Human placental villi contain stromal macrovesicles associated with networks of stellate cells.

Placental function is essential for fetal development and establishing the foundations for lifelong health. The placental villous stroma is a connective tissue layer that supports the fetal capillaries and villous trophoblast. All the nutrients that cross the placenta must also cross the stroma, and yet little is known about this region. This study uses high-resolution three-dimensional imaging to explore the structural complexity of this region within the placental villi. Serial block-face scanning electron microscopy and confocal microscopy were used to image the placental villous stroma in three-dimensions. Transmission electron microscopy (TEM) was used to generate high resolution two-dimensional images. Stereological approaches were used to quantify volumes of stromal constituents. Three-dimensional imaging identified stromal extracellular vesicles, which constituted 3.9% of the villous stromal volume. These stromal extracellular vesicles were ovoid in shape, had a median length of 2750 nm (range 350-7730 nm) and TEM imaging confirmed that they were bounded by a lipid bilayer. Fifty-nine per cent of extracellular vesicles were in contact with a fibroblast-like stellate cell and these vesicles were significantly larger than those where no contact was observed. These stellate cells formed local networks with adherent junctions observed at contact points. This study demonstrates that the villous stroma contains extracellular macrovesicles which are considerably larger than any previously described in tissue or plasma. The size and abundance of these macrovesicles in the villous stroma highlight the diversity of extracellular vesicle biology and their roles within connective tissues.

Low prevalence of vaccine-type HPV infections in young women following the implementation of a school-based and catch-up vaccination in Quebec, Canada.

BACKGROUND: In Quebec, Canada, a school-based HPV vaccination for girls has been offered since 2008. The vaccine used in the program targets HPV16/18, responsible for ∼70% of cervical cancers and HPV6/11, responsible for the majority of anogenital warts. The objective of this study was to assess the prevalence of HPV in vaccinated and unvaccinated women. METHODS: Women aged 17-29 years were eligible to participate. Participants' age, vaccination status and diverse risk factors were assessed by a computer-assisted questionnaire. Biological specimens were obtained by self-sampling. HPV genotyping was performed by Linear Array. RESULTS: A total of 2,118 women were recruited. 2,042 completed the questionnaire and 1,937 provided a vaginal sample. Vaccination coverage varied from 83.5% in women aged 17-19 to 19.1% in those aged 23-29. The overall prevalence of HPV in sexually active women was 39.4% (95%CI: 37.0-41.7) and 56.7% of infected women had multiple type infections. The prevalence of vaccine HPV types varied by age and vaccination status except for women aged 23-29 for whom similar results were observed. Vaccine HPV types were detected in 0.3%, 1.4% and 10.5% of vaccinated women aged 17-19, 20-23, and 23-29 (p<0.05), respectively. HPV16 or HPV18 were detected in 10 women having received at least one dose of vaccine. Nine of these women were already sexually active at the time of vaccination. CONCLUSION: Infections with HPV types included in the vaccine are rare in women aged less than 23 years and are virtually absent in those who received at least one dose of vaccine before sexual debut.

High-resolution 3D imaging of osteocytes and computational modelling in mechanobiology: insights on bone development, ageing, health and disease.

Osteocytes are involved in mechanosensation and mechanotransduction in bone and hence, are key to bone adaptation in response to development, ageing and disease. Thus, detailed knowledge of the three-dimensional (3D) structure of the osteocyte network (ON) and the surrounding lacuno-canalicular network (LCN) is essential. Enhanced understanding of the ON&LCN will contribute to a better understanding of bone mechanics on cellular and sub-cellular scales, for instance through improved computational models of bone mechanotransduction. Until now, the location of the ON within the hard bone matrix and the sub-µm dimensions of the ON&LCN have posed significant challenges for 3D imaging. This review identifies relevant microstructural phenotypes of the ON&LCN in health and disease and summarises how light microscopy, electron microscopy and X-ray imaging techniques have been used in studies of osteocyte anatomy, pathology and mechanobiology to date. In this review, we assess the requirements for ON&LCN imaging and examine the state of the art in the fields of imaging and computational modelling as well as recent advances in high-resolution 3D imaging. Suggestions for future investigations using volume electron microscopy are indicated and we present new data on the ON&LCN using serial block-face scanning electron microscopy. A correlative approach using these high-resolution 3D imaging techniques in conjunction with in silico modelling in bone mechanobiology will increase understanding of osteocyte function and, ultimately, lead to improved pathways for diagnosis and treatment of bone diseases such as osteoporosis.

Screening histories and contact with physicians as determinants of cervical cancer risk in Montreal, Quebec.

BACKGROUND: Cervical cancer (cca) is largely a preventable disease if women receive regular screening, which allows for the detection and treatment of preinvasive lesions before they become invasive. Having been inadequately screened is a common finding among women who develop cca. Our primary objective was to determine the Pap screening histories of women diagnosed with cca in Montreal, Quebec. Secondary objectives were to determine the characteristics of women at greatest risk of cca and to characterize the level of physician contact those women had before developing cca. METHODS: The Invasive Cervical Cancer Study, a population-based case-control study, consisted of Greater Montreal residents diagnosed with histologically confirmed cca between 1998 and 2004. Respondents to the 2003 Canadian Community Health Survey and a sample of women without cca obtained from Quebec medical billing records served as controls. RESULTS: During the period of interest, 568 women were diagnosed with cca. Immigrants and women speaking neither French nor English were at greatest risk of cca. Most of the women in the case group had been screened at least once during their lifetime (84.8%-90.4%), but they were less likely to have been screened within 3 years of diagnosis. Having received care from a family physician or a medical specialist other than a gynecologist within the 5 years before diagnosis was associated with a greater risk of cca development. CONCLUSIONS: Our findings provide evidence of the need for an organized population-based screening program. They also underscore the need for provider education to prevent missed opportunities for cca screening when at-risk women seek medical attention.

CC-10004 but not thalidomide or lenalidomide inhibits lamina propria mononuclear cell TNF-α and MMP-3 production in patients with inflammatory bowel disease.

BACKGROUND: Thalidomide, one of whose activities is to inhibit Tumour Necrosis Factor (TNF)-α production, has been reported to be an effective treatment for refractory inflammatory bowel disease (IBD). TNF-α driven production of matrix metalloproteinase (MMP)-3 by gut lamina propria mononuclear cells (LPMCs) is a major pathway of tissue injury in IBD; however the effect of thalidomide and newer more potent immunomodulatory derivatives on this pathway has not been studied. AIM: To investigate the effect of thalidomide, CC-4047 (pomalidomide), CC-5013 (lenalidomide), and CC-10004 (apremilast) on gut LPMC TNFα and MMP-3 production in patients with IBD. METHODS: Gut LPMCs and myofibroblasts were isolated from patients with IBD, and cultured with thalidomide, CC-4047, CC-5013, and CC-10004. MMP-3 and TIMP-1 levels were determined by western blotting and real-time PCR, and TNF-α levels by ELISA. RESULTS: CC-10004 significantly reduced both TNF-α production and MMP-3 production by cultured LPMCs. Thalidomide and CC-4047 and CC-5013 had no significant effect on the production of TNF-α or MMP-3 by LPMCs. CONCLUSION: These results provides a mechanistic rationale for both the failure of lenalidomide (CC-5013) in a recent randomised controlled trial in Crohn's disease, and for the evaluation of CC-10004 as a novel oral therapy in the treatment of CD and UC.

The evolution of HPV-related anogenital cancers reported in Quebec - incidence rates and survival probabilities.

Non-cervical anogenital cancers (i.e. anal, vulvar, vaginal and penile cancers) associated with the human papillomavirus (HPV), for which HPV is known to be the necessary cause of carcinogenesis, are poorly documented due to their relatively low incidence rate. The aim of this study is to describe the incidence rates of these cancers between 1984 and 2001, and their relative survival probabilities, in Quebec (Canada) between 1984 and 1998. The incidence of these cancers is on the rise, particularly anal cancer in women and, more recently (since 1993-95), vulvar cancer. Between 1984-86 and 1993-95, the 5-year relative survival probability for men with anal cancer decreased from 57% to 46%, while that for penile cancer dropped from 75% to 59%. However, during the same period, the 5-year relative survival probability for women with anal cancer rose from 56% to 65%, and remained stable for cervical and vulvar cancers, at 74% and 82%, respectively.

Cancer cachexia.

Cancer cachexia is a severe debilitating disorder for which there are currently few therapeutic options. It is driven by the release of pro-inflammatory cytokines and cachectic factors by both host and tumour. Over the past few years, basic science advances have begun to reveal the breadth and complexity of the immunological mechanisms involved, and in the process have uncovered some novel potential therapeutic targets. The effectiveness of thalidomide and eicosapentaenoic acid at attenuating weight loss in clinical trials also provides a further rationale for modulating the immune response. We are now entering an exciting period in cachexia research, and it is likely that the next few years will see effective new biological therapies reach clinical practice.

Thalidomide in the treatment of cancer cachexia: a randomised placebo controlled trial.

BACKGROUND: Proinflammatory cytokines, especially tumour necrosis factor alpha (TNF-alpha), play a prominent role in the pathogenesis of cancer cachexia. Thalidomide, which is an inhibitor of TNF-alpha synthesis, may represent a novel and rational approach to the treatment of cancer cachexia. AIMS: To assess the safety and efficacy of thalidomide in attenuating weight loss in patients with cachexia secondary to advanced pancreatic cancer. METHODS: Fifty patients with advanced pancreatic cancer who had lost at least 10% of their body weight were randomised to receive thalidomide 200 mg daily or placebo for 24 weeks in a single centre, double blind, randomised controlled trial. The primary outcome was change in weight and nutritional status. RESULTS: Thirty three patients (16 control, 17 thalidomide) were evaluated at four weeks, and 20 patients (eight control, 12 thalidomide) at eight weeks. At four weeks, patients who received thalidomide had gained on average 0.37 kg in weight and 1.0 cm(3) in arm muscle mass (AMA) compared with a loss of 2.21 kg (absolute difference -2.59 kg (95% confidence interval (CI) -4.3 to -0.8); p = 0.005) and 4.46 cm(3) (absolute difference -5.6 cm(3) (95% CI -8.9 to -2.2); p = 0.002) in the placebo group. At eight weeks, patients in the thalidomide group had lost 0.06 kg in weight and 0.5 cm(3) in AMA compared with a loss of 3.62 kg (absolute difference -3.57 kg (95% CI -6.8 to -0.3); p = 0.034) and 8.4 cm(3) (absolute difference -7.9 cm(3) (95% CI -14.0 to -1.8); p = 0.014) in the placebo group. Improvement in physical functioning correlated positively with weight gain (r = 0.56, p = 0.001). CONCLUSION: Thalidomide was well tolerated and effective at attenuating loss of weight and lean body mass in patients with cachexia due to advanced pancreatic cancer.

Thalidomide and its derivatives: emerging from the wilderness.

Forty years on from its worldwide withdrawal, thalidomide is currently undergoing a remarkable renaissance as a novel and powerful immunomodulatory agent. Over the last decade it has been found to be active in a wide variety of inflammatory and malignant disorders where conventional therapies have failed. Recently, considerable progress has been made in elucidating its complex mechanisms of action, which include both anticytokine and antiangiogenic properties. However, in addition to its well known teratogenic potential, it has a significant side effect profile that leads to cessation of treatment in up to 30% of subjects. In response to this, two new classes of potentially safer and non-teratogenic derivatives have recently been developed. This review summarises the biological effects, therapeutic applications, safety profile, and future potential of thalidomide and its derivatives.

Enteral nutrition by nasojejunal tube in hyperemesis gravidarum.

We describe two cases in which self-propelling, blind placed nasojejunal tubes were placed in severe hyperemesis gravidarum. This method provides an alternative to parenteral nutrition and to percutaneous endoscopic tubes, is well tolerated, cost effective and with a low rate of complication. Both mothers were given nutritional support at home, had normal subsequent pregnancies and normal babies.

Colonic lymphoid hyperplasia in melanosis coli.

We describe the case of a patient with Rett syndrome, a syndrome characterized by progressive infant encephalopathy, developmental delay, dementia, autism, ataxia, microcephaly, spastic paraparesis, and autonomic neuropathy with constipation. At colonoscopy, multiple foci of tiny white, sessile, polypoid lesions were seen throughout the colon and rectum, mimicking the appearances of small hyperplastic or adenomatous polyps, associated with generalized melanosis coli. This is the first case to our knowledge describing melanosis coli in a patient with Rett syndrome. As melanosis pigment deposition is characteristically not seen in lymphoid tissue, the lymphoid tissue was identifiable at endoscopy as multiple white nodules mimicking generalized colonic polyposis throughout the colon. We discuss the likely mechanisms of lymphoid hyperplasia and coexistent melanosis coli in Rett syndrome.

The 'cut and push' method of percutaneous endoscopic gastrostomy tube removal.

BACKGROUND AND AIMS: The standard method of removing percutaneous endoscopic gastrostomy tubes is by gastroscopy. This has implications for endoscopy time and resources, and we believe is not always necessary. Depending on the type of percutaneous endoscopic gastrostomy tube used we often used the 'cut and push' method. This involves cutting the catheter at skin level and allowing the tube and internal bumper to spontaneously pass. The cut and push method also represents a considerable resource saving compared to the endoscopic method that we think warrants further discussion. METHOD: We reviewed all the files of the percutaneous endoscopic gastrostomy tubes removed in our unit over the last 4 years. RESULTS: During the period of July 1995 to July 1999, we have inserted 384 percutaneous endoscopic gastrostomy tubes. Seven tubes have been removed endoscopically and 73 tubes have been removed with the cut and push method. Only two possible complications have been recorded (2.7%). CONCLUSIONS: We believe that we have provided further evidence that percutaneous endoscopic gastrostomy tubes can be removed safely using the cut and push method. Patients who are often frail and who have multiple medical problems are saved an often-long journey to the endoscopy unit as well as the hazards of an endoscopy. The saving in resources in what is already an overworked system by not performing endoscopies is also considerable.

An investigation into the supramolecular structure of ternary gel systems using oscillatory rheometry, microscopy, and low frequency dielectric spectroscopy.

A series of ternary gel systems based on cetostearyl alcohol (CSA) and cetomacrogol 1000 or sodium lauryl sulfate have been studied using oscillatory rheology, differential interference contrast (DIC) microscopy, cryoscanning electron microscopy (cryo-SEM), and low-frequency dielectric analysis in order to elucidate the nature of the lamellar structures formed in relation to composition. The effects of altering the concentration of CSA (0.25% to 8% w/w) for 1% and 2% w/v cetomacrogol 1000 and 0.5% and 1% w/v sodium lauryl sulfate systems have been investigated, with marked increases in the storage and loss moduli seen on increasing the concentration of CSA for both surfactants. DIC microscopy indicated that at low CSA concentrations, needlelike structures were seen which, on increasing the concentration, were observed to congregate into nuclei. At concentrations of 4% CSA and above, neospherical structures were also observed. Cryo-SEM revealed that the needlelike objects were sheet structures ascribed to lamellar gel phases, while the nuclei were folded "rosettes" formed by those sheets, with the spherical structures being ascribed to cetostearyl alcohol. It was also noted that the lamellae were more tightly folded at 8% w/w CSA, which may be associated with the higher rheological moduli for these systems. Low-frequency dielectric analysis was performed over a frequency range of 10(4) Hz to 10(-2) Hz. A decrease in both the dielectric loss and capacitance was observed as the concentration of cetostearyl alcohol was increased. The dielectric data were described in terms of an equivalent circuit model based on a modified Maxwell-Wagner response. A good correlation was found between the fitted and experimental data and the effect of altering the gel composition on specific features of the equivalent circuit are discussed.

Metal stents improve dysphagia, nutrition and survival in malignant oesophageal stenosis: a randomized controlled trial comparing modified Gianturco Z-stents with plastic Atkinson tubes.

OBJECTIVE: To compare modified Gianturco metal stents with plastic Atkinson tubes in the palliation of malignant dysphagia. DESIGN: Patient single-blind, multi-centre prospective, randomized trial. SETTING: Three district general hospitals in the Wessex region. PARTICIPANTS: Thirty one consecutive patients with inoperable malignant oesophageal stenosis causing dysphagia and suitable for treatment with an endoprosthesis. INTERVENTIONS: Patients were randomized to receive either a modified Gianturco metal stent or a plastic Atkinson tube. Sedation was similar and patients were given identical dietary advice. Data were collected after insertion until the patients' death. MAIN OUTCOME MEASURES: Procedural mortality/morbidity; hospital stay; weight loss; quality of life (Nottingham Health Profile, Spitzer QL index and specific questions about dysphagia and enjoyment of food); duration of survival after insertion; cost effectiveness of each intervention. RESULTS: Overall complication rates were similar in the two groups. Compared with Atkinson tubes, patients with Gianturco stents had better palliation of dysphagia (median dysphagia score 1 vs 2, P = 0.04), maintained their weight longer (median percent weight loss 0.66 vs 6.51, P = 0.007), enjoyed food more (enjoyment score 2 vs 1, P = 0.03) and survived longer (log rank P < 0.025). Patients with metal stents were discharged from hospital earlier (Gianturco 4 days, Atkinson 10 days, P = 0.001), and initial treatment cost was lower if the cost of hospital stay exceeded pound sterling 120 per day. CONCLUSION: Gianturco stents are superior to Atkinson tubes in the palliation of malignant oesophageal stenosis.

An investigation into the use of low-frequency dielectric spectroscopy as a means of characterizing the structure of creams based on Aqueous Cream BP.

A range of creams based on Aqueous Cream BP have been analyzed using low-frequency dielectric spectroscopy, with accompanying circuit modeling in combination with rheological and microscopic supportive techniques, to explore the use of the dielectric approach as a novel means of characterizing cream systems. Creams based on the formula for Aqueous Cream BP were produced by hand-mixing and mechanical mixing, with and without the inclusion of the preservative phenoxyethanol. Dielectric analysis was performed over a frequency range of 10(-2)-10(5) Hz. Cream samples were also examined using stress scan rheology and differential interference contrast microscopy. Dielectric analysis indicated that the presence of preservative decreased the capacitance and loss of the creams. The responses were modeled in terms of a dispersive capacitance in series with two RC circuits (series and parallel). Rheological studies indicated higher viscosities for the hand-mixed and unpreserved systems. Differential interference contrast microscopy showed marked differences in the distribution of the oil droplets, depending on the method of mixing. The study has demonstrated that dielectric spectroscopy, with accompanying circuit analysis, may be used as a means of modeling the structure of cream systems. The investigation has also shown that the formulation and preparation method of Aqueous Cream BP may have a profound effect on sample structure.

Growth in infancy, infant feeding, childhood living conditions, and Helicobacter pylori infection at age 70.

AIM: To examine childhood correlates of Helicobacter pylori infection in adults. DESIGN: Follow up study of men and women whose birth weight, weight at age 1 year, and feeding in infancy were recorded by health visitors. Data on childhood housing conditions were obtained by recall. SUBJECTS: 631 men and 389 women born in Hertfordshire during 1920-30 and still living in the east or northwest districts of the county. MAIN OUTCOME MEASURES: Serum H pylori IgG antibodies measured by enzyme linked immunosorbent assay. RESULTS: Independent of their current social class, subjects were more likely to be H pylori seropositive if they had large numbers of siblings (p < 0.0001), and if they had lived in a crowded house (p = 0.001), or shared a bedroom or bed in childhood (p = 0.02). Low weight at 1 year was associated with increased seropositivity rates in men (p = 0.0002), but not women (p = 0.8). Men and women who were breast fed in infancy were less likely to be seropositive than those who were bottle fed (p = 0.08). CONCLUSIONS: The findings support the current view that H pylori infection is often acquired in childhood by close person to person contact, and persists into adult life. H pylori infection may be a cause of failure to thrive in infancy, especially in boys. Alternatively, small infants may be more susceptible to infection. Breast feeding may prevent early infection.

Estimation of breast cancer risk by women aged 40 and over: a population-based study.

OBJECTIVE: Identify factors associated with knowledge of breast cancer and estimation of risk. METHODS: Telephone survey of 412 women aged 40 and over, living in Montreal and selected by random digit dialing. RESULTS: The majority of the respondents had recently been exposed to some information on breast cancer, but only a third quoted the average lifetime probability estimate of about 1 in 10. Older individuals systematically considered themselves at low risk (odds ratio (OR) of perceiving risk as lower than average for women aged 50 or over versus under 50: 2.6, 95% confidence interval: (1.5, 4.6)). In addition, both a first-degree family history of breast cancer (OR: 5.3 (1.7, 17.0)) and a recent mammogram (OR: 3.0 (1.4, 6.2)) were strongly associated with a woman's probability of perceiving herself at high risk. CONCLUSIONS: Information campaigns should emphasize the frequency of breast cancer in different age groups and the strength of the established associations with specific risk factors. Better knowledge of risk could promote sustained participation in breast screening programs.

Intrahepatic biliary cholesterol and phospholipid transport in humans: effect of obesity and cholesterol cholelithiasis.

The mode of transport of biliary lipids within the hepatocyte and the role of the bile canalicular membrane (BCM) in biliary lipid secretion are not well understood. We hypothesized that biliary cholesterol and phospholipid are co-transported across the hepatocyte in vesicular form from the endoplasmic reticulum to the bile across the BCM. We obtained wedge liver biopsies and fasting gallbladder bile from 15 cholesterol gallstone patients and 10 control subjects. BCM, basolateral membrane (BLM), and many microsomal vesicular fractions were isolated by centrifugation. One of the vesicular fractions (V3) was enriched in both the microsomal and the BCM marker enzymes and had a high phosphatidylcholine proportion in its phospholipid with a fatty acid pattern similar to biliary phosphatidylcholine. Moreover, its cholesterol content was increased in the obese cholesterol gallstone subjects, who had an increase in cholesterol synthesis, as indicated by the increased activity of the HMG-CoA reductase. The cholesterol content correlated with HMG-CoA reductase activity. A direct correlation was found between cholesterol/phospholipid ratio in V3, BCM, and in bile but not in the BLM. These data are in agreement with the assumption that this vesicular fraction is involved in the transport of cholesterol and phospholipid from the endoplasmic reticulum to the site of secretion in the BCM, and thence to bile, and that this transport is enhanced in obese gallstone patients.