The role of hypnotherapy in evidence-based clinical practice.

The purpose of this review was to discuss the place of hypnotherapy in a modern medical world dominated by so-called evidence-based clinical practice. Hypnosis is an easily learned technique that is a valuable adjuvant to many medical, dental and psychological interventions.

Increased expression of GDF-15 may mediate ICU-acquired weakness by down-regulating muscle microRNAs.

RATIONALE: The molecular mechanisms underlying the muscle atrophy of intensive care unit-acquired weakness (ICUAW) are poorly understood. We hypothesised that increased circulating and muscle growth and differentiation factor-15 (GDF-15) causes atrophy in ICUAW by changing expression of key microRNAs. OBJECTIVES: To investigate GDF-15 and microRNA expression in patients with ICUAW and to elucidate possible mechanisms by which they cause muscle atrophy in vivo and in vitro. METHODS: In an observational study, 20 patients with ICUAW and seven elective surgical patients (controls) underwent rectus femoris muscle biopsy and blood sampling. mRNA and microRNA expression of target genes were examined in muscle specimens and GDF-15 protein concentration quantified in plasma. The effects of GDF-15 on C2C12 myotubes in vitro were examined. MEASUREMENTS AND MAIN RESULTS: Compared with controls, GDF-15 protein was elevated in plasma (median 7239 vs 2454 pg/mL, p=0.001) and GDF-15 mRNA in the muscle (median twofold increase p=0.006) of patients with ICUAW. The expression of microRNAs involved in muscle homeostasis was significantly lower in the muscle of patients with ICUAW. GDF-15 treatment of C2C12 myotubes significantly elevated expression of muscle atrophy-related genes and down-regulated the expression of muscle microRNAs. miR-181a suppressed transforming growth factor-ß (TGF-ß) responses in C2C12 cells, suggesting increased sensitivity to TGF-ß in ICUAW muscle. Consistent with this suggestion, nuclear phospho-small mothers against decapentaplegic (SMAD) 2/3 was increased in ICUAW muscle. CONCLUSIONS: GDF-15 may increase sensitivity to TGF-ß signalling by suppressing the expression of muscle microRNAs, thereby promoting muscle atrophy in ICUAW. This study identifies both GDF-15 and associated microRNA as potential therapeutic targets.

Paediatric meningitis in the conjugate vaccine era and a novel clinical decision model to predict bacterial aetiology.

OBJECTIVES: The aims of this study were to assess aetiology and clinical characteristics in childhood meningitis, and develop clinical decision rules to distinguish bacterial meningitis from other similar clinical syndromes. METHODS: Children aged <16 years hospitalised with suspected meningitis/encephalitis were included, and prospectively recruited at 31 UK hospitals. Meningitis was defined as identification of bacteria/viruses from cerebrospinal fluid (CSF) and/or a raised CSF white blood cell count. New clinical decision rules were developed to distinguish bacterial from viral meningitis and those of alternative aetiology. RESULTS: The cohort included 3002 children (median age 2·4 months); 1101/3002 (36·7%) had meningitis, including 180 bacterial, 423 viral and 280 with no pathogen identified. Enterovirus was the most common pathogen in those aged <6 months and 10-16 years, with Neisseria meningitidis and/or Streptococcus pneumoniae commonest at age 6 months to 9 years. The Bacterial Meningitis Score had a negative predictive value of 95·3%. We developed two clinical decision rules, that could be used either before (sensitivity 82%, specificity 71%) or after lumbar puncture (sensitivity 84%, specificity 93%), to determine risk of bacterial meningitis. CONCLUSIONS: Bacterial meningitis comprised 6% of children with suspected meningitis/encephalitis. Our clinical decision rules provide potential novel approaches to assist with identifying children with bacterial meningitis. FUNDING: This study was funded by the Meningitis Research Foundation, Pfizer and the NIHR Programme Grants for Applied Research.

Post-acute serum eosinophil and neutrophil-associated cytokine/chemokine profile can distinguish between patients with neuromyelitis optica and multiple sclerosis; and identifies potential pathophysiological mechanisms - a pilot study.

Neuromelitis optica (NMO) is an inflammatory, demyelinating disease of the central nervous system. It is distinguished from multiple sclerosis (MS) by clinical and radiological features and the presence of aquaporin 4 antibodies in approximately 70%. Despite the discovery of these antibodies and the evidence of neutrophils and eosinophils in the CNS parenchyma, the immunopathogenesis of NMO remains poorly understood. Previous studies attempting to assess the role cytokines and chemokines in NMO have primarily been conducted in acute cerebrospinal fluid from East Asian cohorts, have assessed small numbers of mediators in isolation and have not accounted for important confounding factors including antibody status and disease severity. Therefore we conducted a study of a more extensive range of cytokines and associated mediators in post-acute serum from a UK cohort using unsupervised and multivariate analytical techniques to assess the relative concentration of mediators in concert. Our study of 29 patients (aquaporin 4 antibody positive NMO n=19, MS n=10), matched where possible, including for disease severity, has identified and confirmed some key cytokine/chemokine markers in NMO distinct from MS. Our findings shed further light on the importance of specific inflammatory mediators with predominant function in the differentiation, chemotaxis and activity of neutrophils and eosinophils, particularly CCL4, CCL11, granulocyte-colony stimulating factor and myeloperoxidase, and these may represent potential immunomodulatory targets.

Extracorporeal carbon dioxide removal to "protect" the lung.

The case histories are presented of three adults who had severe hypercapnic acidosis despite mechanical ventilation with what were considered to be injurious tidal volumes and airway pressures. The use of a percutaneously inserted arteriovenous extracorporeal carbon dioxide removal (AV-ECCO(2)R) device facilitated a dramatic reduction in the amount of ventilatory support required, achieving a "lung-protective" level. Two patients survived to hospital discharge. One patient died after it became apparent that her late-stage interstitial lung disease was unresponsive to immunosuppression. AV-ECCO(2)R may be a useful strategy in facilitating lung-protective ventilation.

Variation in the ICAM1 gene is not associated with severe malaria phenotypes.

Evidence from autopsy and in vitro binding studies suggests that adhesion of erythrocytes infected with Plasmodium falciparum to the human host intercellular adhesion molecule (ICAM)-1 receptor is important in the pathogenesis of severe malaria. Previous association studies between polymorphisms in the ICAM1 gene and susceptibility to severe malarial phenotypes have been inconclusive and often contradictory. We performed genetic association studies with 15 single nucleotide polymorphisms (SNPs) around the ICAM1 locus. All SNPs were screened in a family study of 1071 trios from The Gambia, Malawi and Kenya. Two key non-synonymous SNPs with previously reported associations, rs5491 (K56M or 'ICAM-1(Kilifi)') and rs5498 (K469E), were tested in an additional 708 Gambian trios and a case-control study of 4058 individuals. None of the polymorphisms were associated with severe malaria phenotypes. Pooled results across our studies for ICAM-1(Kilifi) were, in severe malaria, odds ratio (OR) 1.02, 95% confidence interval (CI) 0.96-1.09, P=0.54, and cerebral malaria OR 1.07, CI 0.97-1.17, P=0.17. We assess the available epidemiological, population genetic and functional evidence that links ICAM-1(Kilifi) to severe malaria susceptibility.

TGF-beta is a critical mediator of acute lung injury.

We have shown that the integrin alphavbeta6 activates latent TGF-beta in the lungs and skin. We show here that mice lacking this integrin are completely protected from pulmonary edema in a model of bleomycin-induced acute lung injury (ALI). Pharmacologic inhibition of TGF-beta also protected wild-type mice from pulmonary edema induced by bleomycin or Escherichia coli endotoxin. TGF-beta directly increased alveolar epithelial permeability in vitro by a mechanism that involved depletion of intracellular glutathione. These data suggest that integrin-mediated local activation of TGF-beta is critical to the development of pulmonary edema in ALI and that blocking TGF-beta or its activation could be effective treatments for this currently untreatable disorder.

B-type natriuretic peptide in reversible myocardial ischaemia.

BACKGROUND: Coronary heart disease is associated with increased B-type natriuretic peptides (BNPs), and, although controversial, may cause exaggerated exercise-induced BNP secretion. We investigated BNP in relation to reversible myocardial ischaemia. MATERIALS AND METHODS: Serum N-terminal proBNP (NT-proBNP) was measured before and after an exercise electrocardiogram test (ETT) in 14 patients with and 45 patients without exercise-induced myocardial ischaemia. Statistical analysis was carried out on logarithmically transformed data. Results, however, are pre-transformed data. RESULTS: NT-proBNP increased with exercise both in ETT-positive patients (mean (SD) 71.4 (41.2) v 76.8 (44.0) ng/l; p<0.001) and ETT-negative patients (54.0 (61.2) v 60.1 (69.0) ng/l; p<0.001). Pre-exercise and post-exercise NT-proBNP were higher (p<0.05) in ETT-positive than in ETT-negative patients. Incremental NT-proBNP was similar in ETT-positive (4.7 (4.2) ng/l) and ETT-negative (6.2 (8.6) ng/l) patients. CONCLUSION: Serum NT-proBNP concentrations are higher in patients with exercise-induced myocardial ischaemia than in those without. Exercise-induced electrocardiographic myocardial ischaemia, however, is not associated with exaggerated BNP secretion.

Repopulation of human pulmonary epithelium by bone marrow cells: a potential means to promote repair.

After lung injury and damage to the alveolar epithelium, the underlying basement membranes become exposed. Proliferation of type II pneumocytes and their differentiation to the type I phenotype have been considered to be the mechanism by which repopulation of the alveolar epithelium occurs. A growing body of evidence has shown that tissues can be repaired by cells acquired via the circulation. For the lung, bone marrow stem cells have been shown in mice to regenerate epithelium as well as give rise to the expected mesodermal derivatives. We hypothesized that extrapulmonary cells, including those from the bone marrow, can contribute to the reepithelialization of human alveoli. To investigate this, we examined samples of peripheral lung from patients who had undergone cross-gender transplantation of lung or bone marrow. Thus, archival blocks of peripheral lung were analyzed from male patients (surgical samples, n = 8) who had received a lung transplant from a female donor and female patients (postmortem samples, n = 3) who had male bone marrow transplants. In both cases, male cells were identified in the female lungs by Y chromosome in situ hybridization. Male cells could be identified in the alveolar epithelium where, in the better preserved, transplanted lungs, it was possible to show that some had differentiated to type II pneumocytes. In addition, Y chromosomes were found to be widespread in cells of mesenchymal lineage, including macrophages and endothelial cells. Concomitant visualization of Y and X chromosomes, using fluorescence immunolabeling, yielded no evidence of cellular fusion, although the poor quality of the autopsy samples studied meant that the possibility could not be excluded. These observations suggest that, as occurs in rodents, the epithelium of the adult human lung has the capacity to renew itself, using cells recruited from extrapulmonary sources, including the bone marrow. This finding could provide new therapeutic opportunities for a range of pulmonary diseases by providing means to repair the lung and a novel route for gene therapy.

Prenatal origin of hyperdiploid acute lymphoblastic leukemia in identical twins.

Studies in identical twins and with neonatal blood spots (Guthrie cards) have backtracked the origin of childhood acute leukemia and their associated chromosomal translocations to before birth. High hyperdiploidy is the most common genetic abnormality in childhood acute lymphoblastic leukemia (ALL). Evidence for an in utero initiation of this important genetic event in ALL is available from blood spots but remains limited. Twin children with hyperdiploid ALL have not hitherto been reported. We describe a pair of 2-year-old monozygotic twins with concordant B-cell precursor ALL and hyperdiploid karyotypes. One twin's leukemic cells had two rearranged TCRD alleles and one of these was a clonotypic Vdelta2-Ddelta3 sequence shared with leukemic cells of the other twin. The twins' leukemic cells had several different IGH V(H)-J(H) rearrangements but shared two common D(H)-J(H) 'stem' sequences. We conclude that ALL in these twins is likely to have originated prenatally in one fetus before spreading to the other via intraplacental anastomoses. It is likely that one or more additional postnatal genetic events was required for overt leukemogenesis.

Adult spontaneous hypoglycaemia.

Spontaneous hypoglycaemia is not a diagnosis, but a manifestation of a disease process. It is important to recognize spontaneous hypoglycaemia, as treatment may be preventative or curative. It is equally important to avoid mislabelling healthy individuals as having hypoglycaemia as this may have a negative impact on the quality of life and use of scarce health-care resources.

Will mixed chimerism cure autoimmune diseases after a nonmyeloablative stem cell transplant?

BACKGROUND: Mixed chimerism after allogeneic bone marrow transplantation has been shown to cure a number of genetic disorders in both the clinical and experimental settings. Although encouraging results have been reported from animal experiments, the role of mixed chimerism in eliminating autoimmune disorders is not clear. METHODS: A 50-year-old man with extensive psoriasis received an allogeneic transplant from his brother after nonmyeloablative conditioning with fludarabine, melphalan, and Campath-1H for relapsed non-Hodgkin's lymphoma. The chimerism status and the immunological recovery after the transplant were serially monitored. RESULTS: Twenty-one months after the transplant, the patient continues to be in complete remission from psoriasis and lymphoma with stable mixed chimerism (30% to 40% donor cells), despite significant recovery of T-cell subsets and antigen-specific response. CONCLUSIONS: If mixed chimerism can be achieved safely with novel low-intensity conditioning regimens and results in sustained remission of autoimmune diseases, allogeneic transplantation may become a realistic therapy in the management of some patients with autoimmune disease.

Aminoguanidine selectively inhibits inducible nitric oxide synthase.

1. Endotoxin induces nitric oxide synthase in vascular tissue, including rat main pulmonary artery. Currently available agents that cause inhibition of nitric oxide synthase are relatively non-selective between the constitutive and inducible forms of the enzyme. 2. Aminoguanidine caused a dose-dependent increase in phenylephrine-induced tension in intact and endothelium-denuded pulmonary artery rings from endotoxin-treated rats, but had no effect on sham-treated controls. 3. Contraction caused by aminoguanidine in endothelium-denuded vessels from endotoxin-treated rats was unaffected by indomethacin (10 microM), and by cimetidine and mepyramine (both 10 microM), excluding an effect of aminoguanidine mediated by arachidonic acid metabolites or histamine. 4. Contraction caused by aminoguanidine in endothelium-denuded vessels from endotoxin-treated rats was abolished by L-arginine (2 mM) and L-NG-monomethyl arginine (300 microM), but unaffected by D-arginine and D-NG-monomethyl arginine, suggesting that its action is mediated by the L-arginine/nitric oxide pathway. 5. Aminoguanidine had no effect on acetylcholine-induced relaxation of intact vessels from shamtreated rats. However, relaxation of artery rings from endotoxin-treated rats by L-arginine was competitively inhibited by aminoguanidine.6. These results in isolated main pulmonary arteries of the rat confirm previous reports that aminoguanidine is a selective inhibitor of inducible nitric oxide synthase.

A fatal case of disseminated aspergillosis caused by a non-sporulating strain of Aspergillus fumigatus.

This report describes the case of a 38 year old pregnant woman with fatal disseminated aspergillosis and multiorgan failure, which was preceded by a long history of allergic bronchopulmonary aspergillosis. Postmortem revealed massive infarction and abscess formation in both lungs. Histology revealed a focal granulomatous response. Fungal infiltration with areas of necrosis were also seen in the liver, spleen, and paratracheal, mediastinal, para-aortic, and hilar lymph nodes. Culture of tissue samples produced a non-sporulating, beige coloured fungus that developed green pigmentation only after three weeks of incubation. Nucleotide sequencing of the D1-D2 region of the large ribosomal subunit revealed 100% homology with Aspergillus fumigatus. Minimum inhibitory concentrations for amphotericin B and itraconazole were both 0.25 mg/litre (susceptible). Further work is urgently required to determine the prevalence of such non-sporulating strains and their relevance to clinical infection.

Chromosome abnormalities involving band 13q14 in hematologic malignancies.

Fifteen patients with hematologic disorders showed abnormalities involving chromosome band 13q14. Nine patients had an interstitial deletion of this band, similar to that reported in some retinoblastoma tumors and as a constitutional abnormality in a small proportion of cases of familial retinoblastoma. In five patients, band 13q14 was involved in translocations and in one case there was a deletion of one chromosome #13 and a translocation involving the homologous #13. The diagnosis in the majority of our patients (11 of 15) was chronic lymphocytic leukemia. In these patients the abnormalities were detected in cultures stimulated with 4-phorbol 12-myristate 13-acetate (PMA). It is possible that the utilization of this agent is a fundamental requirement for the reliable demonstration of abnormalities involving 13q14 in patients with B-cell malignancies. The incidence of abnormalities involving 13q14 and their significance in the development of neoplasias, other than retino-blastoma, is discussed.

An intra-oral telemetry system for the continuous recording of vertical jaw movement.

Continuous measurement of the separation between upper and lower dental arches, the so-called interocclusal distance (10D), is of interest in dentistry. Criteria for making such measurements by radio telemetry are discussed. It is concluded that a transmitter small enough to fit in a molar tooth gap is necessary in order to minimize interference with normal function; other design factors are related to obtaining adequate frequency stability, on which measurement accuracy depends. A transmitter fulfilling these requirements is described which sensed the instantaneous value of 10D by the frequency change produced when a metallic object (dental filling, gold crown, shorted turn of wire or piece of ferrite) in one dental arch moved relative to the transmitter in the other. Errors due to lateral and protrusive jaw movements were measured. Careful design and the use of high grade ceramic chip capacitors resulted in a transmitter of good frequency stability (+/- 0.03% in 10 h, +/- 0.02%/degrees c) and small size (10 X 7 X 5 mm). An example is given illustrating 10D movements due to swallowing, speech and respiration.

Telemetry and the study of vertical jaw relations.

A method of monitoring vertical jaw separation over extended periods by radiotelemetry is given. The patterns of mandibular movement evoked by different activities such as rest, work, sleep and swallowing and the effect of a bite-raising splint are described. The influence of gravity and friction on mandibular rest position is discussed. The results were consistent with the view that the rest position of the mandible is determined by passive soft tissue balance, but subject to overriding muscular control as shown when a bite-raising splint was worn.

The de Lange syndrome in association with a bleeding tendency: oral surgical implications.

A patient with de Lange syndrome who also had a variant of von Willebrand's disease is reported. The problems with dental surgery, particularly with respect to difficulty of extraction and bleeding tendency, are discussed.

In vitro and in vivo studies of homocysteine in equine tissues: implications for the pathophysiology of laminitis.

REASONS FOR PERFORMING STUDY: Elevated plasma homocysteine (HCy) concentration is a risk factor for cardiovascular diseases associated with endothelial dysfunction, including the human digital ischaemic disease, Raynaud's phenomenon. HYPOTHESIS: HCy causes dysfunction of equine vascular endothelium and elevated plasma concentrations predispose to laminitis. OBJECTIVES: To determine 1) the concentration of HCy in vitro, which inhibits equine vascular endothelial cell function and 2) any association between risk of laminitis and plasma HCy concentration. METHODS: Endothelial function was studied by measuring endothelium-dependent vasodilatory responses of the equine isolated perfused digit and basal nitric oxide (NO) production by cultured equine digital vein endothelial cells (EDVECs). Total plasma HCy (tHCy) concentrations were measured in samples collected in the winter and spring from normal ponies and ponies predisposed to laminitis. RESULTS: HCy (10 and 100 micromol/l) inhibited endothelial function and, at concentrations above 100 micromol/l, inhibited NO production by EDVECs. Plasma tHCy concentration ranged from 13 to 14.7 micromol/l. There was no effect of season or disease status on the concentration measured. CONCLUSIONS: In vitro, HCy was shown to interfere with endothelial cell function at physiologically relevant concentrations. No evidence was found for an association between risk of laminitis and high plasma concentrations of HCy. POTENTIAL RELEVANCE: Elevated plasma HCy concentrations could adversely affect endothelial cell function and mangement regimens that lead to increases in plasma HCy concentration should be avoided in ponies predisposed to laminitis.