The Global Task Force for Chronic Pain in People with HIV (PWH): Developing a research agenda in an emerging field.

Chronic pain is a common comorbidity in people with HIV (PWH), with prevalence estimates of 25-85%. Research in this area is growing, but significant gaps remain. A Global Task Force of HIV experts was organized to brainstorm a scientific agenda and identify measurement domains critical to advancing research in this field. Experts were identified through literature searches and snowball sampling. Two online questionnaires were developed by Task Force members. Questionnaire 1 asked participants to identify knowledge gaps in the field of HIV and chronic pain and identify measurement domains in studies of chronic pain in PWH. Responses were ranked in order of importance in Questionnaire 2, which was followed by a group discussion. 29 experts completed Questionnaire 1, 25 completed Questionnaire 2, and 21 participated in the group. Many important clinical and research priorities emerged, including the need to examine etiologies of chronic pain in PWH. Pain-related measurement domains were discussed, with a primary focus on domains that could be assessed in a standardized manner across various cohorts that include PWH in different countries. We collaboratively identified clinical and research priorities, as well as gaps in standardization of measurement domains, that can be used to move the field forward.

The sensory and affective components of pain: are they differentially modifiable dimensions or inseparable aspects of a unitary experience? A systematic review.

BACKGROUND: Pain is recognised to have both a sensory dimension (intensity) and an affective dimension (unpleasantness). Pain feels like a single unpleasant bodily experience, but investigations of human pain have long considered these two dimensions of pain to be separable and differentially modifiable. The evidence underpinning this separability and differential modifiability is seldom presented. We aimed to fill this gap by evaluating the current evidence base for whether or not the sensory and affective dimensions of pain can be selectively modulated using cognitive manipulations. METHODS: A rigorous systematic search, based on a priori search terms and consultation with field experts, yielded 4270 articles. A detailed screening process was based on the following recommendations: (i) evaluation of effectiveness; (ii) examination of methodological rigour, including each study having an a priori intention to cognitively modulate one of the two dimensions of pain; and (iii) sound theoretical reasoning. These were used to ensure that included studies definitively answered the research question. RESULTS: After in-depth critique of all 12 articles that met the inclusion criteria, we found that there is no compelling evidence that the sensory and affective dimensions of pain can be selectively and intentionally modulated using cognitive manipulations in humans. CONCLUSIONS: We offer potential explanations for this discrepancy between assumptions and evidence and contend that this finding highlights several important questions for the field, from both the research and clinical perspectives.

Warm Homes, Healthy People Fund 2011/12: a mixed methods evaluation.

OBJECTIVES: To assess how the Warm Homes Healthy People Fund 2011/12 was used by English local authorities and their partners to tackle excess winter mortality. STUDY DESIGN: Mixed-methods evaluation. METHODS: Three sources of data were used: an online survey to local authority leads, document analysis of local evaluation reports and telephone interviews of local leads. These were analysed to provide numerical estimates, key themes and case studies. RESULTS: There was universal approval of the fund, with all survey respondents requesting the fund to continue. An estimated 130,000 to 200,000 people in England (62% of them elderly) received a wide range of interventions, including structural interventions (such as loft insulation), provision of warm goods and income maximization. Raising awareness was another component, with all survey respondents launching a local media campaign. Strong local partnerships helped to facilitate the implementation of projects. The speed of delivery may have resulted in less strategic targeting of the most vulnerable residents. CONCLUSIONS: The Fund was popular and achieved much in winter 2011/2012, although its impact on cold-related morbidity and mortality is unknown.

An evaluation of two decision-making scales for children with life-limiting illnesses.

PURPOSE: Annually, about 500,000 children are coping with life-limiting illnesses. Many of these children could benefit from pediatric palliative care which provides supportive services. These services can also aid parents in decision making. In order to measure the effect of pediatric palliative care programs on decision making, a valid and reliable tool must be identified. This study aims to validate the psychometric properties of the Decisional Conflict Scale (DCS) and the COMRADE instruments for children with life-limiting illnesses. METHODS: Analyses were conducted using survey data collected from 266 parents whose Medicaid enrolled children have life-limiting illnesses. RESULTS: Results of the analyses suggest that the DCS has better psychometric properties for measuring decision making within the population of children with life-limiting illnesses than the COMRADE. CONCLUSION: Pediatric palliative care programs should use the DCS to measure the effectiveness of services aimed at supporting families with high levels of decisional conflict.

Paediatricians' perceptions on referrals to paediatric palliative care.

Children have traditionally been referred to palliative care when curative treatments were exhausted. Recently, experts have suggested that children could benefit from palliative care early in their courses of illness. Using survey data from 303 paediatricians in Florida and California, this study assesses if paediatricians would refer children to palliative care early in their course of illness. Results showed that more years in practice were associated with decreased odds of referring children to palliative care. Academic practice setting and more Medicaid patients were associated with greater odds of referral prior to the end of life. Hispanic paediatricians, those with more experience and those who practice in a hospital setting were associated with decreased odds of referral prior to the end of life. Results suggest that health planners who wish to implement or refine integrated paediatric palliative care programs should consider outreach strategies targeted at paediatricians with specific characteristics.

Smooth muscle in the annulus fibrosus of the tympanic membrane in bats, rodents, insectivores, and humans.

The annulus fibrosus and its attachment to the bony tympanic ring were studied in a series of mammals. In the pallid bat, Antrozous pallidus, there is an extensive plexus of large interconnected blood sinuses in the part of the annulus that borders the tympanic bone. The spaces between the sinuses are packed with smooth muscle cells. Most of the cells have a predominately radial orientation; they extend from the bony tympanic sulcus to a dense collagenous matrix (apical zone) where radially oriented fibers of the pars tensa are confluent with the annulus. The muscles and vessels constitute a myovascular zone. A structurally similar myovascular zone is also present in the European hedgehog. In rodents, the annulus lacks the large interconnected blood sinuses but many small vessels are present. Smooth muscle is concentrated in the broad area of attachment of the annulus to the tympanic bone. In the gerbil, smooth muscle seems to be concentrated in the central part of the width of the annulus where it is attached to bone and radiates toward the tympanic membrane. In humans collections of radially oriented smooth muscle cells were found in several locations. The smooth muscle in all species studied appears to form a rim of contractile elements for the pars tensa. This arrangement suggests a role in controlling blood flow and/or creating and maintaining tension on the tympanic membrane.

Gene therapy for prostate cancer delivered by ovine adenovirus and mediated by purine nucleoside phosphorylase and fludarabine in mouse models.

A gene-directed enzyme pro-drug therapy (GDEPT) based on purine nucleoside phosphorylase (PNP), that converts the prodrug, fludarabine to 2-fluoroadenine, has been described, but studies are limited compared with other GDEPTs. We investigated the in vitro and in vivo efficacies of PNP-GDEPT for treating androgen-independent (AI) prostate cancer. The PNP gene controlled by Rous sarcoma virus (RSV) constitutive promoter was delivered using a recombinant ovine adenovirus vector (OAdV220) that uses a different receptor from human adenovirus type 5. In vitro, OAdV220 provided increased transgene expression over a comparable human Ad5 vector in infected AI, murine RM1 prostate cancer cells. Subsequent in vivo testing was therefore confined to OAdV220. Transduction of RM1 cells with OAdV220 before implantation in immunocompetent mice dramatically inhibited subcutaneous (s.c.) tumor growth when fludarabine phosphate was administered systemically and increased mouse survival in a dose-dependent manner. In tumor-bearing C57BL/6 mice, a single intratumoral injection of OAdV220 produced detectable PNP activity for at least 6 days and with prodrug, retarded the growth of aggressive RM1 s.c. tumors by 35% at day 14. There was a consistent trend to reduction of pre-established intraprostatic RM1 tumors. A similar regimen induced significant therapeutic efficacy in human PC3 xenografts. Thus, ovine adenovirus-mediated GDEPT using the PNP system was effective in vivo against AI prostate cancers, the aggressive murine RM1, and the human PC3 lines. Methods that improve viral dissemination and stimulate the immune system in vivo may further improve efficacy.

Adult-derived stem cells from the liver become myocytes in the heart in vivo.

Recent evidence suggests that adult-derived stem cells, like their embryonic counterparts, are pluripotent. These simple, undifferentiated and uncommitted cells are able to respond to signals from their host tissue microenvironment and differentiate, producing progeny that display a phenotype characteristic of the mature cells of that tissue. We used a clonal stem cell line (termed WB-F344) that was derived from an adult male rat liver to investigate the possibility that uncommitted stem cells from a nonmyogenic tissue source would respond to the tissue microenvironment of the heart in vivo and differentiate into cardiac myocytes. Male WB-F344 cells that carry the Escherichia coli beta-galactosidase gene were identified in the left ventricular myocardium of adult female nude mice 6 weeks after transplantation. We confirmed the presence of a rat Y-chromosome-specific repetitive DNA sequence exclusively in the beta-galactosidase-positive myocytes by polymerase chain reaction and fluorescence in situ hybridization. Immunohistochemistry, using a cardiac troponin T-specific monoclonal antibody, and ultrastructural analysis confirmed a cardiac myocyte phenotype of the stem cell-derived myocytes. The beta-galactosidase-positive myocytes ranged from < 20 microm to 110 microm in length. The longer of these cells contained well-organized sarcomeres and myofibrils, and formed intercalated disks and gap junctions with endogenous (host-derived) myocytes, suggesting that WB-F344-derived myocytes participate in the function of the cardiac syncytium. These results demonstrate that adult liver-derived stem cells respond to the tissue microenvironment of the adult heart in vivo and differentiate into mature cardiac myocytes.

Ultrastructure of the inner ear of NKCC1-deficient mice.

The transduction of the auditory signal is dependent on the flow of ions within the inner ear. We have generated mice deficient in NKCC1, an ion cotransporter that is thought to be involved in the secretion of K+ by the strial marginal cells. Inner ear histology revealed partial to almost total absence of the scala media and collapse of Reissner's membrane. Ultrastructural analysis showed that Reissner's membrane consists of 3-4 cell layers instead of the usual two, and a substance of unknown composition is present between Reissner's membrane and underlying structures. Within the tunnel of Corti, hair cells and supporting cells were difficult to identify. The location of the tectorial membrane was altered, and a precipitate was observed surrounding it. Severe structural defects were noted in the interdental cells and Boettcher cells, and mild defects were observed in the stria vascularis and in type II and type IV fibrocytes. The finding that major defects occur predominantly in cells that are not known to express NKCC1 suggests that loss of NKCC1 results in functional defects in cells expressing NKCC1 and a morphological effect on cell populations downstream in the proposed K+ recycling pathway.

A newly characterized human endometrial adenocarcinoma cell line (CAC-1) differentiates in response to retinoic acid treatment.

A new cell line of poorly differentiated human endometrial adenocarcinoma cells termed "CAC-1" cells has been established. These cells are epithelial, as indicated by positive cytokeratin and negative vimentin staining. They are rounded and possess a high nuclear-to-cytoplasmic ratio, desmosomes, surface microvilli, intercelular lumens, and pleomorphic nuclei containing multiple nucleoli. These cells have been in long-term culture for 2 years. Our previous studies demonstrated that moderately differentiated (RL95-2) cells differentiated in response to retinoic acid treatment, illustrated by their reorganization of actin filaments and cell enlargement (Carter et al., 1996; Anticancer Res. 16, 17-24). CAC-1 cells exhibited a similar response because they also organized actin filaments and enlarged in response to retinoic acid treatment. Concurrently, retinoic acid treatment caused a 40% decrease in cell detachment in an in vitro detachment assay compared to controls. A slight lag in cell growth was observed when CAC-1 cells were treated with 1 microM 13-cis or all-trans retinoic acid during a 12-day growth curve. In addition, we examined the effects of retinoic acid on protein kinase C-alpha (PKC-alpha) and myristoylated alanine-rich C-kinase substrate (MARCKS). Treatment with retinoic acid caused cytoplasmic PKC-alpha to increase concomitant with a decrease in PKC-alpha in the membrane. In contrast, MARCKS increased in the membrane in response to retinoic acid treatment. These data indicate that retinoid treatment causes inactivation of PKC-alpha, allowing MARCKS to relocalize to the membrane, where it can cross-link actin filaments. CAC-1 cells represent an ideal model for investigating the effects of retinoids on differentiation induction concomitant with actin reorganization.

Procathepsin L self-association as a mechanism for selective secretion.

The lysosomal cysteine pro-protease procathepsin L was enriched in dense vesicles detectable when microsomes prepared from wild-type or transformed mouse fibroblasts were resolved on sucrose gradients. These dense vesicles did not comigrate with proteins characteristic of the endoplasmic reticulum, Golgi, endosomes or lysosomes. When gradient fraction vesicles were lysed at acidic pH in the presence of excess mannose 6-phosphate to prevent binding to mannose phosphate receptors, the majority of the procathepsin L was associated with the membrane, not the soluble, fraction. Immunogold labeling of procathepsin L in thin sections of cells or gradient fractions, using antibodies directed against the propeptide to avoid detection of the mature enzyme in dense lysosomes, revealed that the proenzyme was concentrated in dense cores localized in small vesicles near the plasma membrane and in multivesicular bodies. Consistent with the density of the gradient fraction and the electron density of the cores, yeast two-hybrid assays indicated the proenzyme could bind itself but could not interact with the aspartic proprotease procathepsin D. The data suggest that in mouse fibroblasts procathepsin L may self-associate into aggregates, initiating the formation of dense vesicles that could mediate the selective secretion of procathepsin L independent of mannose phosphate receptors.

Nutritional benefits of drinks.

Much is known about the importance of promoting adequate nutrition, but the fluid content of a patient's diet is not always as strongly emphasised. Vicki Madden discusses the benefits of various drinks in helping to keep patients hydrated.

Comparative neurotoxicity of oxaliplatin, cisplatin, and ormaplatin in a Wistar rat model.

Oxaliplatin (4 mg/kg), cisplatin (2 mg/kg with 20 mg/kg mannitol) and ormaplatin (2 mg/kg) were administered i.p. twice weekly for 4.5 weeks. Lactose injections (0.9%) were used as a control for oxaliplatin and 0.9% saline injections were used as a control for cisplatin and ormaplatin. Morphometric changes to dorsal root ganglia L4-L6 were quantitated as a measure of neurotoxicity. Drug treatment resulted in a decrease in cell and nuclear area and an increase in the percentage of cells with eccentric nucleoli for neuronal cell bodies in the DRG. Immediately following treatment the order of morphometric changes was ormaplatin > cisplatin > or = oxaliplatin. The accumulation of platinum in the DRG was measured by inductively coupled plasma mass spectrometry. The order of accumulation was cisplatin > oxaliplatin > ormaplatin. Following an 8-week recovery period the order of morphometric changes to the DRG was ormaplatin approximately equal to oxaliplatin > cisplatin. This correlated with a greater retention of platinum by the DRG for ormaplatin and oxaliplatin than for cisplatin. The results suggest that ormaplatin is uniquely neurotoxic immediately following treatment in the Wistar rat model. However, following an 8-week recovery period both ormaplatin and oxaliplatin are more neurotoxic than cisplatin and this neurotoxicity correlates with a greater retention of platinum by the DRG.

Rapid decalcification of temporal bones with preservation of ultrastructure.

Decalcification of temporal bones, especially from primates, has routinely required long periods of time and has been a major deterrent to many types of morphological studies. In this investigation, temporal bones from the monkey, Macaca fuscata, were decalcified with ethylene diamine tetraacetic acid (EDTA) in a microwave oven. To isolate effects of microwaves on decalcification, tissue was fixed and embedded using routine methods; only decalcification was carried out in the microwave oven. The procedure is described in detail. Instead of months, decalcification was complete in two working days. Control procedures included decalcification at room temperature and use of a regular oven at a temperature equal to that reached in the microwave. The ultrastructure of cochlear tissue was equal to or better than that obtained with routine decalcification.

Host-derived intracellular immunization against mouse hepatitis virus infection.

Mouse hepatitis virus (MHV) utilizes the murine biliary glycoprotein receptor (BgpA) for entry into susceptible cells. The Bgp1 gene was transfected into a murine DBT cell clone that expressed little if any BgpA receptor and resisted wild-type MHV infection. Clones which expressed low levels of receptor were efficient hosts for MHV-A59 replication. Clones which expressed 20- to 69-fold more BgpA receptor than controls were also susceptible to MHV-A59 infection, yet few infectious progeny virions were released. Pretreatment of clones with monoclonal antibody CC1, which binds to the N-terminus of BgpA, blocked MHV-A59 replication in DBT clones that expressed wild-type levels of receptor protein. In the overexpressing cell clones, however, CC1 pretreatment reversed the BgpA overexpression blockade and increased virus titers by 3-4 logs. BgpA overexpression inhibited the formation of infectious extracellular and intracellular virions, but levels of virus transcription were equivalent to those of controls. Ultrastructural studies revealed normal cell cytopathology in both the MHV-A59-infected controls and the overexpressing cell clones. Although equivalent numbers of virions were released compared with the control, peplomer spike glycoproteins were rarely evident in virions derived from the BgpA-overexpressing cell clones. Consonant with these findings, purified virions from BgpA-overexpressing cell clones demonstrated a 70% reduction in the amount of S glycoprotein, but not of N or M proteins. These data suggest that BgpA receptor overexpression establishes an intracellular trap which blocks MHV replication during the maturation and release of infectious progeny virions.

Croup.

As many as 3% of children under six years of age are affected by croup, usually at two to three years. Symptoms include a barking cough and inspiratory stridor. The preceding infection of the larynx is usually viral; bacterial infection can complicate the condition. Mist inhalation has been the traditional treatment. Dexamethasone and now budesonide may be used as first-line treatment.

Asthma: how early to start using inhaled steroids?

Using inhaled steroids to prevent inflammation is a standard part of treatment for moderate to severe asthma. The "early intervention concept" is to give inhaled steroids early in the disease--in children as well as adults--to prevent irreversible lung damage. The START study, involving nearly 7,000 patients in 32 countries, will investigate the effectiveness of early intervention with inhaled steroids in newly-diagnosed asthmatics aged 6-60 years. Results from a 10 year Danish study by Professor Pedersen suggests that in children, early preventive intervention with inhaled steroids leads to improved lung function with no significant adverse effect on the child's growth rate. At present, medical opinion is divided about whether very early use of inhaled steroids is justified, particularly in children. The START study should provide more evidence about the optimum time to begin this treatment.