The modified-Angoff method was found to have good reliability for use with a professional qualifying dental examination.

Impaired eIF5A function causes a Mendelian disorder that is partially rescued in model systems by spermidine

The structure of proline prevents it from adopting an optimal position for rapid protein synthesis. Poly-proline-tract (PPT) associated ribosomal stalling is resolved by highly conserved eIF5A, the only protein to contain the amino acid hypusine. We show that de novo heterozygous EIF5A variants cause a disorder characterized by variable combinations of developmental delay, microcephaly, micrognathia and dysmorphism. Yeast growth assays, polysome profiling, total/hypusinated eIF5A levels and PPT-reporters studies reveal that the variants impair eIF5A function, reduce eIF5A-ribosome interactions and impair the synthesis of PPT-containing proteins. Supplementation with 1 mM spermidine partially corrects the yeast growth defects, improves the polysome profiles and restores expression of PPT reporters. In zebrafish, knockdown eif5a partly recapitulates the human phenotype that can be rescued with 1 µM spermidine supplementation. In summary, we uncover the role of eIF5A in human development and disease, demonstrate the mechanistic complexity of EIF5A-related disorder and raise possibilities for its treatment.

Temporal changes in the gut microbiota in farmed Atlantic cod (Gadus morhua) outweigh the response to diet supplementation with macroalgae

BACKGROUND

Aquaculture successfully meets global food demands for many fish species. However, aquaculture production of Atlantic cod (Gadus morhua) is just 2.5% of total market production. For cod farming to be a viable economic venture specific challenges on how to increase growth, health and farming productivity need to be addressed. Feed ingredients play a key role here. Macroalgae (seaweeds) have been suggested as a functional feed supplement with both health and economic benefits for terrestrial farmed animals and fish. The impact of such dietary supplements to cod gut integrity and microbiota, which contribute to overall fish robustness is unknown. The objective of this study was to supplement the diet of juvenile Atlantic cod with macroalgae and determine the impacts on fish condition and growth, gut morphology and hindgut microbiota composition (16S rRNA amplicon sequencing). Fish were fed one of three diets: control (no macroalgal inclusion), 10% inclusion of either egg wrack (Ascophyllum nodosum) or sea lettuce (Ulva rigida) macroalgae in a 12-week trial.

RESULTS

The results demonstrated there was no significant difference in fish condition, gut morphology or hindgut microbiota between the U. rigida supplemented fish group and the control group at any time-point. This trend was not observed with the A. nodosum treatment. Fish within this group were further categorised as either 'Normal' or 'Lower Growth'. 'Lower Growth' individuals found the diet unpalatable resulting in reduced weight and condition factor combined with an altered gut morphology and microbiome relative to the other treatments. Excluding this group, our results show that the hindgut microbiota was largely driven by temporal pressures with the microbial communities becoming more similar over time irrespective of dietary treatment. The core microbiome at the final time-point consisted of the orders Vibrionales (Vibrio and Photobacterium), Bacteroidales (Bacteroidetes and Macellibacteroides) and Clostridiales (Lachnoclostridium).

CONCLUSIONS

Our study indicates that U. rigida macroalgae can be supplemented at 10% inclusion levels in the diet of juvenile farmed Atlantic cod without any impact on fish condition or hindgut microbial community structure. We also conclude that 10% dietary inclusion of A. nodosum is not a suitable feed supplement in a farmed cod diet.

Missense variants in the N-terminal domain of the A isoform of FHF2/FGF13 cause an X-linked developmental and epileptic encephalopathy

Fibroblast growth factor homologous factors (FHFs) are intracellular proteins which regulate voltage-gated sodium (Nav) channels in the brain and other tissues. FHF dysfunction has been linked to neurological disorders including epilepsy. Here, we describe two sibling pairs and three unrelated males who presented in infancy with intractable focal seizures and severe developmental delay. Whole-exome sequencing identified hemi- and heterozygous variants in the N-terminal domain of the A isoform of FHF2 (FHF2A). The X-linked FHF2 gene (also known as FGF13) has alternative first exons which produce multiple protein isoforms that differ in their N-terminal sequence. The variants were located at highly conserved residues in the FHF2A inactivation particle that competes with the intrinsic fast inactivation mechanism of Nav channels. Functional characterization of mutant FHF2A co-expressed with wild-type Nav1.6 (SCN8A) revealed that mutant FHF2A proteins lost the ability to induce rapid-onset, long-term blockade of the channel while retaining pro-excitatory properties. These gain-of-function effects are likely to increase neuronal excitability consistent with the epileptic potential of FHF2 variants. Our findings demonstrate that FHF2 variants are a cause of infantile-onset developmental and epileptic encephalopathy and underline the critical role of the FHF2A isoform in regulating Nav channel function.

A randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185)

Background

Hip fracture is a procedure with high mortality and complication rates, and there exists a group especially at risk of these outcomes identified by their Nottingham Hip Fracture Score (NHFS). Meta-analysis suggests a possible benefit to this patient group from intravascular volume optimisation. We investigated whether intraoperative fluid and blood pressure optimisation improved complications in this group.

Methods

Patients with a NHFS ≥ 5 were enrolled into this multicentre observer-blinded randomised control trial. Patients were allocated to either standard care or a combination of fluid optimisation and blood pressure control using a non-invasive system. The primary outcome was the number of patients with one or more complications in each group. Secondary outcomes included hospital length of stay (LOS), incidence of hypotension and fluid and vasopressor usage.

Results

Forty-six percent of patients in the intervention group suffered one or more complications compared to the 51% in the control group (OR 0.82 (95% CI 0.49–1.36)). Per-protocol analysis improved the OR to 0.73 (95% CI 0.43–1.24). Median LOS was the same between both groups; however, the mean LOS on a per-protocol analysis was longer in the control group compared to the intervention group (23.2 (18.0) days vs. 18.5 (16.5), p = 0.047).

Conclusions

Haemodynamic optimisation including blood pressure management in high-risk patients undergoing repair of a hip fracture did not result in a statistically significant reduction in complications; however, a potential reduction in length of stay was seen.

Trial registration

A randomised trial of non-invasive cardiac output monitoring to guide haemodynamic optimisation in high risk patients undergoing urgent surgical repair of proximal femoral fractures (ClearNOF trial NCT02382185).

Prognostic Markers of Outcome in Patients Undergoing Infra-inguinal Revascularisation: A Prospective Observational Pilot Study

OBJECTIVES

The aim was to investigate whether cardiopulmonary exercise testing (CPET) variables derived from cycle and arm ergonometry correlate, and whether CPET variables and pre-operative N-terminal pro-brain natriuretic peptide (NT-proBNP) have prognostic significance and if the combination of the two has incremental value.

METHODS

A prospective observational pilot study was conducted; 70 patients who underwent infra-inguinal bypass surgery were recruited. Pre-operatively subjects underwent CPET with both arm and leg ergonometry, to measure peak oxygen consumption, anaerobic threshold (AT), and ventilatory equivalents. In addition pre-operative serum samples of NT-proBNP were obtained. The primary endpoint was 1 year all-cause mortality; in addition, data were collected on complications, morbidity, length of stay, and major adverse cardiac events (MACE).

RESULTS

The 1 year mortality rate was 6%, the overall complications rate was 23%, and the combined incidence of MACE and 1 year mortality was 10%. Cycle ergonometry peak VO₂ 14 mL/kg/min (RR 5.5, 95% CI 1.4-22.4, p = .007) and AT < 10mL/kg/min (RR 3.0, 95% CI 1.1-7.0, p = .03) were predictors of post-operative complications. Pre-operative NT-proBNP > 320 ng/L (RR 18, 95% CI 2.5-140 p = .0003) was the sole predictor of 1 year mortality or MACE.

CONCLUSION

The measurement of pre-operative NT-proBNP in peripheral vascular disease patients undergoing infra-inguinal bypass can predict 1 year mortality and MACE. CPET variables from cycle ergonometry are predictors of post-operative complications in this patient group.

De Novo Truncating Mutations in the Kinetochore-Microtubules Attachment Gene CHAMP1 Cause Syndromic Intellectual Disability

A rare syndromic form of intellectual disability with impaired speech was recently found associated with mutations in CHAMP1 (chromosome alignment-maintaining phosphoprotein 1), the protein product of which is directly involved in microtubule-kinetochore attachment. Through whole-exome sequencing in six unrelated nonconsanguineous families having a sporadic case of intellectual disability, we identified six novel de novo truncating mutations in CHAMP1: c.1880C>G p.(Ser627*), c.1489C>T; p.(Arg497*), c.1876_1877delAG; p.(Ser626Leufs*4), c.1043G>A; p.(Trp348*), c.1002G>A; p.(Trp334*), and c.958_959delCC; p.(Pro320*). Our clinical observations confirm the phenotypic homogeneity of the syndrome, which represents therefore a distinct clinical entity. Besides, our functional studies show that CHAMP1 protein variants are delocalized from chromatin and are unable to bind to two of its direct partners, POGZ and HP1. These data suggest a pathogenic mechanism of the CHAMP1-associated intellectual disability syndrome mediated by direct interacting partners of CHAMP1, several of which are involved in chromo/kinetochore-related disorders.

Dietary administration of a commercial mixed-species probiotic improves growth performance and modulates the intestinal immunity of tilapia, Oreochromis niloticus

The growth performance, immunological status, intestinal morphology and microbiology of tilapia, Oreochromis niloticus, were investigated after dietary administration of the commercial probiotic AquaStar(®) Growout. Tilapia (29.02 ± 0.33 g) were split into five treatments; control (CON), 1.5 g kg(-1) probiotic (PRO-1.5), 3 g kg(-1) probiotic (PRO-3), pulsed probiotic feeding (PRO-PULSE) or an initial probiotic feed followed by control feeding (PRO-INI). After six weeks of experimental feeding, fish fed PRO-3 displayed significantly higher final weight, weight gain and SGR compared to the CON or PRO-INI treatments. Supplementation of the probiotic at this dose induced an up-regulation of intestinal caspase-3, PCNA and HSP70 mRNA levels compared to the CON fed fish. Immuno-modulatory pathways were also affected; significantly higher expression of TLR2, pro-inflammatory genes TNFα and IL-1β, and anti-inflammatory genes IL-10 and TGFβ suggest that the probiotic may potentiate a higher state of mucosal tolerance and immuno-readiness. Histological appraisal revealed significantly higher numbers of intraepithelial leucocytes in the intestine of PRO-3 fed fish compared with treatments CON, PRO-PULSE and PRO-INI but not PRO-1.5. Additionally, fish receiving PRO-3 had a significantly higher abundance of goblet cells in their mid-intestine when compared with fish from all other treatments. Together, these data suggest that continuous provision of AquaStar(®) Growout at 3 g kg(-1) can improve tilapia growth and elevate the intestinal immunological status of the host.

Heimler Syndrome Is Caused by Hypomorphic Mutations in the Peroxisome-Biogenesis Genes PEX1 and PEX6

Heimler syndrome (HS) is a rare recessive disorder characterized by sensorineural hearing loss (SNHL), amelogenesis imperfecta, nail abnormalities, and occasional or late-onset retinal pigmentation. We ascertained eight families affected by HS and, by using a whole-exome sequencing approach, identified biallelic mutations in PEX1 or PEX6 in six of them. Loss-of-function mutations in both genes are known causes of a spectrum of autosomal-recessive peroxisome-biogenesis disorders (PBDs), including Zellweger syndrome. PBDs are characterized by leukodystrophy, hypotonia, SNHL, retinopathy, and skeletal, craniofacial, and liver abnormalities. We demonstrate that each HS-affected family has at least one hypomorphic allele that results in extremely mild peroxisomal dysfunction. Although individuals with HS share some subtle clinical features found in PBDs, the diagnosis was not suggested by routine blood and skin fibroblast analyses used to detect PBDs. In conclusion, our findings define HS as a mild PBD, expanding the pleiotropy of mutations in PEX1 and PEX6.

Training for the future NHS: training junior doctors in the United Kingdom within the 48-hour European working time directive

Since August 2009, the National Health Service of the United Kingdom has faced the challenge of delivering training for junior doctors within a 48-hour working week, as stipulated by the European Working Time Directive and legislated in the UK by the Working Time Regulations 1998. Since that time, widespread concern has been expressed about the impact of restricted duty hours on the quality of postgraduate medical training in the UK, particularly in the "craft" specialties--that is, those disciplines in which trainees develop practical skills that are best learned through direct experience with patients. At the same time, specialist training in the UK has experienced considerable change since 2007 with the introduction of competency-based specialty curricula, workplace-based assessment, and the annual review of competency progression. The challenges presented by the reduction of duty hours include increased pressure on doctors-in-training to provide service during evening and overnight hours, reduced interaction with supervisors, and reduced opportunities for learning. This paper explores these challenges and proposes potential responses with respect to the reorganization of training and service provision.

Dietary synbiotic application modulates Atlantic salmon (Salmo salar) intestinal microbial communities and intestinal immunity

A feeding trial was conducted to determine the effect of dietary administration of Pediococcus acidilactici MA18/5M and short chain fructooligosaccharides (scFOS) on Atlantic salmon (Salmo salar L.) intestinal health. Salmon (initial average weight 250 g) were allocated into triplicate sea pens and were fed either a control diet (commercial diet: 45% protein, 20% lipid) or a synbiotic treatment diet (control diet + P. acidilactici at 3.5 g kg(-1) and 7 g kg(-1) scFOS) for 63 days. At the end of this period, fish were sampled for intestinal microbiology, intestinal histology and the expression of selected immune-related genes (IL1β, TNFα, IL8, TLR3 and MX-1) in the intestine. Compared to the control fish, the total bacterial levels were significantly lower in the anterior mucosa, posterior mucosa and posterior digesta of the synbiotic fed fish. qPCR revealed good recovery (log 6 bacteria g(-1)) of the probiotic in the intestinal digesta of the synbiotic fed fish and PCR-DGGE revealed that the number of OTUs, as well as the microbial community diversity and richness were significantly higher in the anterior digesta of the synbiotic fed fish than the control. Compared to the control fed fish, the mucosal fold (villi) length and the infiltration of epithelial leucocytes were significantly higher in the anterior and posterior intestine, respectively, in the synbiotic group. Real-time PCR demonstrated that all of the genes investigated were significantly up-regulated in the anterior and posterior intestine of the synbiotic fed salmon, compared to the control group. At the systemic level, serum lysozyme activity was significantly higher in the synbiotic fed fish and growth performance, feed utilisation and biometric measurements (condition factor, gutted weight and gut loss) were not affected. Together these results suggest that the synbiotic modulation of the gut microbiota has a protective action on the intestinal mucosal cells, improving morphology and stimulating the innate immune response without negatively affecting growth performance or feed utilization of farmed Atlantic salmon.

Probiotic Pediococcus acidilactici modulates both localised intestinal- and peripheral-immunity in tilapia (Oreochromis niloticus)

The application of probiotics in aquaculture has received concerted research efforts but the localised intestinal immunological response of fish to probiotic bacteria is poorly understood. Therefore, a study was conducted to evaluate the probiotic effect of Pediococcus acidilactici on Nile tilapia (Oreochromis niloticus) with specific emphasis on intestinal health and probiotic levels as well as system level responses such as growth performance, feed utilization and haemato-immunological parameters under non-challenged conditions. Fish (9.19 ± 0.04 g) were fed either a control diet or a P. acidilactici supplemented diet (at 2.81 × 10(6) CFU g(-)(1)) for six weeks. At the end of the study the probiotic was observed to populate the intestine, accounting for ca. 3% (1.59 × 10(5) CFU g(-)(1)) of the cultivable intestinal bacterial load. Real-time PCR indicated that the probiotic treatment may potentiate the immune-responsiveness of the intestine as up-regulation of the gene expression of the pro-inflammatory cytokine TNFα was observed in the probiotic fed fish (P < 0.05). Light microscopy observations revealed elevated intraepithelial leucocyte (IEL) levels in the intestine of P. acidilactici fed tilapia after six weeks (P < 0.05) of feeding and a trend towards elevated goblet cells was also observed after six weeks feeding (P = 0.08). Concomitantly at week six, along with elevated IELs and elevated TNFα mRNA levels in the intestine, an increased abundance of circulating neutrophils and monocytes were observed in fish fed the probiotic supplemented diet (P < 0.05). This haemopoietic expansion of innate immune cells could be reflective of an elevated state of immuno-readiness. Together these results suggest that the probiotic has a protective action on the intestinal mucosal cells, stimulating the innate immune response after feeding for a period of six weeks. These immunological modulations did not impair growth performance or the remaining haematological and zootechnical parameters compared to the control group (P > 0.05).

Crystalloid or colloid for goal-directed fluid therapy in colorectal surgery

BACKGROUND

Goal-directed fluid therapy has been shown to improve outcomes after colorectal surgery, but the optimal type of i.v. fluid to use is yet to be established. Theoretical advantages of using hydroxyethyl starch (HES) for goal-directed therapy include a reduction in the total volume of fluid required, resulting in less tissue oedema. Recent work has demonstrated that new generations of HES have a good safety profile, but their routine use in the perioperative setting has not been demonstrated to confer outcome benefit.

METHODS

We randomly assigned 202 medium to high-risk patients undergoing elective colorectal surgery to receive either balanced 6% HES (130/0.4, Volulyte) or balanced crystalloid (Hartmann's solution) as haemodynamic optimization fluid. The primary outcome measure was the incidence of gastrointestinal (GI) morbidity on postoperative day 5. Secondary outcome measures included the incidence of postoperative complications, hospital length of stay, and the effect of trial fluids on coagulation and inflammation.

RESULTS

No difference was seen in the number of patients who suffered GI morbidity on postoperative day 5 [30% in the HES group vs 32% in the crystalloid group; adjusted odds ratio=0.96 (0.52-1.77)]. Subjects in the crystalloid group received more fluid [median (inter-quartile ranges) 3175 (2000-3700) vs 1875 (1500-3000) ml, P<0.001] and had a higher 24 h fluid balance [+4226 (3251-5779) vs +3610 (2443-4519) ml, P<0.001]. No difference in the incidence of postoperative complications was seen between the groups.

CONCLUSIONS

Goal-directed fluid therapy is possible with either crystalloid or HES. There is no evidence of a benefit in using HES over crystalloid, despite its use resulting in a lower 24 h fluid balance.

Habitat filtering across tree life stages in tropical forest communities

Tropical tree communities are shaped by local-scale habitat heterogeneity in the form of topographic and edaphic variation, but the life-history stage at which habitat associations develop remains poorly understood. This is due, in part, to the fact that previous studies have not accounted for the widely disparate sample sizes (number of stems) that result when trees are divided into size classes. We demonstrate that the observed habitat structuring of a community is directly related to the number of individuals in the community. We then compare the relative importance of habitat heterogeneity to tree community structure for saplings, juveniles and adult trees within seven large (24-50 ha) tropical forest dynamics plots while controlling for sample size. Changes in habitat structuring through tree life stages were small and inconsistent among life stages and study sites. Where found, these differences were an order of magnitude smaller than the findings of previous studies that did not control for sample size. Moreover, community structure and composition were very similar among tree sub-communities of different life stages. We conclude that the structure of these tropical tree communities is established by the time trees are large enough to be included in the census (1 cm diameter at breast height), which indicates that habitat filtering occurs during earlier life stages.

Effects of a dietary β-(1,3)(1,6)-D-glucan supplementation on intestinal microbial communities and intestinal ultrastructure of mirror carp (Cyprinus carpio L.)

AIM

To assess the effects of dietary Saccharomyces cerevisiae β-(1,3)(1,6)-D-glucan supplementation (MacroGard(®)) on mirror carp (Cyprinus carpio L.) intestinal microbiota and ultrastructure of the enterocyte apical brush border.

METHODS AND RESULTS

Carp were fed either a control diet or diets supplemented with 0.1, 1 or 2% w/w MacroGard(®). Culture-dependent microbiology revealed that aerobic heterotrophic bacterial levels were unaffected by dietary MacroGard(®) after 2 and 4 weeks. No effects were observed on the allochthonous lactic acid bacteria (LAB) populations at either time point; however, reduced autochthonous LAB populations were observed at week 4. PCR-DGGE confirmed these findings through a reduction in the abundance of autochthonous Lactococcus sp. and Vagococcus sp. in MacroGard(®)--fed fish compared with the control-fed fish. Overall, sequence analysis detected microbiota belonging to the phyla Proteobacteria, Firmicutes, Fusobacteria and unidentified uncultured bacteria. DGGE analyses also revealed that dietary MacroGard(®) reduced the number of observed taxonomical units (OTUs) and the species richness of the allochthonous microbiota after 2 weeks, but not after 4 weeks. In contrast, dietary MacroGard(®) reduced the number of OTUs, the species richness and diversity of the autochthonous microbiota after 2 weeks, and those parameters remained reduced after 4 weeks. Transmission electron microscopy revealed that intestinal microvilli length and density were significantly increased after 4 weeks in fish fed diets supplemented with 1% MacroGard(®).

CONCLUSIONS

This study indicates that dietary MacroGard(®) supplementation modulates intestinal microbial communities of mirror carp and influences the morphology of the apical brush border.

SIGNIFICANCE AND IMPACT OF THE STUDY

To the authors' knowledge, this is the first study to investigate the effects of β-(1,3)(1,6)-D-glucans on fish gut microbial communities, using culture-independent methods, and the ultrastructure of the apical brush border of the enterocytes in fish. This prebiotic-type effect may help to explain the mechanisms in which β-glucans provide benefits when fed to fish.

Effects of dietary β-(1,3)(1,6)-D-glucan supplementation on growth performance, intestinal morphology and haemato-immunological profile of mirror carp (Cyprinus carpio L.)

In recent years, aquaculture research has focused on probiotics, prebiotics, and β-glucans, in order to improve health status and growth performance. Information regarding the effects of β-glucan on growth performance and intestinal immunity of mirror carp (Cyprinus carpio L.) is scarce. An experiment was therefore conducted to investigate the effects of a yeast β-glucan preparation (MacroGard(®) ) on growth performance, intestinal morphology and haemato-immunological indices of mirror carp. Carp (initial weight 11.1 ± 0.0 g) were fed highly purified diets supplemented with 0% (control), 0.1%, 1% or 2% MacroGard(®) for 8 weeks. Fish fed diets containing 1% and 2% MacroGard(®) showed significant improvements in weight gain, specific growth rate and feed conversion ratio compared to fish fed both the control and the 0.1% MacroGard(®) containing diet. Histological appraisal of the intestine showed a significantly higher infiltration of leucocytes into the epithelial layer of fish fed diets supplemented with 1% and 2% MacroGard(®) in the anterior intestine compared to fish fed the control and 0.1% MacroGard(®) diet. This effect was not observed in the posterior intestine. There were no significant differences in the intestinal absorptive surface area and number of goblet cells in either intestinal region. At the end of the experiment, the haematological status of the fish was examined. Compared to control fed fish, the haematocrit value was significantly elevated in fish fed the 2% MacroGard(®) diet. Furthermore, the blood monocyte fraction was significantly higher in fish fed the 1% and 2% MacroGard(®) diets. No significant changes were observed in the other blood parameters assessed. The present study shows that high dietary β-glucan inclusion increases growth performance without detrimental effects on the health indicators assessed. Increased intraepithelial leucocytes in the anterior intestine may indicate a localized immune response; no detrimental effects on intestinal morphology were observed.

Haemato-immunological and growth response of mirror carp (Cyprinus carpio) fed a tropical earthworm meal in experimental diets

An investigation was conducted to evaluate the effect of feeding a tropical earthworm meal (Perionyx escavatus) on the haemato-immunological response and growth performance of mirror carp (Cyprinus carpio). Fish were fed diets for a total of 88 days, fishmeal served as the main protein source in the control diet. Two remaining diets consisted of fishmeal fixed at 33.65% provision of protein and the remaining 66.35% protein was provided by soybean meal (SBM diet) or P. excavatus meal (EW diet). Compared to control and SBM fed fish (7.69 ± 0.28 and 5.92 ± 0.31 g/dl, respectively), a significant increase in haemoglobin was measured in EW fed fish (9.57 ± 0.24 g/dl). Consequently significant elevations were also observed in mean corpuscular haemoglobin (MCH; 79.13 ± 4.59 pg) and mean corpuscular haemoglobin concentration (MCHC; 22.69 ± 0.54 pg) in EW fed fish. On the contrary, compared to control and SBM fed carp total leukocyte levels (2.72 ± 0.17 and 3.10 ± 0.17 × 10(4)/mm(3), respectively) were significantly decreased in the EW group (2.15 ± 0.14 × 10(4)/mm(3)). Moreover at day 14 and 21 post immunisation with bacterin isolated from Aeromonas hydrophila fish fed the EW diet displayed a significant reduction in respiratory burst activity (RBA) compared to control and SBM fed fish. After 60 days of feeding, fish fed EW diet showed a significant elevation in final body weight compared to fish fed a fishmeal based diet (control treatment) and fish fed a soybean meal based diet. Similar improvements were observed in feed utilisation efficiency. The present study shows that feeding P. excavatus meal to mirror carp decreases some aspects of the innate immune response, but at the same time gives rise to significant enhancement of growth and feed utilisation efficiency.

Nodal cryptococcal immune reconstitution inflammatory syndrome masquerading as tuberculosis in an HIV-infected patient

An African HIV-infected patient presented with widespread necrotic lymphadenopathy five months after starting combination antiretroviral therapy (cART) and was thought to have disseminated tuberculosis in the context of an immune reconstitution inflammatory syndrome (IRIS) on the basis of typical imaging appearances and suggestive appearances from a fine needle aspirate of a nodal mass. The patient deteriorated despite empirical antituberculosis therapy and the correct diagnosis of nodal cryptococcal infection was subsequently established by histological examination of a core biopsy from a lymph node. IRIS should be borne in mind when considering the differential diagnosis in a patient who has recently started cART.

How genetically heterogeneous is Kabuki syndrome?: MLL2 testing in 116 patients, review and analyses of mutation and phenotypic spectrum

MLL2 mutations are detected in 55 to 80% of patients with Kabuki syndrome (KS). In 20 to 45% patients with KS, the genetic basis remains unknown, suggesting possible genetic heterogeneity. Here, we present the largest yet reported cohort of 116 patients with KS. We identified MLL2 variants in 74 patients, of which 47 are novel and a majority are truncating. We show that pathogenic missense mutations were commonly located in exon 48. We undertook a systematic facial KS morphology study of patients with KS at our regional dysmorphology meeting. Our data suggest that nearly all patients with typical KS facial features have pathogenic MLL2 mutations, although KS can be phenotypically variable. Furthermore, we show that MLL2 mutation-positive KS patients are more likely to have feeding problems, kidney anomalies, early breast bud development, joint dislocations and palatal malformations in comparison with MLL2 mutation-negative patients. Our work expands the mutation spectrum of MLL2 that may help in better understanding of this molecule, which is important in gene expression, epigenetic control of active chromatin states, embryonic development and cancer. Our analyses of the phenotype indicates that MLL2 mutation-positive and -negative patients differ systematically, and genetic heterogeneity of KS is not as extensive as previously suggested. Moreover, phenotypic variability of KS suggests that MLL2 testing should be considered even in atypical patients.

Occlusal considerations in implantology: good occlusal practice in implantology

This article is concerned with implants that are being used for fixed crown and bridgework rather than removable prostheses. The huge increase in the provision of implants over the past two decades is set to continue. Most of the research is related to avoiding failures in implants. This research, in the main, has concentrated on the essential interface between the artificial implant and living bone: osseointegration. The other interface, which is worthy of our full attention, is the one between the implant-supported crown and the antagonist tooth: the occlusion.

Soybean meal alters autochthonous microbial populations, microvilli morphology and compromises intestinal enterocyte integrity of rainbow trout, Oncorhynchus mykiss (Walbaum)

Abstract Rainbow trout were fed either a diet containing fishmeal (FM) as the crude protein source or a diet containing 50% replacement with soybean meal (SBM) for 16 weeks. An enteritis-like effect was observed in the SBM group; villi, enterocytes and microvilli were noticeably damaged compared with the FM group. The posterior intestine microvilli of SBM-fed fish were significantly shorter and the anterior intestine microvilli significantly less dense than the FM-fed fish. Electron microscopy confirmed the presence of autochthonous bacterial populations associated with microvilli of both fish groups. Reduced density of microvilli consequently led to increased exposure of enterocyte tight junctions, which combined with necrotic enterocytes is likely to diminish the protective barrier of the intestinal epithelium. No significant differences in total viable counts of culturable microbial populations were found between the groups in any of the intestinal regions. A total of 1500 isolates were tentatively placed into groups or genera, according to standard methods. Subsequent partial 16S rRNA sequencing revealed species that have not been identified from the rainbow trout intestine previously. Compared with the FM group levels of Psychrobacter spp. and yeast were considerably higher in the SBM group; a reduction of Aeromonas spp. was also observed.

The geography of diversification in mutualistic ants: a gene's-eye view into the Neogene history of Sundaland rain forests

We investigate the geographical and historical context of diversification in a complex of mutualistic Crematogaster ants living in Macaranga trees in the equatorial rain forests of Southeast Asia. Using mitochondrial DNA from 433 ant colonies collected from 32 locations spanning Borneo, Malaya and Sumatra, we infer branching relationships, patterns of genetic diversity and population history. We reconstruct a time frame for the ants' diversification and demographic expansions, and identify areas that might have been refugia or centres of diversification. Seventeen operational lineages are identified, most of which can be distinguished by host preference and geographical range. The ants first diversified 16-20 Ma, not long after the onset of the everwet forests in Sundaland, and achieved most of their taxonomic diversity during the Pliocene. Pleistocene demographic expansions are inferred for several of the younger lineages. Phylogenetic relationships suggest a Bornean cradle and major axis of diversification. Taxonomic diversity tends to be associated with mountain ranges; in Borneo, it is greatest in the Crocker Range of Sabah and concentrated also in other parts of the northern northwest coast. Within-lineage genetic diversity in Malaya and Sumatra tends to also coincide with mountain ranges. A series of disjunct and restricted distributions spanning northern northwest Borneo and the major mountain ranges of Malaya and Sumatra, seen in three pairs of sister lineages, further suggests that these regions were rain-forest refuges during drier climatic phases of the Pleistocene. Results are discussed in the context of the history of Sundaland's rain forests.

Malocclusion – a term in need of dropping or redefinition?

I believe the time is coming when we should consider dropping the term 'malocclusion'. In its present meaning it is too mechanical and misrepresents the fundamental fact that an occlusion can only be judged against the tissue reactions to it or the patient's assessment of it.

Mitigating peritoneal membrane characteristics in modern peritoneal dialysis therapy

Membrane function at the start of peritoneal dialysis (PD) treatment, measured as solute transport rate and ultrafiltration capacity, varies considerably between individuals. Although this can be correlated to clinical factors such as age and body habitus, this accounts for little of the variance seen. It is increasingly clear, however, that this variability in membrane function does impact on clinical outcomes. Specifically, high solute transport increases mortality risk, independent of other known factors such as age, comorbidity, and residual renal function. High solute transport causes earlier loss of the osmotic gradient when a low molecular weight osmolyte such as glucose is used. This will result in an earlier and lower peak in the ultrafiltration achieved combined with a higher fluid absorption rate once the osmotic gradient is lost. It is therefore quite plausible that the worse clinical outcomes associated with high transport reflect less good ultrafiltration, although other explanations must be considered, including higher peritoneal protein losses and a possible association with systemic inflammation. Strategies now exist to mitigate the effects of high transport on fluid removal. These include optimization of the short dwell lengths using automated PD (APD) combined with icodextrin which will result in sustained ultrafiltration and thus prevention of reabsorption in the long dwell. Survival analysis of APD patients, especially in cohorts in which icodextrin has been used, would suggest that high transport status is not a risk factor, although some of these data are only preliminary. In contrast, low ultrafiltration capacity of the membrane seems to be more important in these patients, especially if anuric. Here the best strategy would seem to be prevention as patients who develop low ultrafiltration capacity are not easily treated on PD. Avoiding excessive hypertonic glucose exposure and preserving residual renal function offers the best available approach.

Enlarged parietal foramina caused by mutations in the homeobox genes ALX4 and MSX2: from genotype to phenotype

Heterozygous mutations of the homeobox genes ALX4 and MSX2 cause skull defects termed enlarged parietal foramina (PFM) and cranium bifidum (CB); a single MSX2 mutation has been documented in a unique craniosynostosis (CRS) family. However, the relative mutational contribution of these genes to PFM/CB and CRS is not known and information on genotype-phenotype correlations is incomplete. We analysed ALX4 and MSX2 in 11 new unrelated cases or families with PFM/CB, 181 cases of CRS, and a single family segregating a submicroscopic deletion of 11p11.2, including ALX4. We explored the correlations between skull defect size and age, gene, and mutation type, and reviewed additional phenotypic manifestations. Four PFM cases had mutations in either ALX4 or MSX2; including previous families, we have identified six ALX4 and six MSX2 mutations, accounting for 11/13 familial, but only 1/6 sporadic cases. The deletion family confirms the delineation of a mental retardation locus to within 1.1 Mb region of 11p11.2. Overall, no significant size difference was found between ALX4- and MSX2-related skull defects, but the ALX4 mutation p.R218Q tends to result in persistent CB and is associated with anatomical abnormalities of the posterior fossa. We conclude that PFM caused by mutations in ALX4 and MSX2 have a similar prevalence and are usually clinically indistinguishable. Mutation screening has a high pickup rate in PFM, especially in familial cases, but is not indicated in CRS.

Tissue astaxanthin and canthaxanthin distribution in rainbow trout (Oncorhynchus mykiss) and Atlantic salmon (Salmo salar)

A comparative investigation of tissue carotenoid distribution between rainbow trout, Oncorhynchus mykiss, and Atlantic salmon, Salmo salar, was undertaken to identify the relative efficiency of utilization of astaxanthin and canthaxanthin. Higher apparent digestibility coefficients (ADCs) (96% in trout vs. 28-31% in salmon; P<0.05), and pigment retention efficiencies (11.5-12.5% in trout vs. 5.5% in salmon; P<0.05), for both astaxanthin and canthaxanthin, were observed for rainbow trout. Astaxanthin deposition was higher than canthaxanthin in rainbow trout, while the reverse was true for Atlantic salmon, suggesting species-specificity in carotenoid utilization. The white muscle (95% in trout vs. 93% in salmon) and kidneys (0.5% in trout vs. 0.2% in salmon) represented higher proportions of the total body carotenoid pool in rainbow trout than in Atlantic salmon (P<0.05), whereas the liver was a more important storage organ in Atlantic salmon (2-6% in salmon vs. 0.2% in trout; P<0.05). The liver and kidney appeared to be important sites of carotenoid catabolism based on the relative proportion of the peak chromatogram of the fed carotenoid in both species, with the pyloric caecae and hind gut being more important in Atlantic salmon than in the rainbow trout. Liver catabolism is suspected to be a critical determinant in carotenoid clearance, with higher catabolism expected in Atlantic salmon than in rainbow trout.

Dietary carotenoid pigment supplementation influences hepatic lipid and mucopolysaccharide levels in rainbow trout (Oncorhynchus mykiss)

We assessed the effects of dietary carotenoid pigment supplementation on liver histochemistry in the rainbow trout. One hundred and eight rainbow trout (mean mass 266+/-10 g) were assigned to each of three replicate tanks for each of three dietary treatments; astaxanthin, canthaxanthin, or control at a target dietary inclusion of 100 mg/kg, by top-coating a pigment-free commercially extruded basal diet (Trouw Aquaculture, U.K.). Fish were fed for 3 weeks at a ration of 1.2% body mass/day, in a recirculating freshwater system maintained at 16 degrees C. Frozen liver sections were stained for total lipids, unsaturated lipids, glycogen, mucopolysaccharides, glycogen phosphorylase and aspartate aminotransferase. Relative amounts were measured quantitatively by image analysis. Carotenoid treatment significantly (P<0.05) altered the total lipid profile and hepatic mucopolysaccharide contents of livers of rainbow trout. Results are discussed in relation to the catabolic potential of the liver in carotenoid pigment metabolism.

Gross rearrangements of the MECP2 gene are found in both classical and atypical Rett syndrome patients

MECP2 mutations are identifiable in approximately 80% of classic Rett syndrome (RTT), but less frequently in atypical RTT. We recruited 110 patients who fulfilled the diagnostic criteria for Rett syndrome and were referred to Cardiff for molecular analysis, but in whom an MECP2 mutation was not identifiable. Dosage analysis of MECP2 was carried out using multiplex ligation dependent probe amplification or quantitative fluorescent PCR. Large deletions were identified in 37.8% (14/37) of classic and 7.5% (4/53) of atypical RTT patients. Most large deletions contained a breakpoint in the deletion prone region of exon 4. The clinical phenotype was ascertained in all 18 of the deleted cases and in four further cases with large deletions identified in Goettingen. Five patients with large deletions had additional congenital anomalies, which was significantly more than in RTT patients with other MECP2 mutations (2/193; p<0.0001). Quantitative analysis should be included in molecular diagnostic strategies in both classic and atypical RTT.

Electrocardiographic parameters of normal alpacas (Lama pacos)

The electrocardiographic parameters of 40 healthy alpacas (Lama pacos) were recorded with a base-apex lead system to establish the normal resting electrocardiographic parameters in this species. The following parameters were measured: heart rate and rhythm, QRS and T morphology, ST segment position, P amplitude and duration, QRS duration and PQ and QT intervals. The heart rate varied between 50 and 110 bpm, with a mean (sd) of 80 (17.8) bpm, and no significant differences were observed between males and females or between alpacas of different ages. Sinus arrhythmia was observed in 35 of the animals, and a regular sinus rhythm was recorded in the other five. The QRS morphology was variable, with an 'rS' pattern observed in 29 animals, 'RS' in six, 'Rs' in three and 'QS' in the other two. A variable morphology was also observed for the T wave, which was positive in 27 animals, negative in seven and biphasic in the other six. All the electrocardiographic parameters were normally distributed and no significant differences were observed between the sexes, except that the amplitude of the P wave was higher in males. The PQ interval was significantly shorter in animals less than six months old.

Blindness following retrobulbar haemorrhage--it can be prevented

Delay in diagnosis and treatment of an elderly woman with a malar fracture that caused retrobulbar haemorrhage resulted in complete loss of vision in the right eye.

Possible link between extraction of wisdom teeth and temporomandibular disc displacement with reduction: matched case control study

We undertook a case control study that compared 220 patients diagnosed with disc displacement with reduction at the Dental Hospital of Manchester with 1100 controls drawn from participants in the 1998 Adult Dental Health Survey. We found that patients were not significantly more likely to have had extraction of third molars than controls; odds ratio: 1.28, 95% CI: 0.96-1.71. Also only 21 patients (9.5%) reported having had extraction of third molars in the 5 years before their diagnosis. We conclude that for most patients extraction of third molars is unlikely to have caused disc displacement with reduction.

The ‘Chesterfield stent’: an aid to the placement of midpalatal implants

A palatal endosseous implant is a valuable adjunct to orthodontic treatment. Its insertion is considerably simplified by the use of a stent that was designed in our department and that we describe here.

Mapping of three translocation breakpoints associated with orofacial clefting within 6p24 and identification of new transcripts within the region

Orofacial clefting (OFC) is a common congenital malformation. Here we report the refinement of three translocation breakpoints of patients exhibiting OFC within the 6p24 region, and the isolation and characterisation of novel genes, one of which is directly disrupted by the translocation breakpoint of a patient. The gene has been characterized and orthologues identified in bovine, murine and pufferfish.

Does the procedure of arthrography affect the range of movement in patients with locking of the temporomandibular joint?

The aim of this study was to investigate whether arthrography itself altered the range of mandibular movements, in a group of patients with locking of the temporomandibular joint (TMJ). The clinical records of a series of 161 patients who were diagnosed with locking of the TMJ were retrospectively analysed. Mouth opening had improved in 57 out of 161 patients (35%). Twenty-three patients (14%) had improved by 5 mm or less. Nineteen patients (11%) had improved by more than 5 mm but less than 10 mm, whereas 15 patients (9%) had improved by more than 10 mm. Of the patients who experienced an improved mouth opening, only nine (15%) had improved from their pre-arthrography restricted maximum opening to beyond the lower limit of normal. This suggests that the injection of contrast medium had an effect on the range of vertical opening in patients with displacement of the disc without reduction.

The potentially fatal vascular anomaly and orthodontic treatment--a case report

Oral vascular lesions are of clinical importance to the dental profession because they pose serious bleeding risks. A case report is presented here where a patient with a complex palatal vascular malformation was successfully treated with fixed appliances. The problems encountered during treatment are discussed.

Physiological modulation of iron metabolism in rainbow trout (Oncorhynchus mykiss) fed low and high iron diets

Iron (Fe) is an essential element, but Fe metabolism is poorly described in fish and the role of ferrireductase and transferrin in iron regulation by teleosts is unknown. The aim of the present study was to provide an overview of the strategy for Fe handling in rainbow trout, Oncorhynchus mykiss. Fish were fed Fe-deficient, normal and high-Fe diets (33, 175, 1975 mg Fe kg(-1) food, respectively) for 8 weeks. Diets were chosen so that no changes in growth, food conversion ratio, haematology, or significant oxidative stress (TBARS) were observed. Elevation of dietary Fe caused Fe accumulation particularly in the stomach, intestine, liver and blood. The increase in total serum Fe from 10 to 49 micro mol l(-1) over 8 weeks was associated with elevated total Fe binding capacity and decreased unsaturated Fe binding capacity, so that in fish fed a high-Fe diet transferrin saturation increased from 15% at the start of the experiment to 37%. Fish on the high-Fe diet increased Fe accumulation in the liver, which was correlated with elevation of hepatic ferrireductase activity and serum transferrin saturation. Conversely, fish on the low-Fe diet did not show tissue Fe depletion compared with normal diet controls and did not change Fe binding to serum transferrin. Instead, these fish doubled intestinal ferrireductase activity which may have contributed to the maintenance of tissue Fe status. The absence of clear treatment-dependent changes in branchial Fe accumulation and ferrireductase activity indicated that the gills do not have a major role in Fe metabolism. Some transient changes in Cu, Zn and Mn status of tissues occurred.

Stabilisation splint therapy for temporomandibular pain dysfunction syndrome

BACKGROUND

Pain dysfunction syndrome (PDS) is the most common temporomandibular disorder (TMD). There are many synonyms for this condition including facial arthromylagia, TMJ dysfunction syndrome, myofacial pain dysfunction syndrome, craniomandibular dysfunction and myofacial pain dysfunction. The aetiology of PDS is multifactorial and many different therapies have been advocated.

OBJECTIVES

To establish the effectiveness of stabilisation splint therapy in reducing symptoms in patients with pain dysfunction syndrome.

SEARCH STRATEGY

Electronic databases (including the Cochrane Oral Health Group's Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); The Cochrane Library Issue 2, 2003; MEDLINE (1966 to June 2001); EMBASE (1966 to June 2001)) were searched. Handsearching of relevant journals was undertaken and reference lists of included studies screened. Experts in the field were contacted to identify unpublished articles. There was no language restriction.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs), in which splint therapy was compared concurrently to no treatment, other occlusal appliances, or any other active intervention.

DATA COLLECTION AND ANALYSIS

Data extraction was carried out independently and in duplicate. Validity assessment of the included trials was carried out at the same time as data extraction. Discrepancies were discussed and a third reviewer consulted. The author of the primary study was contacted where necessary. The studies were grouped according to treatment type and duration of follow up.

MAIN RESULTS

Twenty potentially relevant RCTs were identified. Eight trials were excluded leaving 12 RCTs for analysis. Stabilisation splint therapy was compared to: acupuncture, bite plates, biofeedback/stress management, visual feedback, relaxation, jaw exercises, non-occluding appliance and minimal/no treatment. There was no evidence of a statistically significant difference in the effectiveness of stabilisation splint therapy (SS) in reducing symptoms in patients with pain dysfunction syndrome compared with other active treatments. There is weak evidence to suggest that the use of SS for the treatment of PDS may be beneficial for reducing pain severity, at rest and on palpation, when compared to no treatment.

REVIEWER'S CONCLUSIONS

There is insufficient evidence either for or against the use of stabilisation splint therapy for the treatment of temporomandibular pain dysfunction syndrome. This review suggests the need for further, well conducted RCTs that pay attention to method of allocation, outcome assessment, large sample size, and enough duration of follow up. A standardisation of the outcomes of the treatment of PDS should be established in the RCTs.

Determination of carotenoid and vitamin A concentrations in everted salmonid intestine following exposure to solutions of carotenoid in vitro

Carotenoid (astaxanthin and canthaxanthin) concentrations in everted intestine from rainbow trout (Oncorhynchus mykiss, Walbaum) and Atlantic salmon (Salmo salar, L.) exposed to micelle solubilised carotenoid, have been determined. Following exposure (1 h) to astaxanthin solution (5 mg l(-1)), trout pyloric caeca and mid intestine had higher (P<0.05) mean tissue astaxanthin concentrations (0.50+/-0.08 microg g(-1) and 0.54+/-0.09 microg g(-1), respectively) compared to hind intestine (0.04+/-0.01 microg g(-1); n=11+/-S.E.). Furthermore, the astaxanthin concentration in pyloric caeca (0.50+/-0.08 microg g(-1)) was greater (P<0.05) than that of canthaxanthin (0.11+/-0.01 microg g(-1); n=11, +/-S.E.) when exposed to solutions of similar carotenoid concentration (5.11+/-0.16 mg l(-1) and 5.35+/-0.16 mg l(-1), respectively; n=3+/-S.E.). However, no differences (P>0.05) were recorded between trout and salmon intestinal tissue in terms of astaxanthin concentration following exposure. Trout caeca exposed to astaxanthin solution had significantly (P<0.05) more vitamin A (514.1+/-36.4 microg g(-1)) compared to control tissues (316.5+/-61.7 microg g(-1); n=8+/-S.E.). Vitamin A(1) concentrations in caeca (287.7+/-11.0 microg g(-1)) exposed to astaxanthin solution were significantly higher (P<0.05) compared to controls (174.9+/-26.9 microg g(-1)). However, vitamin A(2) concentrations were not significantly (P>0.05) different (226.3+/-28.2 microg g(-1) and 141.6+/-35.2 microg g(-1), respectively).