GNAS1 mutation screening in primary and metastatic colorectal tumours using high-resolution melting analysis
DP van Berkel
University of Nottingham, Nottingham, UK
Background: Colorectal cancer is the third most common cancer in the UK, and with the arrival of more personalised treatments it is important that its full genetic profile is understood. This has led to the description of novel mutations such as GNAS1, suggested to present at low frequencies in clinical colorectal cancer cohorts. Using high-resolution melting analysis, a relatively novel technique for mutation screening, a new cohort of colorectal cancer clinical samples will be screened for GNAS1 mutation. It is hypothesised that the mutation frequency will be low and there will be no difference of frequency between paired primary tumours and metastases. Methods: Nested PCR followed by high-resolution melting was used on 22 colorectal cell lines and 118 clinical samples. Normalised melt curves and difference plots were analysed for changes in melting profile that may indicate a mutational base change. Results: Analysis suggested no mutation in the clinical sample set, and 1 mutation in the cell lines, which gave an overall colorectal cancer GNAS1 mutation rate of 0.7%. Conclusion: The results concur with a previously published study for GNAS1 mutation frequency at <1%, with no frequency differences in paired cases. This study explores the limitations and potential clinical application of high-resolution melting analysis.
BCG ‘vaccination complication incidence in Greater Glasgow and Clyde – Epidemiology of TB, BCG vaccine efficacy and mechanisms of complication incidence reduction
R Manson
University of Glasgow Medical School, Glasgow, UK
Introduction: Currently the BCG vaccine is used according to guidelines, with the aim of reducing tuberculosis. The vaccine is associated with a number of complications, including abscesses and lymphadenitis. Aims: To establish the incidence of complication post-vaccination and to make recommendations on how to reduce the incidence of complication within NHSGGC. Methods: This was a retrospective study which investigated the incidence of complication following vaccination between 2007 and 2011. In total, 8846 neonates were immunised (all in line with guidelines from the Green Book on immunisation). Complications were identified by searching archives within the paediatric infectious diseases and surgical units to identify those who had been referred or treated for complications associated with BCG vaccination. Results: In total, 26 patients experienced complications post-vaccination. 13 developed abscesses, 9 developed lymphadenitis, 1 had a combination of the two, and 3 had other less common complications. In total 5 required surgical intervention, 12 required clinic follow-up or medical treatment and 9 required no treatment after initial consultation. Conclusion: The literature suggests that the incidence of complication following vaccination stands between 1.2% and 2.5%. The data from NHSGGC compares favourably to this at 0.1%. However, it should be noted that the literature focuses on multi-centre prospective studies, each aiming to detect all complications following vaccination, regardless of how minor this was. This study also looked to establish methods aimed at reducing the incidence of complication associated with BCG. Recommendations include: reduction in age and child anxiety at vaccination and a change in vaccine strain.
Does experience with an improvised Windkessel model improve understanding of cardiac physiology in medical students and junior doctors?
C Smart1, S Jolliffe2, R Keating2, A McKirdy2 and T Parasuraman2
1Anaesthetic Department, Crosshouse Hospital, UK
2Wolfson Medical School, University of Glasgow, UK
The ‘Windkessel effect’ describes modulation of the arterial waveform produced by change in arterial vasculature, which analogises to a ‘Windkessel’, an air chamber downstream of a piston pump which dampens pressure oscillations. We constructed a model which comprises ‘ventricle’ (low resistance syringe between two valves), ‘aorta’ (syringe containing air – the Windkessel), ‘resistance vessels’ (roller clamp) and ‘venous reservoir’ (fluid warmer cassette). Intraluminal pressures were transduced, producing realistic arterial waveforms. Various parameters could be altered to study its effects. Our aim was to evaluate the model as an aid for teaching medical students and junior doctors basic cardiac physiology. Thirteen subjects were recruited for the study. Following a short presentation, outlining the model, subjects were presented with a 20 questions true/false style blood pressure exam (of Primary FRCA difficulty).They then worked through a workbook, using the model to investigate. Teaching was not given. The subjects were then invited to amend. An anonymous questionnaire was distributed to assess the effectiveness of the model as a learning tool. Overall, the subjects scored better in the second attempt at the exam (p = 0.009).With a highest possible score of 20, the mean score in the first exam was 13.85 ± 2.99 (mean ± SD) compared to 16.31 ± 1.44 in the second attempt. Nearly all subjects showed an improvement, with only 1 student’s score decreasing on the second exam. 53.8% of subjects said they ‘strongly agree’ and the remainder said that they ‘agree’ that the model improved their understanding of blood pressure and cardiac physiology. 92.3% of students rated the model as either ‘excellent’ or ‘good’. Conclusions: The improvised Windkessel model provides a simple yet cheap way of demonstrating cardiovascular physiology. It could be considered as a teaching adjunct in the basic sciences component.
Temporal and spatial distribution of matrix metalloproteinase-2 and its role in the pathogenesis of pre-eclampsia
S Grant, F Jordan, S Huda, DJ Freeman and L Marks
Department of Obstetrics and Gynaecology, University of Glasgow, UK
Background: Matrix metalloproteinase (MMP)-2 and MMP-9 degrade components of the extracellular matrix and have been implicated in impaired trophoblast invasion in pre-eclampsia (PE). The purpose of this study was to investigate expression of MMP-2 and MMP-9 mRNA in placentae from healthy, PE and IUGR pregnancies, and to elucidate the expression of MMP-2 protein in a gestational series of placentae. Methods: MMP-2 and MMP-9 mRNA were quantitated using real-time PCR in third trimester placental tissue samples from healthy pregnancies (n = 37) and those affected by PE (n = 22) and IUGR (n = 12). Immunohistochemistry and a weighted histoscore method were used to determine the expression patterns of MMP-2 in placentae from 7 to 17 weeks’ and 34 to 41 weeks’ gestation. Results: There was no difference in levels of MMP-2 (p = 0.75) or MMP-9 (p = 0.20) expression among control, PE and IUGR placentae. MMP-2 was greater than MMP-9 mRNA expression in all samples. Median fold expression of MMP-2 relative to MMP-9 was 73.8 (95% CI 58.6–91.8). A negative correlation between MMP-2 protein expression and gestation in endothelial cells (rs = −0.43, p = 0.025) and a trend towards a negative correlation between MMP-2 expression in trophoblasts (rs = −0.33, p = 0.093) and gestation were observed. Conclusions: Placental MMP-2 expression appears to decrease throughout gestation. While we did not find evidence of a difference in MMP-2 or MMP-9 mRNA expression among PE, IUGR or healthy third trimester placentae, this may not reflect in situ MMP activity. Reduced trophoblast invasion in PE may depend on the balance between MMP and TIMP expression, an area which warrants further investigation.
Minimisation of treatment-related toxicity in the vasculitis clinic
AE Mason and MD Morgan
College of Medical and Dental Sciences, University of Birmingham, UK
Background: ANCA-associated vasculitis (ASV) is treated with corticosteroids and immunosuppressants. These are associated with adverse effects, including obesity and increased infection. Clinical audit was undertaken to assess the implementation of local guidelines for the vaccination of vasculitis patients to reduce infection risk. We also investigated the incidence of weight gain to develop new practice guidelines. Methods: Data was collected by case note review from 43 consecutive patients attending vasculitis clinics at University Hospitals Birmingham NHS Foundation Trust during January and February 2012. Local audit standards were used: (1) all patients on low-dose immunosuppression should be vaccinated against pneumococcal, meningococcal and haemophilus infection, (2) vaccine responses should be monitored, (3) all patients should have their clinic weight and BMI recorded. Results: 52% of patients eligible for vaccination had received all recommended vaccines and had responses monitored. All patients had weight recorded and 74% had a recorded BMI. 14% of patients had gained >10 kg since diagnosis, which was consistent with significant treatment-related morbidity. Conclusions: Vaccination guidelines should be implemented more consistently to reduce the risk of serious infections. Vaccination status should be checked at every appointment and re-audit should occur in 12 months. Steroid-induced weight gain was an important clinical issue. Diet and exercise advice should be given to all patients and guidelines developed for the management of those with significant weight gain. As a result of this audit, funding for a Clinical Nurse Specialist has been secured to improve management of long-term complications of treatment for ASV.
Influence of ROS-induced DNA damage pathways on premature ageing using cell-based assays
MW Mather1 and CJ Hutchison2
1Newcastle University, UK
2Durham University, UK
Background: Laminopathies are inheritable diseases arising through mutations in the gene LMNA. These diseases mimic aspects of normal ageing and are therefore considered to be models of ageing.1 Recently it has been shown that at least some aspects of premature ageing arising from these diseases are caused by the accumulation of un-repairable oxidative DNA damage.2 The ability of NAC (an antioxidant) to improve rates of repair and to prevent the accumulation of un-repairable DNA damage will be assessed in cells from each patient. Methods: Skin fibroblasts from laminopathic patients or from age-matched normal individuals will be treated with H2O2 to induce irreparable oxidative stress or with etoposide to induce repairable DNA damage genotoxically, each with and without NAC present. DNA double strand breaks will be detected via confocal microscopy using antibodies against DNA repair protein H2AX. Rates of DNA repair and the accumulation of un-repaired DNA damage sites will be determined using a mathematic model adapted by Richards.3Results: Data showed that NAC increased the damaging effects of etoposide, and had varying impact in protecting against H2O2-induced damage. We also demonstrated that DNA damage is well modelled using a negative binomial distribution. Conclusions: We have found that normal and laminopathic fibroblasts respond differently to oxidative stress in the presence of NAC. Unexpectedly, we also found that NAC potentiates the damaging effects of etoposide. Finally, we demonstrated that DNA damage in this assay can be modelled by a negative binomial distribution.
References
Broers JLV, Ramaekers FCS, Bonne G, et al. Nuclear lamins: Laminopathies and their role in premature ageing. Physiological Reviews 2006; 86: 967–1008.Liu BH, Wang JM, Chan KM, et al. Genomic instability in laminopathy-based premature aging. Nature Medicine 2005; 11: 780–785.Richards SA. Dealing with overdispersed count data in applied ecology. Journal of Applied Ecology 2008; 45(1): 218–227.
Bioinformatic analysis and predicted translational efficiency of alternative transcripts of Alpha-1 antitrypsin gene
F Ahmed
School of Molecular Medical Sciences, The University of Nottingham, Nottingham, UK
Alpha-1 antitrypsin (AAT) plays a critical role in maintaining the structural integrity of the lung through inhibition of the powerful protease, neutrophil elastase. Whilst its main site of synthesis is the liver, a significant increase in local AAT production in the lung, thought to be of physiological importance, has been noted in inflammatory states. To date, 11 alternative transcripts of this gene have been recognised but failure of previous experiments to determine the cause of this local production suggest that our current knowledge of transcripts is incomplete. By means of multiple sequence alignment, genome mapping and predicted splice site analysis, this study structurally annotated the 5′-untranslated region (UTR) of 13 putative transcripts of the AAT gene. Findings include the existence of 6 previously unidentified alternative exon lengths, most due to intron inclusion, and the identification of 2 novel AAT isoforms. Further characterisation of these transcripts on the basis of their translational efficiency as measured through 5′UTR length, predicted secondary structure and presence of upstream ATG codons allows us to hypothesise that three transcripts, one of the newly discovered isoform -1A-1B, and two variants of the -1B and -1B-1C isoforms, are likely to be of importance in local lung AAT induction.
A cadaveric study of the upper limb’s vasculature: The existence of anatomical relationships between properties of the brachial, radial and ulnar arteries and their venae comitantes
AL Skervin
University of Manchester, Manchester, UK
With the brachial, radial and ulnar arteries commonly being used in cardiovascular and radiological medicine, knowledge of the variability in their patterning is of great importance to clinicians and surgeons. From the early literature, the embryological development of the brachial artery and its site of bifurcation have been widely understood. Yet, mechanisms responsible for its abnormalities such as high bifurcation and those of the radial and ulnar arteries and their venae comitantes remain obscure. Using 10 upper limbs, this cadaveric study examined the diameter of the brachial, radial and ulnar arteries; the brachial artery site of bifurcation (BASB) relative to the interepicondylar line, radial head, brachioradialis and pronator teres; and the pattern of their venae comitantes. Measurements were obtained under magnification and with the use of a digital caliper. The results revealed that: (a) the mean brachial diameter 0.5 cm proximal to its terminus was 5.23 mm, which correlated with the BASB relative to the interepicondylar line and the radial head; (b) the radial artery was smaller than the ulnar artery; (c) 40% of brachial arteries bifurcated at aberrant sites; (d) gender differences existed; and (e) variations in the patterning of the venae comitantes existed in 40% of cadavers. Taken together these findings show that the vasculature of the upper limb exhibits great inter-individual variation. Such variability should be greatly considered before undertaking any medical or surgical procedures.
Diaphragmatic pacing in motor neurone disease: A literature review
Sheelagh MA Harwell
University of Glasgow Medical School, UK
In a rapidly degenerating neurological disease such as motor neuron disease (MND), there are few interventions to slow disease progression. Focus is therefore directed towards improving symptom control and quality of life. At present, non-invasive ventilation is the standard treatment for respiratory weakness in MND, with problems such as mobility, communication and eventual degeneration and requirement for invasive ventilation. A novel option could be diaphragmatic pacing. Pacing of the diaphragm to artificially assist breathing has been used with success in high quadriplegia, where the phrenic nerves remain excitable but the tracts from the medullary respiratory control centre are disrupted, inhibiting spontaneous breathing. MND, however, is a spectrum of variable upper and lower motor neuron losses. Therefore, the use of diaphragmatic pacing in MND is more complex and limited to a number of specific patients. Moreover, safety data from high quadriplegic patients cannot be extrapolated to MND. In July 2011, the Health Technology Assessment Programme funded a large randomised controlled trial of a diaphragmatic pacing system in Sheffield, UK. The Food and Drug Administration in the USA approved a similar trial in September 2011. This paper reviews the currently available data on diaphragmatic pacing in MND. In carefully selected patients diaphragmatic pacing appears to be efficacious and safe in the short term. However, current reporting is inconsistent and thus results of the larger trials are awaited.
Collagen-4-α-5 is a potential target of miR-199a-3p in COPD smokers
G Watt
University of Glasgow Medical School, UK
Background: microRNAs (miRNA) are non-coding, post-transcriptional regulators of gene expression. They have been implicated in the pathogenesis of various diseases; however, their role in COPD is unknown. Methods: The expression of miRNA-199 in respiratory epithelial cell samples obtained from COPD (12 smokers, 14 ex-smokers) and healthy controls (10 smokers, 14 non-smokers) was investigated. RNA was isolated and miRNA relative expression was measured by quantitative real-time PCR (qRT-PCR). Software packages were used to identify mRNA genes that were down-regulated and target genes (Collagen-4-α-5, PPAR-γ) were selected. qRT-PCR was performed on patient samples using target gene primers. mRNA levels were analysed using Mann–Whitney U test and Pearson’s correlation co-efficient. Results: The relative expression of miR-199a-3p and miR-199b-5p was greater in COPD patients compared to healthy controls (p<0.001, p = 0.008). PPAR-γ has been implicated in reducing oxidative stress within cells. Our results show that COPD patients have decreased PPAR-γ expression compared to control subjects (p = 0.0071). There was no correlation between PPAR-γ and miR-199a-3p/b-5p expression (p = 0.282, p = 0.992). Collagen-4-α-5, a component of the ECM, has been shown to have increased expression in COPD. We found no difference in collagen-4-α-5 expression between COPD and healthy subjects (p = 0.2034); however, COPD smokers have decreased collagen-4-α-5 expression compared to COPD ex-smokers (p = 0.0221). There was no correlation between target genes and lung function. Conclusions: Our results demonstrate that there is differential miRNA expression in COPD patients, particularly in relation to the miR-199 family. Collagen-4-α-5 is a potential target of miR-199a-3p and may be linked to smoking-related pathological changes seen in COPD.
The prevalence of depression in elderly in-patients in Community Hospitals
NDR Denny and JA Fee
University of Oxford Medical School, UK
Introduction: Depression is prevalent among general medical in-patients ≥60 years old, yet the reported prevalence varies considerably, and has not been adequately described in the community hospital setting. Description of the prevalence of depression among in-patients with moderate–severe cognitive impairment is also lacking. The objectives of this study were to establish the point prevalence of depressive symptoms in elderly in-patients in community hospitals and to identify the point prevalence of patients unsuitable for screening with GDS-15 due to cognitive impairment. Methods: 107 patients were identified in 5 wards at 3 community hospitals in Oxfordshire. All in-patients were included subject to their consent. Patients were excluded if they were <60 years old, confused, dysphasic, currently prescribed antidepressants or had moderate–severe cognitive impairment (AMTS ≤ 5). Selected patients were subsequently asked the Whooley screening questions and completed GDS-15. Results: 102 patients consented. 53 were excluded; 30 had moderate–severe cognitive impairment; 23 were prescribed antidepressants; 3 were <60 years old; 3 were confused; and 4 were dysphasic. 10 patients met multiple exclusion criteria. 49 patients were selected; 27 (55%) screened Whooley positive and 13 (27%) scored ≥7 on GDS-15, suggesting significant depressive symptoms that met criteria for further assessment. The median GDS-15 score was 4 (range 1–13). Discussion: These results are consistent with previous studies and highlight the potential role of screening for depression in elderly in-patients. 29% of patients had cognitive impairment that precluded the use of GDS-15; consideration must be given to alternative means of detecting depression in this cohort.
Class I HLA typing using plasma as a source of genomic DNA
R Nicoll1, M Jäpel2 and E Thomson2
1Wolfson Medical School Building, University of Glasgow, UK
2MRC Centre for Virus Research, UK
Background and aims: Class I human leucocyte antigens (HLA) determine the effectiveness of the immune response to infection as they govern presentation of antigen to CD8+ cytotoxic T cells. Studies of HLA association with disease can improve understanding of disease pathogenesis but whole blood is not always available as a source of genomic DNA. We aimed to the test the feasibility of using plasma as a source of genomic DNA for HLA typing in a cohort of HIV-positive individuals with acute HCV infection. Methods: Genomic DNA was extracted from 32 plasma samples and exons 2 and 3 of HLA A, B and C were amplified using nested PCR. PCR products were extracted following gel electrophoresis and sequenced. Secondary peaks were identified from sequence chromatograms using CLC Genomics software and HLA allele interpretation was performed using the dbMHC database held at the National Centre for Biotechnology Information. Results: Plasma DNA extractions yielded median DNA concentrations of 3.2 ng/µL (IQR 3.5 ng/µL). Target products were successfully amplified from the majority of samples (A – 30/32, B –27/32, C – 29/32) generating quality chromatograms with clearly visible mixed bases in heterozygotes. HLA alleles were successfully typed at low resolution. Conclusions: We have shown that Class I HLA typing using genomic DNA sourced from plasma is feasible and reproducible. This enables HLA typing in patients where whole blood is unavailable and therefore increases samples available for inclusion in studies investigating the role of HLA in Hepatitis C infection and other disease processes.
Incontinentia pigmenti in horses
RE Towers1, A Clarke2, D Millar2, E Glen3, A Topf3 and J Goodship3
1University of Glasgow, UK
2Cardiff University, UK
3University of Newcastle, UK
Introduction: Incontinentia pigmenti (IP) is a disease affecting ectodermal derived tissues (hair, teeth, skin and eyes) caused by X-linked dominant mutations in the IKBKG gene.1 NEMO, the protein product of IKBKG, is involved in inflammation, immunity, cell proliferation and cell survival.1 Human mutations are often caused by a recombination event between two MER67B repeat sequences resulting in an exon 4–10 deletion.1 A pedigree of horses is exhibiting signs consistent with IP in humans, including linear skin lesions. MER67B repeat sequences are conserved in the horse gene, a similar recombination event could therefore occur in horses. The disease has not previously been identified in horses; this could therefore produce another model organism for IP research. Aims: To establish whether the condition in horses is caused by a mutation in the IKBKG gene. Materials and methods: Supported by the Ectodermal Dysplasia Society we compared clinical features in affected horses and humans. We sequenced exonic and intronic regions of the IKBKG gene to assess variation and heterozygosity. Results and discussion: Horse clinical features were consistent with IP in humans. Heterozygosity within intronic regions between the MER67B repeat sequences was observed excluding an MER67B mediated deletion; however, a smaller deletion or another recombination event could be present. Future study of this family may highlight a novel IP mutation bringing new insight.
Neuritis-induced changes in the expression of the sodium channel Nav1.8 along the rat sciatic nerve
AC Debrach-Schneider, N Richards and A Dilley
Division of Clinical and Laboratory Investigation, Brighton & Sussex Medical School, Brighton, East Sussex, UK
Introduction: Studies on the neuritis model suggest that localised peripheral nerve inflammation is sufficient to cause neuropathic pain behaviours. In this model, intact primary sensory neurons become hyper-excitable and fire spontaneously. Such neuronal hyper-excitability may underlie the development of neuropathic pain behaviours. Changes in the expression of the voltage-gated sodium channel Nav1.8 along nociceptive neurons is considered to play a role in this mechanism. Therefore, the present study has used immunohistochemistry to investigate Nav1.8 distribution along the sciatic nerve in the neuritis model. Methods: The left sciatic nerve was removed from four uninjured adult rats and from three rats where neuritis of the sciatic nerve had been induced by local application of complete Freund’s adjuvant. Tissue was obtained from the neuritis treatment site and an area just proximal, 2–3 days following inflammation. Immunohistochemistry was carried out on tissue sections using the avidin-biotin method. Results: There was a significant increase in the intensity of Nav1.8 immunolabelling at the neuritis site (3.0±0.2%) compared to untreated nerve (1.1±0.4%, p<0.05). A significantly higher level of staining was also observed at the proximal site (3.9±0.1%) compared to the treatment site (p<0.05). Conclusions: Induction of a neuritis resulted in a significant increase in Nav1.8 immunoreactivity proximal to and to a lesser extent at the treatment site itself. This finding infers a role for Nav1.8 in inflammatory pain mechanisms. In particular, Nav1.8 may play a role in the development of neuropathic pain, which makes this channel an interesting molecular target.
An audit on secondary prevention medications following coronary arterial bypass graft (CABG) or cardiac valve replacement or repair during discharge in Ward 50, Cardiothoracic Unit of Aberdeen Royal Infirmary
HG Sim
University of Glasgow Medical School, UK
Background: Recent studies have shown that between 60% and 90% of post-myocardial infarction patients receive each of the discharge medications as recommended by the National Institute for Health and Clinical Excellence (NICE). Methods: This is a prospective audit to evaluate whether all the patients with first time discharge from 1 August 2012 to 22 August 2012 in Ward 50, who had undergone coronary arterial bypass graft (CABG) or heart valve replacement or repair, are discharged with the necessary secondary prevention medications in accordance with national and local guidelines. Results: Among the 30 cardiac surgical patients, 80% of them had CABG and 26.7% had cardiac valve replacement or repair. 80% of the cardiac patients, including contraindicated cases, were discharged with each of the recommended secondary prevention medications in accordance to the guidelines, with 73.9% compliance in CABG and 100% compliance in valve replacement or repair. The use of statin is slightly low (77.8%) whereas the use of angiotensin-converting-enzyme inhibitor is very low (44.4%) in post-CABG patients with acute coronary syndrome (ACS) in the past year. Besides, 83.3% of discharge letters have instruction for their general practitioner to commence prescribing the missing medication. Conclusions: 4 out of the 5 criteria are above the standard of 90%. Hence, the planning of secondary prevention medications during hospital discharge in Ward 50 is excellent in all types of cardiac surgeries except that there is still room for improvement for CABG surgery in patients with ACS in the past year, where ACE-inhibitor and statin are under-prescribed.
Reaudit on the prescription of 300 mg aspirin within 48 hours in in-patients with ischaemic stroke in Gilbert Bain Hospital, Shetland
SL Yew
University of Aberdeen, UK
Background: Stroke causes approximately 53,000 deaths annually in United Kingdom with a north-south gradient in mortality rate of 50% higher in Scotland. The Scottish Stroke Care Audit 2010 showed an improvement in the prescription of aspirin from an average of 41% in 2005 to 73% in 2010. The first audit in 2010 in Gilbert Bain Hospital, Shetland showed a compliance rate of 50% and this was followed by an introduction of stroke care pathway sheet. Method: This was a retrospective reaudit from January 2011 to December 2011. The standard is derived from the Scottish Intercollegiate Guidelines Network, which recommends that all in-patients with ischaemic stroke, diagnosed based on computed tomography scan, should be commenced on 300 mg of aspirin within 48 hours of admission into hospital. Exclusion criteria are patients with haemorrhagic stroke and transient ischaemic attack. Results: There were 28 patients with the diagnosis of ischaemic stroke in 2011. 53.6% (15/28) were given 300 mg aspirin within the 48 hours of admission. On the other hand, 25.0% (7/28) who were not prescribed with aspirin had contraindication, 17.9% (5/28) were without contraindication, and 3.6%(1/28) received therapy after 48 hours. Conclusion: There is a slight improvement in the use of aspirin from 50% in 2010 to 53.6% in 2011, though it still has not met the target of 73%. The delay in the prescription of aspirin is likely to be due to atypical presentations of ischaemic stroke and a limited operational hours of computed tomography scan each day. Hence, more intensive changes are needed.
Evaluation of door-to-ward time in Ayr Hospital
SY Lee
University of Glasgow Medical School, UK
Objectives: 1. To assess time between patient arriving at Emergency Department(ED) and admission in acute medical receiving ward. 2. To identify factors associated with the prolonged time frame if such delay is present. Methods: This was a retrospective study of medical record audit of patients admitted to acute receiving ward of Ayr Hospital during 20 February 2012 to 29 February 2012. Selection was done randomly; 200 eligible patients were enrolled. The time interval of patient leaving A&E and admission to ward were collected and analysed. Inclusion Criteria: Patients transferred from ED to the ward with sufficient time information. Exclusion Criteria: Unrecorded time of arrival in ward, missing A&E sheet, and admissions from other specialties. Results: A door-to-ward time of <4 hours was achieved in 67% of these patients. Mean door-to-ward time was 3 hours 33 minutes (SD 1 hour 39 minutes). Discussion: Government recommends the 4-hour target where patients will wait no longer than 4 hours between arriving at ED and admission, discharge or transfer. Only 67% of the patients in this study met the target. High number of admissions and delays in patient discharge in wards caused this phenomenon. Conclusion: A door-to-ward time of <4 hours was achieved in 67% of these patients. 33% of patients did not meet the 4-hour target. Mean door-to-ward time was 3 hours 33 minutes (SD 1 hour 39 minutes). Prolonged waiting time causes delay in treatment and assessment. A review of management to reduce the waiting time in A&E is essential to improve the quality of patients’ care.
Hypokalaemia: Common things occur commonly
A Reid, G Jones and C Isles
Renal Unit and Department of Biochemistry, Dumfries and Galloway Royal Infirmary, Dumfries, UK
Background: Most reviews of hypokalaemia tend to dwell on syndromes seen only infrequently in clinical practice. We sought to define the typical causes of severe hypokalaemia by undertaking a survey of all adult patients whose serum potassium was ≤2.4 mmol/L during the course of 1 year in South West Scotland (population 147,000). Method: There were 187,704 measurements of urea and electrolytes between 1 January 2010 and 31 December 2010. 61 patients had serum potassium ≤2.4 mmol/L on at least one occasion during that year. Review of case-sheets and lab browser was undertaken in every case. Results: The most common causes were diarrhoea and/or vomiting (51% of cases), diuretic therapy (47%) and nutritional causes, including poor dietary intake, re-feeding syndrome and inadequate potassium supplementation (37%). In 25% of patients a profound fall in serum potassium appeared to coincide with their acute illness. Acute alcohol intoxication and/or alcohol withdrawal were prominent features in 11% of patients. More than one cause was commonly present. There were no cases of Bartter’s, Gitelman’s or Liddle’s syndromes, or of hypokalaemic periodic paralysis in this study. Conclusions: Severe hypokalaemia ≤2.4 mmol/L occurs at least once a week in a district general hospital with a catchment population of around 150,000. Diuretics, vomiting and diarrhoea are commonly implicated, as are nutritional causes, acute illness and alcohol. Our experience suggests that urine potassium is not always measured; urine potassium: creatinine ratio (KCR) is probably the most useful measure of urine potassium loss. Eponymous syndromes and hypokalaemic period paralysis are all extremely uncommon.
Socioeconomic variations in access to smoking cessation interventions in primary care: Insights using the Mosaic classification
L Douglas1 and L Szatkowski2
1University of Nottingham Medical School, UK
2UK Centre for Tobacco Control Studies and University of Nottingham Division of Epidemiology and Public Health, UK
Background: Smoking is the leading cause of preventable illness in the UK, with prevalence being highest amongst more deprived social groups. Using Mosaic classification, a novel measure of socioeconomic status, socioeconomic variations in the delivery of smoking cessation interventions in primary care in the UK were explored. Methods: 460,938 smokers registered in The Health Improvement Network database between July 2008 and June 2010 were analysed. Logistic regression was used to calculate the odds of smokers receiving cessation advice/prescription, by Townsend Index of Multiple Deprivation, the 11 Mosaic groups and 61 Mosaic types. Characteristics of smokers were described qualitatively to suggest ways to target those least likely to receive cessation interventions. Results: The odds of smokers receiving cessation support increased with increasing Townsend deprivation. Using the Mosaic classification, smokers with uncertain employment, living in social housing, in deprived areas were 35% more likely to receive advice than successful professionals living in desirable areas (OR 1.35; 95% CI 1.20–1.52). Furthermore, smokers in low-income families were 50% more likely to receive a prescription than successful professionals (OR 1.50; 95% CI 1.31–1.73). Smokers less likely to receive interventions were well educated, married with no children, and had broadband access. Conclusions: Wide socioeconomic variations exist in the delivery of smoking cessation interventions in UK primary care. Analysis using Mosaic classification suggests that groups with low intervention rates may be best targeted through broadsheet media and the internet, to increase their awareness of the cessation support available in primary care.
The Cog-4 subset of the NIHSS is specific but not sensitive in identifying cognitive impairment as defined using Montréal Cognitive Assessment (MoCA) in stroke patients
GA Shaw1, S Corbet1, C Johnston1, E Moffitt1, J Tan1, J Lua1, E Melling1, Y Miao1 and TJ Quinn2
1University of Glasgow, UK
2Institute of Cardiovascular and Medical Sciences, University of Glasgow, UK
Introduction: The Cog-4 assessment, a subset of items from the National Institutes Health Stroke Scale (NIHSS), used for identifying cognitive impairment has been suggested to be as diagnostically accurate as the Mini Mental State Examination. We sought to compare the Cog-4 with the Montreal Cognitive Assessment, a reliable and valid assessment of cognitive impairment, particularly suited to stroke survivors. We hypothesise that within the acute stroke setting Cog-4 is not sensitive enough an assessment. Methods: A series of sequentially admitted patients following a stroke undertook a battery of assessments. These included the NIHSS, from which the four subsets of the Cog-4 were taken (executive function, orientation, language and inattention), the MoCA, and CAM (Confusion Assessment Method for delirium). We evaluated total Cog-4 and the subsets against the equivalent sections within the MoCA (except inattention which has no equivalent) using specificity and sensitivity measures. We used diagnostic cut-points of 26 for MoCA and 1 for Cog-4. Results: Eighty patients took part; however, 10 patients were unable to complete the MoCA due to blindness or aphasia, leaving 70 patients (mean age 69 (range 28–97), 54% male, 5 with known dementia, 5 CAM positive, OCSP – TACS 15.7%, PACS 27.1%, LACS 28.6%, POCS 8.6%, Other 20%). Overall, the Cog-4 assessment was 83.33% specific and 58.6% sensitive to cognitive impairment. Conclusion: The Cog-4 subscale although specific in identifying cognitive impairment, it is not sensitive enough, in the acute stroke setting, to identify the full extent of a patient’s cognitive impairment compared to the MoCA.
Late outcome after unilateral nephrectomy in Lothian
S Hamilton1, GD Stewart2, SA McNeill2, ACP Riddick2 and R Phelps3
1Medical School, University of Edingburgh, UK
2Department of Urology, Western General Hospital, UK
3Department of Renal Medicine, Royal Infirmary Edinburgh, UK
Introduction: It’s now clear that Chronic Kidney Disease (GFR <60 mL/min) is associated with reduced life expectancy, partly due to an increased risk of cardiovascular disease. To consider the implications for the selection of total versus partial unilateral nephrectomy we compared retrospectively the renal function of patients undergoing either operation in Lothian. Methods: Details were collated across NHS Lothian for 1165 patients. Blood results pre and post-nephrectomy could be retrieved for 334 patients (Group 1). Blood results were also available from at least 6 months post surgery for 194 patients (Group 2). Renal function was estimated using the Abbreviated Modification of Diet in Renal Disease formula. Results: Overall within group 1 total/partial nephrectomy patients’ GFR fell by 14.35 mL/min/1.73m2, (95%CI 11.98–16.72) with new GFR <60 mL/min in 34.1%. Within group 2 patients’ GFR fell by a mean of 14.09 mL/min/1.73 m2, (95%CI 10.93–17.24) with new GFR <60 mL/min in 36.1%. Comparing partial versus total nephrectomy the mean reduction in GFR and occurrence of new GFR <60 mL/min was 8.13, 16.7% and 14.73, 35.4% respectively in group 1 (odds ratio for new GFR <60 2.7 (95%CI 1.4–5.3). Group 2 included too few partial nephrectomy patients for comparison. Conclusions: Smaller reductions of GFR after partial versus total unilateral nephrectomy are of magnitudes that are significant for overall life expectancy in large cohorts, and possibly relevant for patients with indications for nephrectomy and longer life expectancy. Patients that undergo nephrectomy should have their renal function assessed at least 6 months post-surgery to detect new GFR <60 mL/min and trigger appropriate evaluation.
Does hyperglycaemia exacerbate ischaemic brain damage?
R Lim1, D Tarr1, D Graham2, C McCabe1, IM Macrae1, KW Muir1 and D Dewar1
1Institute of Neuroscience and Psychology, University of Glasgow, UK
2BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, College of Medical, Veterinary & Life Sciences, University of Glasgow, UK
Introduction: Post-stroke hyperglycaemia (PSH) is common and associated with increased mortality. Intensive glucose control has not proven beneficial while significantly increasing risk of hypoglycaemia. Few animal studies studying PSH have modelled patients with the metabolic syndrome or induced clinically relevant glucose levels. This study aims to determine the acute effect of clinically relevant hyperglycaemic levels on ischaemic lesion size, using MRI, in normal rats and rats modelling the metabolic syndrome. Methods: Adult male Wistar-Kyoto (WKY) rats modelling normal patients and spontaneously hypertensive stroke-prone rats (SHRSP) modelling metabolic syndrome patients were randomly allocated to normoglycaemic and hyperglycaemic groups (n = 10 each). Diffusion weighted imaging (DWI) was carried out hourly, 1–4 hours after middle cerebral artery occlusion (MCAO). Apparent diffusion coefficient (ADC) values were derived from DWI and each group mean was plotted as a histogram. An ADC threshold of 0.61 × 10−3 mm3/s was applied to define the ischaemic lesion. The volume of ischaemic lesion was calculated as a percentage of the total hemisphere volume and analysed using the 2-way ANOVA. Results: Hyperglycaemia exacerbated ischaemic lesion size in the WKY and SHRSP rats (both p<0.0001). The effect of hyperglycaemia on lesion size was greatest in SHRSP rats, 1-hour post-MCAO (p<0.01). The ischaemic lesion size was bigger in SHRSP rats but the lesion size increased from 1 to 4 hours for WKY rats while growth plateaued at 3-hour post-MCAO for SHRSP rats. Conclusion: The results suggest that glucose levels should be managed in all non-diabetic patients while patients with the metabolic syndrome need to be managed more acutely.
Urinary metabolomics to aid diagnosis of stroke and transient ischaemic attack
CM Keenan, K Burgess, J McClure, M Walters and J Dawson
College of Medicine, Veterinary & Life Sciences, Institute of Cardiovascular and Medical Sciences, Western Infirmary, UK
Minor ischaemic stroke and transient ischaemic attacks (TIAs) can be difficult to diagnose. Brain imaging often supports the diagnosis but even magnetic resonance imaging (the most sensitive technique) only has a sensitivity of 83% for detecting acute ischaemia and less for TIA. Through quantifying the small molecule components of metabolic pathways, metabolomics may help with diagnosis, even when brain imaging is negative. In a retrospective study we used liquid chromatography-mass spectrometry to compare the urinary metabolite profile of cases (patients with recent ischaemic stroke or TIA) to high cardiovascular risk controls. Sixty-four cases (mean age 69 years, 20 TIA, 44 minor stroke) and 42 control subjects (mean age 67 years) were studied. The urine of cases was characterised by increased levels of 2-deoxy-2,3-dehydro-N-acetylneuraminic acid (DANA); [FA dioxo(8:0)] 4,7-dioxo-octanoic acid; suberic acid; 2-keto-4-hydroxybutyrate; 2-dehydro-3-deoxy-L-rhamnonate and 3-ethylmalate and by decreased levels of allantoin; p-benzenediol; dihydroneopterin; hippurate; threonine-alanine-alanine; methanesulfonic acid; alanine-asparagine-aspartic acid and 4,6-dihydroxyquinoline. Using K-Nearest Neighbour analysis we developed a multi-marker classifier to predict patient diagnosis. It contained the metabolites: allantoin; suberic acid; p-benzenediol; hippurate; DANA and dihydroneopterin and differentiated ischaemic stroke from control with 84.1% (76.4%, 91.8%) sensitivity, 85.7% (78.3%, 93.1%) specificity (AUC of 0.80 (0.72, 0.91) on ROC analysis). This study demonstrates the potential of a metabolomic classifier to assist with the diagnosis of minor cerebrovascular events. As the metabolites studied have putative roles in neuronal damage, neurotransmission, oxidative damage and folate biosynthesis, future work with this technique may enhance our understanding of the pathophysiology of acute ischaemic stroke.
Review of viral load blips in HIV patients on treatment – Comparing the performance of different assays in clinical outcome
R Briggs and I Fernando
Chalmers Sexual Health Centre, Edingburgh, UK
HIV can be now be treated effectively with HAART, which prevents viral replication and the efficacy of therapy is monitored using specific assays, which measure the viral load in the plasma of patients’ blood. Although treatment has become more effective over time, these assays have also developed significantly and are now highly sensitive, allowing the detection of even a few copies per millilitre of blood plasma. The increase in efficacy of the assays may have led to a rise in detectable VL results. This study investigates this theory by comparing three different assays each used for 1 year over 3 years in one centre, looking at the first 250 patients to undergo testing. The aim of the study was to look at the number of detectable VLs and determine whether certain assays are more sensitive with regards to producing ‘blips’. The second part of the study looked at comparing the HAART treatment regimens of different patients in order to investigate whether certain types of regimen are more prone to ‘blipping’, as has also been suggested in recent literature. The results illustrated that some assays were more sensitive than others but it appeared that treatment regimen did not impact on VL fluctuations.
Radical hysterectomy: An over treatment for low volume stage IB1 cervical cancer
P Fagan, G Virdi, N Reed and F Alexander-Sefre
Department of Gynaecological Oncology, Glasgow Royal Infirmary, Glasgow, UK
Objective: To identify a subset of patients with low volume stage IB1 cervical cancer who may benefit from simple hysterectomy as opposed to conventional radical hysterectomy. Methods: A retrospective case note review of 90 patients with stage IB1 cervical cancer who underwent radical hysterectomy over 7 consecutive years from April 2001 to April 2008. Following diagnostic Large Loop Excision of the Transformation Zone (LLETZ), tumour volume was assessed by multiplying length × width × depth. Volumes above the cut-off value 500 mm3 were taken as Significant Tumour Volume (STV); and below this value as Non-Significant Tumour Volume (NSTV). Tumours that were macroscopically evident were regarded as STV and only punch biopsies were taken. Results: The median tumour dimensions in patients who underwent LLETZ biopsy were: 11.79 mm length, 6.67 mm width and 6.52 mm depth. There were 51 (56%) patients in the STV group. Within this group, 14 (27%) had parametrial involvement and 7 (14%) had vaginal involvement. There were 39 (44%) cases in the NSTV group and none had parametrial or vaginal involvement (p < 0.001, p = 0.01, respectively). Amongst the patients with STV, 42 (82%) had residual disease as opposed to only 10 (25%) patients in the NSTV group (p<0.0005). The median follow up was 35 months (range 1–85). There were only 3 (3%) recurrences in total, all of whom were within the STV group. Conclusion: Our data supports the current growing opinion that radical hysterectomy can be regarded as over treatment for selected cervical cancer patients with low volume disease.
Evaluation of a prototype infant malnutrition screening tool: Which threshold performs best?
A Tester1, C Woodley1, O Purcell2, M Tsiountsioura2, S Milani2, C Wright2 and K Gerasimidis2
1School of Medicine, University of Glasgow, UK
2Royal Hospital for Sick Children, Glasgow, UK
National guidelines state that all in-patients be screened for malnutrition on admission; currently there is no nutritional screening tool validated for use in infants worldwide. The aim of this pilot study was to assess the diagnostic accuracy of a proposed infant malnutrition screening tool, Infant Paediatric Yorkhill Malnutrition Score – iPYMS. This combines four steps, each predictors of present or future malnutrition, each step scoring up to 2. The validity of iPYMS was assessed by comparing nutritional risk with another screening tool (STRONGKIDS) and dietetic assessment (‘Gold Standard’). Two researchers assessed each of 181 infants and completed both screening tools and dietetic assessment. 53 (30%) of the 177 infants, with a complete iPYMS, had a total score of ≥2. At this level, iPYMS demonstrated high sensitivity (92%) and fair specificity (75%), with positive and negative predictive values of 23% and 99%. iPYMS illustrated poor agreement with the ‘Gold Standard’ (κ = 0.28) and with STRONGKIDS (κ = 0.22), using kappa statistics. Increasing the high risk threshold, to ≥3, slightly decreased sensitivity (85%) but increased specificity (90%), yielding positive and negative predictive values of 41% and 99%. iPYMS demonstrated moderate agreement (κ = 0.50), with dietetic assessment, at this higher threshold. The 42 infants misclassified at high risk with iPYMS, compared with the ‘Gold Standard’, had a longer hospital stay (p = 0.002) and scored highest in Step 4, assessing the effect of their diagnosis on future nutritional status. iPYMS is an acceptable method for assessing infants’ risk of malnutrition; further work is required to optimise its diagnostic performance.
Offer and uptake of HIV testing in the Black African population at Sandyford Clinics across Glasgow
GE Kerridge
Sandyford Sexual Health Services, Glasgow, UK
Background: HIV prevalence is a concern in Scotland. It disproportionately affects Black African communities, accounting for 21% of all HIV diagnoses. Approximately 25% of those with HIV are unaware of their HIV status. Low levels of HIV testing, both offer and uptake, have been reported in Black African communities. Aims: To explore the offer and uptake of HIV testing in the Black African population at Sandyford clinics across Glasgow. Explore reasons for non-offer and opting-out of HIV testing. Method: 101 ‘Black African’ clients who attended the Sandyford between January and October 2011 were randomly selected from the NaSH database and their sexual history and HIV testing information was obtained. Results: HIV testing was offered to 52% (n = 53) clients. Reasons for non-offer of a HIV test were; perceived low risk of client (40%; n = 19), client being HIV positive (10%; n = 5), client within window-period (6%; n = 3) with no reason documented in 44%. Nine clients (21%) had no documentation of any HIV testing on NaSH and were not offered HIV testing. 96.6% who attended for SHS were offered HIV testing with 89.3% accepting. 70.8% of those who attended with STI symptoms were offered HIV testing with 47.1% accepting. 23.3% of clients who attended for contraception were offered HIV testing with none opting for testing. No HIV test was offered to those who attended booked clinics. There was an association between STI-related attendance and offering of HIV testing (p<0.000). Discussion: This audit has highlighted areas where improvement can be made in order to further address the burden of HIV on Black African communities within Glasgow.
Death of the cadaver! A nationwide survey of anatomy teaching across UK medical schools
Z Khan1, A Ali2 and S Elsayed3
1Buckinghamshire Healthcare NHS trust, UK
2Cambridge University Hospitals NHS Trust, UK
3Nottingham University Hospitals NHS Trust, UK
Introduction: Core anatomical knowledge is an integral part of undergraduate medical curriculum. Since the conception of GMC’s Tomorrow’s Doctors, the medical curriculum has steered away from factual content memorisation towards problem-based learning. There has been an associated decline in cadaver dissection. Objectives: To identify how medical students are taught anatomy, establish their preferences and evaluate their confidence in anatomical knowledge. Method: 356 medical students from 20 UK medical schools answered a questionnaire on their experience of anatomy education in UK between 2005 and 2010. Results: Cadaver-dissection as a teaching method has continued to decline. The main method of anatomy teaching was problem-based-learning (35%), lectures (28%) and cadaver dissection (27%). In contrast, dissection was the most preferred method of learning anatomy followed by tutorials and lectures. Furthermore, approximately 50% regarded their knowledge as inadequate at a foundation doctor level. Conclusion: Our study showed a discrepancy between the anatomy teaching methods and student’s preferences for learning. Anatomy teaching should be vertically integrated across the doctor’s training pathway and should remain practically orientated.
Who needs us most? Seeking out those needing rapid neurological assessment
CL Gribbin1, EJ Newman2, P Gallagher2 and JP Leach
1Undergraduate Medical School, University of Glasgow, UK
2Department of Neurology, Southern General Hospital, UK
Introduction: Up to 30% of neurology out-patient referrals result from functional symptoms, many of which are purely sensory. We need to provide faster access to those most in need of our expertise. Methods: General referrals to a neurology service were vetted by a single neurologist (JPL) over a 3-month period (June–August 2011). Communications reporting isolated sensory symptoms were recorded. Histories suggesting peripheral neuropathy or mononeuropathy were excluded. We recorded additional history, examination findings, results of investigations and final diagnosis. Results: 69 patients (68% female, median 43 years) were included. Eleven (15.9%) patients failed to attend. The final diagnosis was as follows: medically unexplained symptoms (MUS) (56.9%); degenerative spinal disease (12.1%); mononeuropathy (12.1%); migraine with aura (6.9%); and multiple sclerosis (5.2%). In 5.2%, the diagnosis remained elusive. The strongest predictors of organic disease were abnormal clinical examination, odds ratio 5.1 (95% CI 1.7–16.0), and additional history of non-sensory symptoms, odds ratio 2.5 (0.8–7.5). Conclusion: The most common underlying diagnosis was functional disorders. The proportion of functional disorders was higher than in previous studies, but only 13.0% had significant neurological conditions unheralded by the referral letter.
The role of micro-RNA in regulating tumour necrosis α factor induced by macrophage and T cell interactions
CR Wood
University of Glasgow, UK
Aims: Macrophage-derived inflammatory cytokines, especially TNFα, are crucial to rheumatoid arthritis (RA) pathology, and understanding their regulation will aid therapeutic design.1 Macrophages produce cytokines following interaction with other cells or activation by endogenous TLR ligands. MicroRNAs are post-transcriptional regulators of gene expression. MiR-155 and miR-146a are implicated in RA macrophage cytokine production.2 This project aimed to investigate whether microRNAs regulate macrophage TNFα production induced by T cells. Methods: CD14+monocytes and CD4+T cells isolated from healthy buffy coats were differentiated into macrophages and cytokine-activated T cells, respectively, and cultured. TNFα concentration and miR-155 expression, in co-cultured and separately cultured cells, were determined by ELISA and real time PCR. Mature macrophages were transfected, 24 hours prior to T cell co-culture, with a control, miR-155 antagomiR or miR-146a antagomiR. TNFα concentration, miR-155 and 146a expression were determined as before. FISH allowed visualisation of miR-155 expression during macrophage and T cell interactions. Results: Co-cultured macrophages exhibited increased TNFα production and upregulated miR-155 expression compared to separately cultured macrophages and T cells. Combined FISH and immunohistochemistry revealed miR-155 expression in co-cultured macrophages, but not co-cultured T cells or macrophages cultured alone. Macrophage TNFα production induced by T cells was unaffected by miR-155 inhibition. MiR-146a inhibition resulted in increased macrophage TNFα production induced by T cells. Conclusions: MiR-155 is dispensable for regulating T cell induced macrophage TNFα production. MiR-146a appears important in macrophage TNFα production induced by T cells, possibly through inhibition of TRAF6 and IRAK1.
References
McInnes IB and Gracie JA. Targeting cytokines beyond tumor necrosis factor-α and interleukin-1 in rheumatoid arthritis. Curr Rheumatol Rep 2004; 6(5): 336–342.Stancyzk J, Pedrioli DML, Brentano F, et al. Altered expression of MicroRNA in synovial fibroblasts and synovial tissue in rheumatoid arthritis. Arthritis Rheum 2008; 58(4): 1001–1009.
Investigation of a novel ACO1 splice variant: Possible implications in lung diseases
N Larsen1, N Kalsheker1, M Ilyas2, S Chappell1 and L Fairclough3
1Human Genetics, School of Molecular Medical Sciences, University of Nottingham, UK
2Department of Pathology, School of Molecular Medical Sciences, University of Nottingham, UK
3Department of Immunology, School of Molecular Medical Sciences, University of Nottingham, UK
Iron is a vital element within the body with roles in many processes essential for cellular survival. At the same time it is capable of causing cellular damage by catalysing the formation of damaging free radicals, which increases levels of cellular oxidative stress. Increased levels of iron have been detected in various pathologies ranging from colorectal cancer to chronic obstructive pulmonary disease suggesting that the above pathway may be implicated in the pathogenesis of these diseases. To prevent excess free iron from causing cellular damage cellular iron homeostasis is tightly regulated by two proteins, aconitase 1 and iron regulatory protein 2. Examination of aconitase 1 mRNA expression in 17 cell lines revealed the presence of a novel splice variant, containing an additional exon in the 5′ untranslated region, which was only expressed in lung cells. Splice variants of this variety have been shown to play a role in disease pathogenesis by altering levels of protein expression and as the lung is particularly susceptible to damage from oxidative stress, increased levels of iron have been detected in lung pathologies such as lung cancer and chronic obstructive pulmonary disease, this alteration may be important. The novel aconitase 1 5′ untranslated region demonstrated significantly altered expression in a reporter gene study using a dual luciferase reporter system. This suggests that the novel variant potentially alters levels of protein expression.
Development of a risk stratification tool for progression of carotid artery stenosis
K Plant and M Walters
Cardiovascular Research Institute, University of Glasgow, UK
Aims: This study explored the relationship between cardiovascular risk factors and progression of carotid artery disease (CAD) in patients presenting to a large urban stroke unit, and investigated the feasibility of a risk stratification instrument to inform clinical management of this population. Methods: The hospital audit registry was consulted to identify patients who had undergone carotid ultrasound imaging on presentation to the acute stroke service more than once between 1990 and 2011. Uni- and multivariate analyses were used to identify associations between the risk factors and CAD progression. Modelling of a risk stratification tool was attempted. Results: 588 patients with more than one carotid imaging episode were identified. 93 (15.8%) patients showed CAD progression and 65 (11.1%) patients showed progression to severe (>70%) stenosis. Multivariate analysis showed increased age (p<0.001), treated hypertension (p<0.031) and male gender (p<0.015) to be predictive of CAD progression, and showed increased age (p<0.008), treated hypertension (p<0.009), smoking (p<0.009) and family history (p<0.045) to be predictive of CAD progression to severe stenosis (>70%). Statistical modelling of these parameters with a view to the development of a clinical risk stratification tool was undertaken and the sensitivity and specificity of the resultant models was promising (AUC of ROC curve 0.7). Conclusion: Treated hypertension, age, smoking, male gender and family history are predictive of CAD progression and may help guide clinicians in assessing the need for repeat carotid artery imaging. Further development of a predictive instrument using additional criteria is justified.
Iron status in severely obese bariatric surgery candidates
R Smith
Department of Medicine, University College London, UK
Background: Obesity is associated with a relatively high prevalence of anaemia and iron deficiency, thought to be due to deranged iron homeostasis. Theories for this include insufficient dietary iron intake; chronic obesity-related inflammation; and social deprivation. Aims: To determine the prevalence of anaemia and iron deficiency in a severely obese cohort of UK bariatric surgery candidates and to explore underlying contributing factors. Methods: A retrospective cohort analysis of 703 patients referred for bariatric surgery was conducted. Patient data was extracted from electronic clinical notes and entered into an anonymous database. Haematological measures relating to iron status (serum iron, total iron binding capacity, iron-binding saturation), nutrition (vitamin B1, B12, D, folate) and inflammation (CRP, white cell count) were measured and tested for associations with BMI, Index of Multiple Deprivation 2007, and co-morbidities. Relationships between iron and inflammation were determined. Results: Anaemia, determined by WHO criteria, was present in 8% of males and 11.5% of females whereas iron deficiency was present in 19.8% of men and 8.2% of women. Patients in the highest quartile of BMI had higher concentrations of inflammatory markers (p<0.01) but poorer iron status (p<0.01). Correlation analysis proved a negative association between measures of inflammation and iron status (p<0.01). Iron-deficient patients were more likely to have vitamin D deficiency; but no association was noted with social deprivation. Conclusions: Iron deficiency is relatively common in severely obese patients. The results suggest connections with inflammation or poor nutrition but not social deprivation; however, analysis of hepcidin is required.
Raising the bar in multidisciplinary record keeping for in-patient notes: An audit of the NHS SBAR tool
H Churchill1, T Dissanayake1, N Record1, V Yeung2 and L Allsopp2
1Medical School, University of Nottingham, UK
2Child and Adolescent Psychiatrist, Thorneywood Adolescent Unit, Specialist Services Directorate - CAMHS, Nottinghamshire Healthcare NHS Trust, UK
Background: With pressure to improve multidisciplinary healthcare, the structure and content of clinical records are essential, enabling effective communication whilst protecting patient and clinician interests. The SBAR (Situation, Background, Assessment, and Recommendations) tool has been adopted as the national NHS standard to assist verbal and written communication. Aims: Increase awareness of the NHS SBAR communications tool. Improve the structure and content of the clinical record across the multidisciplinary team (MDT) by implementing SBAR. Method: A cross-sectional survey of randomly selected multidisciplinary in-patient notes (n = 120) was audited from an adolescent psychiatric ward. The inclusion of SBAR criteria and overall clarity of the entries were recorded. A questionnaire (n = 10) gained staff opinions of note-keeping practices and clarity. There were two cycles of data collection, pre and post MDT education of SBAR. Results: After implementation, the percentage of records including B, A and R increased, as did overall clarity. The percentage including S, however, decreased, but this was not significant overall (1st cycle = 51%, 2nd cycle = 37%). Average record length decreased by 10%. Staff feedback identified a need for better MDT awareness of SBAR, which was achieved by the second cycle, but did not cause a significant change in note-keeping. Conclusion: NHS SBAR communication standards could be better met in the multidisciplinary running records. Further education on the implementation of SBAR needs to be conducted to investigate SBAR efficacy. Recommendations: Further raise MDT awareness of SBAR and its use in clinical note-keeping.
Factors associated with long-term clinical outcomes in a HCV infected cohort
M White1, J John1, R Swann1, E Thomson1 and P Mills2
1University of Glasgow Institute of Infection, Immunity and Inflammation, MRC Centre of Virus Research, Glasgow, UK
2Department of Infectious Diseases, Gartnavel General Hospital, Glasgow, UK
Introduction: Hepatitis C (HCV) diagnostic tests were developed within the last 30 years. Therefore long-term follow-up of patients and factors relating to outcomes are relatively unknown. In Scotland, high HCV prevalence provides a large population to study long-term effects of HCV. Aims: Describe the demographics and long-term outcomes of a single chronically infected cohort of HCV patients and correlate disease progression with clinico-demographic factors. Methods: Retrospective analysis of patients who underwent biopsy staging between 1984 and 2004 from a single centre was preformed. Routinely assessed pathological data and clinico-demographical information was collected. Results were compared statistically using Chi-squared test or Students t-test. Results: A total of 149 patients were studied. The median follow-up from presumed date of infection was 23 years. 18(12%) were lost to follow-up and 32(21%) developed clinical cirrhosis. 93 patients were treated of whom 69% achieved a sustained virological response (SVR). Alcohol consumption and presence of histological steatosis were significantly associated with lower rates of SVR. The majority of our cohort was from deprived areas. Lower deprivation quintile was significantly associated with IVDU use. However, deprivation index itself was not associated with clinical outcomes. Factors associated with development of cirrhosis were increasing age at diagnosis, extensive histological steatosis and increased Ishak fibrosis score at biopsy. Conclusion: The majority of patients in our cohort were infected via IVDU and came from areas of high deprivation. These factors do not seem to affect outcome. However, alcohol excess and steatosis were associated with non-response to treatment.
Utilising adenoviral vectors for therapeutic Timp 3 Gene transfer into vascular smooth muscle cells to prevent restenosis following coronary bypass grafting
S Edwardson, K White and AH Baker
BHF Glasgow Cardiovascular Research Centre, University of Glasgow, UK
Background: The use of adenovirus for gene therapy to treat post-bypass graft vein stenosis has many limitations. The vector’s main cellular entry receptor (CAR) is not present on the smooth muscle cell surface. This has led to a necessity for high viral doses in order to obtain successful TIMP 3 gene expression. Increasing the affinity of the Ad5 vector for CD46 receptor (abundant on smooth muscle cell surface) can increase the vector’s infectivity, using a reporter gene. This potentially facilitates reduction in necessary viral dose, thereby improving its safety. We aimed to demonstrate that increasing the vector’s CD46 affinity (to make T*35++) displays superior infection efficiency and TIMP3 expression in primary cell lines. We also aimed to demonstrate a further reduced cell number and average migration distance when T*35++ is used. Methods: Viral capsid structure was assessed via Silver stain. Western blot and immunofluorescence studies were performed to identify TIMP3 expression. 72 hours post-infection, cell number was counted manually. Average migration distance of the infected samples was assessed using a scratch assay. Results: T*35++ infected cell samples expressed more TIMP3 compared to Ad5 at each viral dose. Cell number was reduced in all infected samples, and was lowest in the T*35++. This was also reflected in the cells’ average migration distance. Conclusions: Increasing the CD46 affinity of Ad5 increases infection efficiency in primary smooth muscle cells, with superior functional outcome. This potentially allows for drastic reduction in necessary viral dose, thereby improving its safety for future clinical trials.
Audit of genetic and biochemical testing in glucose transporter 1 deficiency syndrome and response to ketogenic diet
LN Pascoe
University of Glasgow Medical School, UK
Background: Glucose transporter 1 deficiency syndrome (GLUT1-DS) is a rare condition where there is insufficient transport of glucose into the brain. GLUT1-DS produces a spectrum of clinical features including epilepsy, cognitive impairment and ataxia. The only effective treatment for the condition is the ketogenic diet where ketones produced by the body are used as an alternative energy source by the brain. The aim of this audit was to review the genetic and biochemical diagnosis of GLUT1-DS and determine the necessity of a lumbar puncture for diagnosis. The audit also evaluated the response to the ketogenic diet, particularly seizure control, decrease in movement disorder and improvement in cognitive abilities. Methods: The audit was carried out over a 4-week period at Yorkhill Children’s Hospital. It involved reviewing the case notes of nine patients attending the ketogenic diet clinic at the Fraser of Allander Neurosciences Unit. Results: Seven of the nine patients have a confirmed mutation in the SLC2A1 gene which codes for GLUT1. Five of the nine patients have had a lumbar puncture with four of the five children having abnormally low CSF glucose. The six patients with good compliance to the ketogenic diet have all seen positive results with improvement in their alertness and fewer seizures. Conclusions: Genetic testing is the gold standard for GLUT1-DS and although a lumbar puncture can provide useful information, it is not always necessary for diagnosis and does not improve outcome. Those patients who are able to follow the strict ketogenic diet show good clinical improvement.
Cemented vs. uncemented hemiarthroplasty in femoral neck fracture
AS Leitch, J Joseph, H Murray, TE McMillan and RM Meek
Department of Orthopaedics, Southern General Hospital Glasgow, UK
Background: About 70,000–75,000 hip fractures occur annually in the UK. National guidelines exist to advise management of hip fracture patients, produced by both SIGN and NICE. In patients eligible for hemiarthroplasty, cemented or uncemented prostheses are available. Cemented hemiarthroplasties are associated with better functional outcome and lower incidence of thigh pain and subsidence. There is, however, risk of bone cement implantation syndrome, BCIS, cardiorespiratory compromise around the cementation period. Aim: To assess our centre’s compliance with national guidelines concerning use of cemented vs. uncemented hemiarthroplasty in hip fracture management. Method: This retrospective study examined all hemiarthroplasties performed at the Southern General Hospital between 1 January 2012 and 2 April 2012. Data was collected from theatre logbooks, electronic patient records and patient case notes. The data sought were patient demographics, procedure performed, ASA rating, and pre-morbid functional capacity. Results: 23 hemiarthroplasties were performed with a median patient age/range of 82/70–101 with a male: female ratio of 8:15. 26% (n = 6) received cemented hemiarthroplasty while 74% (n = 17) received uncemented hemiarthroplasty. 75% (n = 3) of patients with an ASA rating of 2 receieved uncemented hemiarthroplasty while 100% (n = 3) of functionally independent patients received uncemented hemiarthroplasty. Conclusions: This audit has highlighted our centre’s poor compliance with existing national guidelines, most notably 75% of patients with ASA 2 and 100% of functionally independent patients being treated with uncemented hemiarthroplasty. In light of these findings, we recommend development and piloting of a clinical assessment tool to determine management taking into consideration: patient age, functional capacity, and pre-morbid state (ASA or BCIS risk factors).
What is the significance of prosthesis selection on the complication rates arising from total elbow arthroplasty for rheumatoid arthritis?
EC Hughes
University of Glasgow Medical School, UK
Introduction: Rheumatoid arthritis of the elbow joint can be a severely debilitating disease. Despite the availability of more conservative treatments, total elbow arthroplasty is currently the recommended approach for late-stage disease. Since many different prosthetic designs exist, this study sought to compare their individual efficacy with respect to resultant complication rates. Methods: The study undertook a literature review, presented in the form of a meta-level study, which cross-tabulated prosthetic design with arising complications. Information on 18 prosthetic designs was collected from which four of the most commonly used prostheses were selected for further analysis; the GSB III, Coonrad-Morrey, Kudo and Souter- Strathclyde. The rates of six common complications were recorded; ulnar nerve damage, infection, fracture, aseptic loosening, dislocation/instability and triceps damage. The results of this cross-tabulation were then compared with findings from other published meta-level reviews. Results: In the study, the GSB III prosthesis appeared to produce slightly higher complication rates than the other three examined designs. However, overall the variance established between prosthesis design and complication rates proved not to be statistically significant. Discussion: The study also draws attention to the many uncontrollable sources of bias that could have affected any reported variation in prosthesis effectiveness. Examples included the involvement of implant designers in the authorship of papers, standardisation of reporting methods and variation in patient sample size. Some wider reflections are offered regarding the interpretative validity of the results and some tentative suggestions made on the causes and solutions for some of the identified complications.
Valganciclovir-induced leucopenia in renal transplant recipients treated with Mycophenolate Mofetil
MA Waduud1 and M McMillan2
1School of Medicine, Wolfson Medical School Building, University of Glasgow, UK
2Glasgow Renal and Transplant Unit, Western Infirmary, UK
Introduction: Cytomegalovirus (CMV) is the most important viral infection in kidney transplant recipients. Current guidelines recommend the prophylactic treatment of patients at risk with oral Valganciclovir (VGC). However, leucopenia is a common side-effect and the severity is thought to be increased when used in combination with Mycophenolate Mofetil (MMF). At present, studies have shown conflicting results. Objective: Evaluate whether using VGC causes leucopenia, white cell count (WCC) less than 4 × 109/L, in patients treated with a MMF immunosuppressive regime post-renal-transplantation. Method: Retrospective analysis of clinical follow-up data of patients’ post-renal-transplantation, from Glasgow, was performed. Patients were analysed depending of treatment received; those treated with MMF and VGC [MMF(+)VGC(+)], those treated with MMF alone [MMF(+)VGC(−)], those treated with VGC alone [MMF(−)VGC(+)] and those treated with neither [MMF(−)VGC(−)]. Blood results and other relevant data were collected from clinical databases: ‘Western Infirmary General (WIG) renal proton’ system and NHS greater Glasgow and Clyde ‘Clinical Portal’. Results: In total data from 78 patients were analysed in this study. All patients had a renal transplant between August 2008 and May 2009. 13 patients were MMF(+)VGC(+), 48 patients were MMF(+)VGC(−), 5 patients were MMF(−)VGC(+) and 12 patients were MMF(−)VGC(−). Of these, 6 MMF(+)VGC(+) patients and 3 MMF(+)VGC(−) patients were leucopenic within the first 3 months post-renal-transplantation (p = 0.001). This difference was not apparent in patients not treated with MMF. Conclusion: Patients treated with MMF and VGC are at a significantly higher risk of leucopenia when compared to patients treated with MMF alone in the first 3 months post-renal-transplantation.
The limitations of transposons as tools of cancer gene discovery
BHJ Rapaport and R Chalmers
School of Biomedical Sciences, University of Nottingham, UK
The identification of the genetic changes that occur in cancer is key to the development of successful therapies. Forward genetic screens for cancer-causing mutations in model organisms offers an attractive approach. The first such screens implemented used retroviruses to generate insertional mutations. However, the limitations of the technique have spurred efforts to develop transposon-based technology. As a group, transposons are attractive because they use a diverse range of mechanisms, which can be adapted for different experimental approaches. Despite the obvious advantages of transposons, they also have several drawbacks. One of the most important recent innovations is to use conditional promoters to restrict transposase expression, and mobility of the element, to specific tissues or stages of development. This approach may hold the key to elucidating the genetic drivers behind metastasis. Following insertional mutagenesis and the recovery of the resulting tumour tissue, candidate cancer genes are identified by virtue of the transposon insertion sites they share in common, which provide a convenient tag. However, this represents a significant experimental challenge because the insertions share a common background of irrelevant insertions. Ideally, the irrelevant insertions should be distributed at random; however, the non-random nature of the insertions produced by some transposons complicates the analysis. A more fundamental problem is that transposon models fail to recapitulate the full complexity of gene aberrations that lead to cancer. The gradual accumulation of mutations, and the progressive genetic instabilities that lead to cancer, remain difficult to address and are one of the main challenges of the future.
The use of Anti-Mullerian Hormone to predict live birth following in vitro fertilisation: an external validation of a prediction model
A Khader
Centre for Population Health, MVLS, University of Glasgow, UK
Introduction: The prediction of outcome of assisted reproductive technology remains inadequate, basing success on maternal age alone. Anti-Mullerian hormone (AMH), produced by ovarian follicles, is an accurate measure of ovarian reserve and is strongly associated with oocyte yield. AMH may therefore act as a predictor of live birth following IVF. A recently constructed nomogram utilises age and AMH levels to stratify people into groups based on chances of success; however, before clinical implementation, requires external validation. The aim of this study was to externally validate the novel prediction model, highlighting the value of AMH. Methods: A cohort of prospectively collected IVF cycles performed from 2006–2010. Predicted probabilities were generated using the nomogram. The relationship between predicted and observed values was calculated. The power of the model was assessed through discrimination (area under ROC curve) and calibration. Results: 822 cycles were included. The clinical pregnancy rate was 32.1% and live birth rate was 29.4%. A non-significant chi-squared value of P = 0.178 confirmed no difference in the predicted and observed values. AUROC was 0.65, similar to the value given for the original study (0.66) and calibration was reasonable. The AUROC of an alternative linear model constructed was 0.65, suggesting no disadvantage to the cut-offs utilized by the nomogram. Conclusion: This study successfully externally validated a novel prediction model for live birth following IVF. It has reasonable discrimination and calibration, stratifying couples into chances of predicted success. The implications of incorporating this model would be in enhancing pre-treatment counselling and aiding the individualization of therapy.
Footnotes
Funding
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
