An international patient-centred study of retroperitoneal fibrosis.

BACKGROUND: The impact that rare chronic disorders, such as retroperitoneal fibrosis (RPF), can have on the physical and psychological aspects of a patient's health is poorly understood. Patient-related outcome measures and experiences provide a unique opportunity to understand the impact rare chronic disorders have on a patient's life as well as allowing healthcare providers to compare and improve performance. AIM: To understand the physical and psychosocial impact that RPF has upon peoples' lives. DESIGN: An international online questionnaire was therefore created to gain insights into how patients with RPF, a rare fibro-inflammatory condition, viewed their health and experiences. METHODS: An international online questionnaire comprising 62 questions/free text options, was designed in collaboration with two patient advocates and the multi-disciplinary Renal Association Rare Disease Registry (RaDaR) RPF Group the questionnaire was anonymous and freely accessible on a GOOGLE Form online platform for 6 months. RESULTS: A total of 229 patients from 30 countries across 5 continents responded. Four key issues were identified; (i) pain; (ii) therapy-related side effects; (iii) lack of informed doctors/information about their condition and its management; and (iv) psychological burden. Variations in diagnosis and management are highlighted with 55% undergoing a biopsy to reach a diagnosis of RPF; 75% of patients underwent a further interventional procedure with 60% concurrently treated medically. CONCLUSION: This study will guide further development of clinical and academic multi-disciplinary activity and shows the importance of trying to understand the impact of rare chronic disorders on the physical and psychological aspects of a patient's health.

BK Virus Associated Haemorrhagic Cystitis. A systematic review of current prevention and treatment strategies.

BACKGROUND: BK virus is a major cause of late onset haemorrhagic cystitis in patients undergoing Haematopoietic Cell Transplantation (HCT). The evidence for the management of BK Virus Associated Haemorrhagic Cystitis (BKV-HC) is limited. Much of the published data consists of non-randomised case series and case reports. To our knowledge this is the first systematic review for the management of BKV-HC in both paediatric and adult populations. Our primary outcome was to examine the evidence for strategies of 1) prevention and 2) cessation of haematuria associated with BKV. Secondary outcomes were to assess the toxicity of treatment strategies and devise management recommendations for clinicians. MATERIALS AND METHODS: We performed a systematic review of the PubMed and Central databases to evaluate the current evidence. A search protocol was prepared and registered with the PROSPERO database (CRD42017082442). The review was conducted in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) statement and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Results were classified by treatment type. Qualitative analysis of included articles was performed, and grades of recommendations were devised for each treatment. RESULTS: Of 896 titles screened, 44 articles were included for qualitative analysis. The overall quality of evidence was low. There is insufficient evidence to recommend prophylactic quinolones. 40 studies evaluated treatments for established BKV-HC. There are no high-quality comparative studies. Cidofovir is the most studied treatment but quality of evidence is low, and grade of recommendation is weak. Hyperbaric oxygen therapy, Fibrin glue, Leflunomide, Sodium Pentosan Polysulfate, Intravesical Alum and Radiological embolisation have all been described but the effectiveness of these treatments is unclear. CONCLUSION: There remains no clear specific treatment for BKV-HC. An effective multi-disciplinary approach leading to early recognition and initiation of treatment is encouraged. The development of novel therapies followed by well-designed clinical studies are urgently needed.

A prospective clinical, cost and environmental analysis of a clinician-led virtual urology clinic.

INTRODUCTION: A virtual clinic is a form of telemedicine where contact between clinical teams and patients occur without face-to-face consultation. Our study aims to quantify the clinical, financial and environmental benefits of our virtual urology clinic. MATERIAL AND METHODS: We collected data prospectively from our weekly follow-up virtual clinic over a continuous four-month period between July and September 2017. RESULTS: In total, we reviewed 409 patients. Following virtual clinic consultation, 68.5% of our patients were discharged from further follow-up. The majority of our patients (male 57.7%, female 55.5%) were of working age. The satisfaction scores were high, at 90.1%, and there were no reported adverse events as a result of using the virtual clinic. Our calculated cost savings were £18,744, with a predicted 12-month cost saving of £56,232. The creation of additional face-to-face clinic capacity has created an estimated 12-month increase in tariff generation for our unit of £72,072. In total, 4623 travel miles were avoided by patients using the virtual clinic, with an estimated avoided carbon footprint of 0.35-1.45 metric tonnes of CO2e, depending on mode of transport. Our predicted 12-month avoided carbon footprint is 1.04-4.04 metric tonnes of CO2e. CONCLUSIONS: Our virtual clinic model has demonstrated a trifecta of positive outcomes, namely, clinical, financial and environmental benefits. The environmental importance and benefits of a virtual clinic should be promoted as a social enterprise value when engaging stakeholders in setting up such a urological service. We propose the adoption of our virtual clinic model in those urological units considering this method of telemedicine.

Tailoring 2D and 3D molecular sieves structures for polyolefin composites: do all roads lead to remarkable performances?

Multiple synthetic strategies were performed in order to tether a zirconium-based catalyst to the 2D and 3D molecular sieves for olefin polymerizations. The anchoring of fluorene silane to the mesoporous MCM-41 was performed in order to obtain a stable catalyst for olefin polymerization (1@MCM-41). Using spectroscopic methods, this system was shown to have the metal center locked on a face down conformation with the surface. Also, immobilized zirconium complexes have been prepared on three different types of aminopropyl-modified supports (2@magadiite, 2@MCM-41 and 3@MCM-48). The advantage of this latter method of immobilization would be the reduction of the steric effect caused by the support: the catalyst, distant from the surface, is more exposed to the monomer and this situation may lead to an increase in the catalytic activity compared to 1@MCM-41. However, a medium size chain as a spacer between the support and the metallocene is still flexible enough to bend and predisposes the metal center to interact with the support surface; this effect is more evident when the nature of the support is of fixed pore dimensions. These supported catalysts exhibited activity for ethylene polymerization, resulting in linear PEs with high melting temperatures. In order to retain a metallocene assembled as in a homogeneous environment, a multi-step reaction was investigated (4@magadiite) but it led to the leaching of the organic moieties from the surface during catalyst preparation. The best catalytic performance was achieved when homogeneous Oct-amido catalyst (5) was reacted with the surface of magadiite and n-alkyl-AlPO-kan.

A snapshot of genetic lineages of Mycobacterium tuberculosis in Ireland over a two-year period, 2010 and 2011.

Mycobacterial interspersed repetitive-unit-variable-number tandem repeat typing alone was used to investigate the genetic lineages among 361 Mycobacterium tuberculosis strains circulating in Ireland over a two-year period, 2010 and 2011. The majority of isolates, 63% (229/361), belonged to lineage 4 (Euro-American), while lineages 1 (Indo-Oceanic), 2 (East-Asian) and 3 (East-African­Indian) represented 12% of isolates each (42/361, 45/361, and 45/361, respectively). Sub-lineages Beijing (lineage 2), East-African­Indian (lineage 1) and Delhi/central-Asian (lineage 3) predominated among foreign-born cases, while a higher proportion of Euro-American lineages were identified among cases born in Ireland. Eighteen molecular clusters involving 63 tuberculosis (TB) cases were identified across four sub-lineages of lineage 4. While the mean cluster size was 3.5 TB cases, the largest cluster (involving 12 Irish-born cases) was identified in the Latin American­Mediterranean sub-lineage. Clustering of isolates was higher among Irish-born TB cases (47 of 63 clustered cases), whereas only one cluster (3/63) involved solely foreign-born individuals. Four multidrug-resistant cases identified during this period represented lineages 2 and 4. This study provides the first insight into the structure of the M. tuberculosis population in Ireland.

Multi-drug resistant tuberculosis: experiences of two tertiary referral centres.

Multi-drug resistant tuberculosis (MDR-TB) is associated with increased morbidity and mortality compared to drug-sensitive disease. Although MDR-TB is infrequent in Ireland, cases continue to be diagnosed in both Irish and foreign-born people. We conducted a clinical audit of 13 MDR-TB patients treated in two tertiary referral centers, the Mercy Hospital, Cork and St James's Hospital, Dublin between 2004 and 2009. The median age was 37 years. Eight patients (61.5%) were foreign-born, five (38.5%) were Irish-born. Seven patients (54%) have now stopped treatment; 6 (86%) were treated successfully and one (14%) defaulted. Mycobacterium tuberculosis isolates were resistant to a median of seven drugs. Eight patients (61.5%) developed ototoxicity from long-term aminoglycoside use. Our patients' treatment outcomes compare favourably with international reports despite a high degree of drug resistance. However, the high incidence of otoxicity is concerning.

Corrugated metallodielectric superlattices via release-rollup assembly.

A 'release-rollup' assembly (RRA) technique is described that yields corrugated metallodielectric superlattices. Bilayers of polymer/Au cast onto diffraction gratings are released and rolled into multilayers with registration of the stacked corrugations across mm-scales. Optical imaging reveals Moiré fringes with reflection spectra that track the bilayer thickness due to mis-stacking. Angular-resolved spectra show spectrally-modulated diffraction opposite to that of the metallic stop-bands, but which agrees with a simple model. This scalable fabrication strategy is thus widely exploitable for laterally patterned metamaterials and optical superlattices.

Smoking prolongs the infectivity of patients with tuberculosis.

We sought to establish if smokers on anti-tuberculosis treatment are more likely to have a prolonged period of infectivity, compared to non-smoking tuberculosis patients, in a low tuberculosis prevalence country. We conducted a cross-sectional, retrospective study in Ireland that recruited 53 microbiologically confirmed cases of pulmonary tuberculosis (PTB). The age-sex adjusted odds ratios (AOR) suggest that the infectivity status of PTB on treatment was four times more likely to be prolonged beyond 6-8 weeks, if the cases had a smoking history (AOR: 4.42; 95% CI: 1.23; 15.9). Smoking was associated with delayed sputum smear conversion in PTB patients on treatment.

TB or not TB?: a case of isolated testicular TB with scrotal involvement.

Despite the genitourinary tract being the most common site affected by extrapulmonary TB, isolated testicular TB remains a rare clinical entity. In patients with co-morbidities such as hepatic impairment, treatment proves a challenge, as first-line hepatotoxic pharmaceuticals are contraindicated. Here, we report a case of isolated testicular TB with scrotal involvement, on a background of hepatic dysfunction.

Use of mobile phones by medical staff at Queen Elizabeth Hospital, Barbados: evidence for both benefit and harm.

All members of medical staff, including students, were asked to participate in a self-administered questionnaire concerning patterns of mobile phone use and care. Participants' phones were cultured for micro-organisms. Healthcare professionals working in close proximity to sensitive equipment were surveyed concerning adverse events associated with mobile phones. Telephone operators were asked to monitor time elapsed as they attempted to contact medical staff by various methods. Of 266 medical staff and students at the time of the study, 116 completed questionnaires (response rate=44%). Almost all (98%) used mobile phones: 67% used their mobile phones for hospital-related matters; 47% reported using their phone while attending patients. Only 3% reported washing their hands after use and 53% reported never cleaning their phone. In total, 101 mobile phones were cultured for micro-organisms; 45% were culture-positive and 15% grew Gram-negative pathogens. The survey of staff working in close proximity to sensitive equipment revealed only one report of minor interference with life-saving equipment. Telephone operators were able to contact medical staff within 2 min most easily by mobile phone. Mobile phones were used widely by staff and were considered by most participants as a more efficient means of communication. However, microbial contamination is a risk associated with the infrequent cleaning of phones. Hospitals should develop policies to address the hygiene of mobile phones.

The Ca2+-binding capacity of epidermal furin is disrupted by H2O2-mediated oxidation in vitiligo.

The Ca(2+)-dependent precursor convertase furin is abundantly expressed in epidermal keratinocytes and melanocytes. In this context, it is noteworthy that proopiomelanocortin (POMC) cleavage is also processed by furin, leading to ACTH, beta-lipotropin, and beta-endorphin. All prohormone convertases including furin are regulated by Ca(2+). Because numerous epidermal peptides and enzymes are affected by H(2)O(2)-mediated oxidation, including the POMC-derived peptides alpha-MSH and beta-endorphin as shown in the epidermis of patients with vitiligo, we here asked the question of whether furin could also be a possible target for this oxidation mechanism by using immunofluorescence, RT-PCR, Western blotting, Ca(2+)-binding studies, and computer modeling. Our results demonstrate significantly decreased in situ immunoreactivity of furin in the epidermis of patients with progressive vitiligo (n = 10), suggesting H(2)O(2)-mediated oxidation. This was confirmed by (45)Ca(2+)-binding studies with human recombinant furin identifying the loss of one Ca(2+)-binding site from the enzyme after oxidation with H(2)O(2). Computer simulation supported alteration of one of the two Ca(2+)-binding sites on furin. Taken together, our results implicate that the Ca(2+)-dependent proteolytic activity of this convertase is targeted by H(2)O(2), which in turn could contribute to the reduced epidermal expression of the POMC-derived peptides alpha-MSH and beta-endorphin as documented earlier in patients with vitiligo.

Hydrogen peroxide-mediated oxidative stress disrupts calcium binding on calmodulin: more evidence for oxidative stress in vitiligo.

Patients with acute vitiligo have low epidermal catalase expression/activities and accumulate 10(-3) M H(2)O(2). One consequence of this severe oxidative stress is an altered calcium homeostasis in epidermal keratinocytes and melanocytes. Here, we show decreased epidermal calmodulin expression in acute vitiligo. Since 10(-3)M H(2)O(2) oxidises methionine and tryptophan residues in proteins, we examined calcium binding to calmodulin in the presence and absence of H(2)O(2) utilising (45)calcium. The results showed that all four calcium atoms exchanged per molecule of calmodulin. Since oxidised calmodulin looses its ability to activate calcium ATPase, enzyme activities were followed in full skin biopsies from lesional skin of patients with acute vitiligo (n=6) and healthy controls (n=6). The results yielded a 4-fold decrease of ATPase activities in the patients. Computer simulation of native and oxidised calmodulin confirmed the loss of all four calcium ions from their specific EF-hand domains. Taken together H(2)O(2)-mediated oxidation affects calcium binding in calmodulin leading to perturbed calcium homeostasis and perturbed l-phenylalanine-uptake in the epidermis of acute vitiligo.

Mycobacterium tuberculosis at autopsy--exposure and protection: an old adversary revisited.

BACKGROUND: The risk of encountering tuberculosis (TB) has reduced with the decreased incidence of the disease; however, it still can be found at autopsy. AIM: To assess the magnitude of exposure to Mycobacterium tuberculosis at autopsy in a large general hospital setting, in a country with low incidence. METHODS: Retrospective search of the autopsy records from 1991 to 2004. Patients' records and histological slides were reviewed, and medical personnel interviewed. RESULTS: 15 cases of active TB were identified in the 14-year period, during which 4930 autopsies were performed (1 case per 329 autopsies); of these, 10 cases were unsuspected (67%). Five of these cases contained abundant acid-fast bacilli. Patients tended to be middle aged and males with complex clinical histories; two were HIV positive. Two patients were brought in dead to hospital, with no clinical indication of TB. Of 15 autopsy staff, 1 required chemoprophylaxis but none contracted TB. CONCLUSION: The risk of unexpectedly encountering TB at autopsy continues even in a low-risk European setting. It has implications for the health of autopsy room staff, autopsy room design and ventilation, choice of protective equipment and for the public health service. Protective strategies include assessment of the risk of a case being infected, early recognition of gross lesions, use of methods for reducing the production of infected aerosols and protection against any aerosols created.

Melanocortins in human melanocytes.

Human epidermal keratinocytes and melanocytes express proopiomelanocortins (POMC) and all of the enzymes for POMC processing, i.e. prohormone convertases PC-1 and PC-2 including the regulatory protein 7B2. In melanocytes POMC processing also occurs in the melanosome, a lysosome-derived organelle that specializes in the biosynthesis of melanin. Consequently, the autocrine synthesis and release of the key hormones ACTH, alpha and beta-MSH and beta-endorphin takes also place in melanocytes. All four hormones have been reported to promote the biosynthesis of eumelanin in melanocytes. ACTH and alpha-MSH bind to the melanocortin-1 receptor (MC-1-R) on the plasma membrane and activate the signalling pathway predominantly coupled to production of cAMP, and in some cell lines raising intracellular calcium levels. In the melanocyte this signalling is redundant due to the high expression of alpha1 and beta2-adrenoceptors. Downstream events increase melanocyte this signalling is redundant due to the high expression of a tyrosinase expression / activity to stimulate eumelanogenesis. Studies with rMC-1-R transfected COS cells showed that both ACTH and alpha-MSH bind to the receptor with similar or different affinity depending on the species (human vs mice). We have modelled the MC-1-R based on the X-ray crystal structure of a homologous 7 receptor rhodopsin. Docking studies with ACTH1-39, ACTH1-17 and ACTH11-17 and alpha-MSH1-13 revealed that all 3 ACTH peptides yield thermodynamically stable (key ACTH1-13 in-lock) complexes. Interestingly, alpha-MSH is predicted to only have a kinetic effect on the MC-1-R and beta-MSH has even a weaker affinity for the MC-1-R than alpha-MSH. Based on these results the relative importance of ACTH versus alpha-MSH in the human epidermis has been re-evaluated.

Long-term outcome of cadaveric renal transplant after treatment of symptomatic lymphocele.

PURPOSE: Between January 1993 and December 2002 a total of 1,289 renal transplants were performed at our institution. Symptomatic post-transplant lymphocele presenting as increased creatinine and hydronephrosis of the allograft was recorded at 0.02%. Records of the 27 patients in whom symptomatic lymphocele developed and of those who underwent contralateral kidney transplant (control group) were compared to determine the long-term effects of lymphocele formation on allograft function. MATERIALS AND METHODS: A total of 37 procedures for the treatment of lymphocele were performed in 24 patients. Open marsupialization (12) and laparoscopic marsupialization (3) procedures were performed as primary treatments. Two patients underwent repeat open marsupialization. Aspiration and percutaneous catheter drainage were performed as a primary procedure in 7 and 1 cases, respectively. Percutaneous nephrostomy was required in 4 cases before definitive treatment. RESULTS: The mean time to development of a lymphocele was 121 days (range 35 to 631). Symptomatic lymphocele did not require treatment in 3 patients. Of 19 patients undergoing primary marsupialization, recurrence in 2 necessitated repeat surgery. However, aspiration and percutaneous drainage proved to be definitive in only 2 cases. In total 8 patients required more than 1 procedure. At a mean followup of 63 months (SD 30.3) 21 allografts continued to function with a mean serum creatinine of 152 mumol/l (SD 67.9). In the control group 3 patients experienced graft failure and mean serum creatinine was 154 mumol/l (SD 51.9). Five patients died in the lymphocele group, 2 with functioning grafts compared to 4 deaths in the control group. CONCLUSIONS: Surgical marsupialization is the preferred primary treatment for symptomatic lymphocele and is associated with excellent long-term allograft outcome.

Learning to karyotype in the university environment: a computer-based virtual laboratory class (KaryoLab) designed to rationalize time for the tutor/researcher and to encourage more students to engage in cytogenetics.

The ability to karyotype G-banded chromosome preparations is an essential skill for chromosome biologists. For this reason, the teaching of the rudiments of G banding analysis forms an integral part of the curriculum in many biology and genetics degree courses. The way in which karyotyping is usually taught involves providing the students with a photograph of G-banded chromosomes, a pair of scissors and some glue from which they can cut out the chromosomes and build the karyotype. This has the disadvantage that large amounts of time are taken in cutting and pasting and comparatively little in learning pattern recognition of individual chromosomes. In this paper we describe the development of a computer-based student practical class "KaryoLab". To the best of our knowledge, this is the first report of a teaching tool that combines instruction in cytogenetic analysis with both formative and summative feedback to the student and a virtual elimination of marking time for the tutor. Chromosome research and diagnostics will only continue while there are sufficiently motivated and trained individuals to perform it. We see the software developed here as a significant step towards training and motivating students in cytogenetics.

Fas-mediated apoptosis of neutrophils in sera of patients with infection.

In the presence of infection, neutropenia is considered to be a marker of poor prognosis; conversely, neutrophilia may not be a determinant of a better prognosis. Since apoptotic neutrophils are compromised functionally, we evaluated the effect of infection on neutrophil apoptosis. The rate of apoptosis was greater for neutrophils isolated from patients with infection than for healthy controls. Escherichia coli did not directly modulate the rate of neutrophil apoptosis. However, sera from infected patients promoted (P < 0.001) neutrophil apoptosis. Interestingly, the sera of patients with different types of infection (gram negative, gram positive, or culture negative) exerted a more or less identical response on neutrophil apoptosis. Sera of infected patients showed a fivefold greater content of FasL compared to controls. Moreover, anti-FasL antibody partly attenuated the infected-serum-induced neutrophil apoptosis. In in vitro studies, E. coli enhanced monocyte FasL expression. Moreover, conditioned media prepared from activated macrophages from control mice showed enhanced apoptosis of human as well as mouse neutrophils. On the contrary, conditioned media prepared from activated macrophages isolated from FasL-deficient mice induced only a mild degree of neutrophil apoptosis. These results suggest that neutrophils in patients with infection undergo apoptosis at an accelerated rate. Infection not only promoted monocyte expression of FasL but also increased FasL content of the serum. Because the functional status of apoptotic cells is compromised, a significant number of neutrophils may not be participating in the body's defense. Since neutrophils play the most important role in innate immunity, their compromised status in the presence of infection may transfer the host defense burden from an innate response to acquired immunity. The present study provides some insight into the lack of correlation between neutrophilia and the outcome of infection.

Tubular cell senescence and expression of TGF-beta1 and p21(WAF1/CIP1) in tubulointerstitial fibrosis of aging rats.

Kidney aging has been recognized as a chronic process of compromised renal function and structural changes in the tubulointerstitium and glomerulus. Cell senescence is associated with alterations in cell structure and function, including expression of cytokines and structural and regulatory components of extracellular matrix proteins. In this investigation, we tested the hypothesis that senescent renal cells may accumulate in vivo with advancing age. We also evaluated the expression of transforming growth factor (TGF)-beta1 and p21WAF1/CIP1 in aging kidneys. Sprague-Dawley rats at the ages of 3, 12, and 24 months were used for this study. Renal tissues were processed for morphometric and senescence analysis. Expression of TGF-beta1 and p21WAF1/CIP1 was evaluated by Northern or Western blot analysis and immunohistochemistry. Substantial tubulointerstitial injury occurred at the age of 12 months, but significant glomerular structure alteration was observed at the age of 24 months. Tubular cells developed senescence, which was detected by beta-galactosidase staining. This staining increased in frequency and intensity with age. Renal cortices showed a significant increase in the mRNA expression for TGF-beta1 and protein level for p21WAF1/CIP1. The enhanced expression of TGF-beta1 and p21WAF1/CIP1 was localized in the tubulointersititial cells. These data suggest that tubular cells undergo senescence and express increased TGF-beta1 and p21WAF1/CIP1 with advancing age. These age-related cellular and molecular alterations may play an important role in the initiation and/or progression of tubulointerstitial fibrosis and glomerulosclerosis in aging.

Glutathione depletion-induced neutrophil apoptosis is caspase 3 dependent.

Resolving inflammation is a vital step in preventing the persistence of inflammatory disorders. Neutrophils play a major role in tissue damage associated with an inflammatory response. Their death by apoptosis is central to the final resolution of this response. Thiol depletion with diethylmaleate (DEM) or diamide represent important triggers for neutrophil apoptosis. The mechanism by which this process occurs remains unknown. The apoptotic cascade is associated with a number of cellular changes, including caspase activation and mitochondrial permeability. The aims of this study were to determine the role of mitochondrial permeability and the caspase cascade in thiol depletion-induced neutrophil apoptosis. Total cellular glutathione was reduced by DEM and diamide. This reduction was associated with neutrophil apoptosis and an increase in caspase 3 activity. The effects of DEM were blocked by the caspase 3 inhibitor, Z-DEVD-FMK. Mitochondrial permeability that occurred was also increased during this induction of apoptosis. Bongkrekic acid, a mitochondrial membrane stabilizer, inhibited DEM-induced apoptosis. The inhibitors' effects of LPS or GM-CSF on spontaneous neutrophil apoptosis was reversed by DEM, which was mediated by an increase in caspase 3 activity and independent of mitochondrial disruption. Caspase activation is an important step in glutathione depletion-induced apoptosis in resting and inflammatory neutrophils. Regulation of caspase activity may represent a possible target to trigger apoptosis and resolve inflammatory disorders.