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Biomedical subjects

A Gardiner

Publications and source records attributed to A Gardiner.

At least 19 recordsLinked to original sources

Investigation and treatment of faecal incontinence.

Faecal incontinence is a debilitating condition affecting people of all ages, and significantly impairs quality of life. Proper clinical assessment followed by conservative medical therapy leads to improvement in more than 50% of cases, including patients with severe symptoms. Patients with advanced incontinence or those resistant to initial treatment should be evaluated by anorectal physiology testing to establish the severity and type of incontinence. Several treatment options with promising results exist. Patients with gross sphincter defects should undergo surgical repair. Those who fail to respond to sphincteroplasty and those with no anatomical defects have the option of either sacral nerve stimulation or other advanced procedures. Stoma formation should be reserved for patients who do not respond to any of the above procedures.

Artificial Organs↗

Neural network analysis of anal sphincter repair.

PURPOSE: Prediction of success after anterior sphincter repair for incontinence is difficult. Standard multivariate analysis techniques have only 75 to 80 percent accuracy. Artificial intelligence, including artificial neural networks, has been used in the analysis of complex clinical data and has proved to be successful in predicting the outcome of other surgical procedures. Using a neural network algorithm, we have assessed the probability of success after anterior sphincter repair. METHODS: Prospective anorectal physiology data of 72 patients undergoing anterior sphincter repair was collected between 1995 and 1999. Complete data sets of 75 percent of the series were used to train an artificial neural network; the remaining 25 percent were used for data validation. The output was continence grading, ranging from 0 to 4 (worse to continent). RESULTS: The outcome at 3, 6, and 12 months postoperatively was obtained and assessed. The best correlation between actual data value and artificial neural network value was found at 12 months (r = 0.931; P = 0.0001). Clear correlations also were found at three months (r = 0.898; P = 0.0001) and six months (r = 0.742; P = 0.002). Results of applying a net to details excluding pudendal nerve latency were poor. CONCLUSIONS: Artificial neural networks are more accurate (93 percent correlation) than standard statistics (75 percent) when applied to the prediction of outcome after anterior sphincter repair. This assessment also confirms the usefulness of pudendal latency in the prediction of anterior sphincter repair outcome. The results obtained highlight the obvious usefulness of artificial neural networks, which could now be used in a prospective evaluation for application of the technique.

Anal Canal↗

Hyperbaric oxygen in the treatment of fecal incontinence secondary to pudendal neuropathy.

PURPOSE: Hyperbaric oxygen therapy has several physiologic effects on damaged nerves in animal models, which lead to an improvement in neurologic function. Idiopathic fecal incontinence secondary to pudendal neuropathy is usually treated with biofeedback, which shows improvement in only 50 percent of patients. METHODS: Thirteen patients (12 females, age range, 40-75 years) with chronic pudendal neuropathy and fecal incontinence were identified. They received 30 treatments of hyperbaric oxygen during a period of 6 weeks. Each treatment was at 2.4 atmospheres breathing pure oxygen for 90 minutes. Pudendal latencies were performed sequentially throughout the treatment and one and six months after it had finished. Questionnaires were used to assess improvements in symptoms and quality of life (Wexner fecal incontinence quality of life score). RESULTS: All patients completed the treatment without major complications. There was a consistent improvement of the latencies (on the left 2.36 msec initially, reduced to 2.08 msec at 6-month follow-up and on the right 2.23 msec, on the left reduced to 2.07 msec at 6 months). These improvements were significant (Wilcoxon's two-tailed, asymptomatic significance, comparing pretreatment to 6-month follow-up, left 0.005, right 0.003). Incontinence sores also improved (12.08 initially to 11.64 at the end of treatment, 10.55 at 1-month follow-up, and 10.45 at 6-month follow-up). Using the same test, the improvement in incontinence scores also was significant when comparing pre-end (0.05) and pre-one month (0.011) but not pre-six month (0.054). CONCLUSIONS: Hyperbaric oxygen therapy has improved pudendal nerve function and continence in this group of patients. The cause for this improvement in latencies is unclear at present but may be because of a direct effect on the nerve or an improvement in blood flow to the nerve through angiogenesis. However, these results are good enough to schedule further trials.

Adult↗

Normal female anal sphincter: difficulties in interpretation explained.

PURPOSE: Our aims were to quantify the nature, characteristics, and frequency of variations in female anal sphincter anatomy. METHODS: Nulliparous patients from the antenatal clinic and healthy volunteers of both genders were studied. Sphincter length was determined by the position of the puborectalis sling. Defects in the external anal sphincter were defined at each level and recorded in degrees. Cylindric longitudinal images of the endoanal scans were created by a three-dimensional-representation software package. Manometry was performed by a pull-through technique. RESULTS: Fifty-seven nulliparous patients and 18 healthy volunteers were included in the study. The mean age was 39 years for males and 28.35 years for females. There was no significant difference in overall sphincter length or in the internal anal sphincter length as a percentage of overall sphincter length between genders. All nine males had a complete ring of external anal sphincter along the full sphincter length. In the external anal sphincter below the level of the puborectalis sling, a natural gap occurred in 43 nulliparous (75 percent) and all 9 female volunteers. The greater the size of the defect, the greater its extent (mean 1.33 cm for >90 degrees and 1.16 cm for <90 degrees; chi-squared P = 0.008, eight degrees of freedom). Manometry provided confirmatory evidence of the gaps seen. Anal manometry was analyzed by Mann-Whitney U test for continuous nonparametric data and t-test for comparison between genders. CONCLUSION: The female sphincter has a variable natural defect occurring along its anterior length. This makes interpretation of the isolated endoanal ultrasound difficult and explains previous overreporting of obstetric sphincter defects.

Adult↗

Inhibition of Wnt activity induces heart formation from posterior mesoderm.

In the chick, heart mesoderm is induced by signals from the anterior endoderm. Although BMP-2 is expressed in the anterior endoderm, BMP activity is necessary but not sufficient for heart formation. Previous work from our lab has suggested that one or more additional factors from anterior endoderm are required. Crescent is a Frizzled-related protein that inhibits Wnt-8c and is expressed in anterior endoderm during gastrulation. At the same stages, expression of Wnt-3a and Wnt-8c is restricted to the primitive streak and posterior lateral plate, and is absent from the anterior region where crescent is expressed. Posterior lateral plate mesoderm normally forms blood, but coculture of this tissue with anterior endoderm or infection with RCAS-crescent induces formation of beating heart muscle and represses formation of blood. Dkk-1, a Wnt inhibitor of a different protein family, similarly induces heart-specific gene expression in posterior lateral plate mesoderm. Furthermore, we have found that ectopic Wnt signals can repress heart formation from anterior mesoderm in vitro and in vivo and that forced expression of either Wnt-3a or Wnt-8c can promote development of primitive erythrocytes from the precardiac region. We conclude that inhibition of Wnt signaling promotes heart formation in the anterior lateral mesoderm, whereas active Wnt signaling in the posterior lateral mesoderm promotes blood development. We propose a model in which two orthogonal gradients, one of Wnt activity along the anterior-posterior axis and the other of BMP signals along the dorsal-ventral axis, intersect in the heart-forming region to induce cardiogenesis in a region of high BMP and low Wnt activity.

Animals↗

Outpatient hand held manometry: comparison of techniques.

OBJECTIVE: Anorectal manometry is an established important investigation in a number of disorders. The specialist ano-rectal laboratory is not always available, and a hand held manometer may be a useful tool in the outpatient setting to avoid an unnecessary visit to the anorectal physiology laboratory. Our aims were to determine whether the hand held manometer was as reliable as the standard system used in the anorectal laboratory, and to correctly compare the results from these two different techniques. PATIENTS AND METHODS: 24 patients visiting the Anorectal physiology laboratory were studies. Resting pressure, squeeze and cough pressures were recorded using the single channel hand held solid pressure transducer and with the dual channel pressure transducer MRP2 recorder. The first measurement by each method is used to illustrate the comparison of methods, the second measurement being used to study repeatability. RESULTS: The two methods correlate well for resting and squeeze pressures (Spearman coefficient with P < 0.01 for both) The level of agreement between the two methods was good for resting pressure recordings with a mean difference of 15 cm H2O. The same cannot be said for squeeze and cough pressures. Repeatability of both methods was good with mean differences on repeated recordings near zero. CONCLUSIONS: The hand held manometer is as repeatable as the laboratory but as some discrepancy occurs between the two methods they are not interchangeable. Thus the hand held manometer used alone in the outpatients Department is a useful screening and research tool.

Journal Article↗

Susceptibility of gram-positive cocci from 25 UK hospitals to antimicrobial agents including linezolid. The Linezolid Study Group.

The prevalence of antibiotic resistance amongst Gram-positive cocci from 25 UK hospitals was studied over an 8 month period in 1999. A total of 3770 isolates were tested by the sentinel laboratories using the Etest; these bacteria comprised 1000 pneumococci, 1005 Staphylococcus aureus, 769 coagulase-negative staphylococci (CNS) and 996 enterococci. To ensure quality, 10% of the isolates were retested centrally, as were any found to express unusual resistance patterns. The prevalence of penicillin-resistant Streptococcus pneumoniae, vancomycin-resistant enterococci and methicillin-resistant S. aureus (MRSA) varied widely amongst the sentinel laboratories. The resistance rates to methicillin among S. aureus and CNS were 19.2 and 38.9%, respectively, with MRSA rates in individual sentinel sites ranging from 0 to 43%. No glycopeptide resistance was seen in S. aureus, but 6.5% of CNS isolates were teicoplanin resistant and 0.5% were vancomycin resistant. Vancomycin resistance was much more frequent among Enterococcus faecium (24.1%) than E. faecalis (0.5%) (P<0.05), with most resistant isolates carrying vanA. The rate of penicillin resistance in pneumococci was 8.9%, and this resistance was predominantly intermediate (7.9%), with only six hospitals reporting isolates with high level resistance. The prevalence of erythromycin resistance among pneumococci was 12.3%, with the majority of resistant isolates having the macrolide efflux mechanism mediated by mefE. All the organisms tested were susceptible to linezolid with MICs in the range 0.12-4 mg/L. The modal MICs of linezolid were 1 mg/L for CNS and pneumococci, and 2 mg/L for S. aureus and enterococci. Linezolid was the most potent agent tested against Gram-positive cocci, including multiresistant strains, and as such may prove a valuable therapeutic option for the management of Gram-positive infections in hospitals.

Acetamides↗

Unmutated Ig V(H) genes are associated with a more aggressive form of chronic lymphocytic leukemia.

Despite having several characteristics of naïve B cells, chronic lymphocytic leukemia (CLL) cells have been shown in some cases to have somatically mutated Ig variable region genes, indicating that the cell of origin has passed through the germinal center. A previous study of patients with CLL found an association between lack of somatic mutation and trisomy 12 and, therefore, possibly with a less favorable prognosis. We have sequenced the Ig V(H) genes of the tumor cells of 84 patients with CLL and correlated our findings with clinical features. A total of 38 cases (45.2%) showed >/= 98% sequence homology with the nearest germline V(H) gene; 46 cases (54.8%) showed >2% somatic mutation. Unmutated V(H) genes were significantly associated with V1-69 and D3-3 usage, with atypical morphology; isolated trisomy 12, advanced stage and progressive disease. Survival was significantly worse for patients with unmutated V(H) genes irrespective of stage. Median survival for stage A patients with unmutated V(H) genes was 95 months compared with 293 months for patients whose tumors had mutated V(H) genes (P =.0008). The simplest explanation is that CLL comprises 2 different diseases with different clinical courses. One, arising from a memory B cell, has a benign course, the other, arising from a naïve B cell, is more malignant.

Adult↗

Cerberus regulates left-right asymmetry of the embryonic head and heart.

BACKGROUND: Most of the molecules known to regulate left-right asymmetry in vertebrate embryos are expressed on the left side of the future trunk region of the embryo. Members of the protein family comprising Cerberus and the putative tumour suppressor Dan have not before been implicated in left-right asymmetry. In Xenopus, these proteins have been shown to antagonise members of the transforming growth factor beta (TGF-beta) and Wnt families of signalling proteins. RESULTS: Chick Cerberus (cCer) was found to be expressed in the left head mesenchyme and in the left flank of the embryo. Expression on the left side of the head was controlled by Sonic hedgehog (Shh) acting through the TGF-beta family member Nodal; in the flank, cCer was also regulated by Shh, but independently of Nodal. Surprisingly, although no known targets of Cerberus are expressed asymmetrically on the right side of the embryo at these stages, misexpression of cCer on this side of the embryo led to upregulation of the transcription factor Pitx2 and reversal of the direction of heart and head turning, apparently as independent events. Consistent with the possibility that cCer may be acting on bilaterally expressed TGF-beta family members such as the bone morphogenetic proteins (BMPs), this result was mimicked by right-sided misexpression of the BMP antagonist, Noggin. CONCLUSIONS: Our findings suggest that cCer maintains a delicate balance of different TGF-beta family members involved in laterality decisions, and reveal the existence of partially overlapping molecular pathways regulating left-right asymmetry in the head and trunk of the embryo.

Amino Acid Sequence↗

Obstetric anal sphincter injury: prospective evaluation of incidence.

PURPOSE: An obstetrically damaged anal sphincter is the principal cause of the development of fecal incontinence in otherwise healthy females. Reports suggest that such damage complicates as many as 35 percent of primiparous vaginal deliveries, with 13 percent of first-time mothers becoming symptomatic. In maternity units delivering 3,000 patients annually, it would follow that 390 symptomatic patients would develop new symptoms each year. This incidence of dysfunction does not reflect current clinical practice. We have investigated this discrepancy to establish the actual incidence of anal sphincter trauma associated with childbirth. METHODS: During a six-week period, 159 females (105 primiparous and 54 para-I) were prospectively assessed postnatally using a standardized symptom questionnaire, endoanal ultrasound, and anal manometry. This group constituted 84 percent of all eligible deliveries occurring in the unit during the study period. RESULTS: One patient developed fecal urgency after this delivery; there were no reports of fecal incontinence. Anal sphincter injuries were identified ultrasonically in 6.8 percent of primiparous patients, 12.2 percent of para-I patients having vaginal deliveries, and 83 percent of patients having forceps deliveries overall. Manometric data provided confirmatory evidence, with significantly reduced maximum squeeze pressures in patients with a disrupted anal sphincter (P<0.0005). CONCLUSIONS: A symptom questionnaire is inadequate to identify anal sphincter injuries. The incidence of sphincter injury in relation to vaginal delivery has been overestimated in previous published work. This study demonstrates that the true incidence is 8.7 percent overall and that symptoms of sphincter dysfunction are uncommon this is in keeping with current clinical practice.

Adolescent↗

PEGylation of cytokines and other therapeutic proteins and peptides: the importance of biological optimisation of coupling techniques.

Polyethylene glycol (PEG) modification, PEGylation, is a well established technique which has the capacity to solve or ameliorate many of the problems of protein and peptide pharmaceuticals. It is one of the most important of the molecule altering structural chemistry (MASC) techniques and in many settings is enabling technology. The use of PEG as a linker molecule is also beginning to make a contribution to the production of exciting new products. We have previously reviewed the marked differences between methods of PEGylation and the surprising and dramatic impact of different coupling techniques (using different activated PEGs) on factors such as retention of bioactivity, stability and immunogenicity of the resulting PEGylated proteins and peptides. Numerous factors play a part in this variation: the presence or absence of linkers between the PEG and the target molecule; the nature and stability of the bond(s) between the PEG, linker and target; the impact of PEG attachment on surface charge; the coupling conditions; and the relative toxicity of the activated polymer and/or coproduct(s). These are not, however, the only sources of qualitative differences in PEGylated products. Our own experience whilst developing a linkerless PEGylation technique (i.e. one attaching only PEG to the target molecule), which we devised to overcome all the major problems of pre-existing PEGylation techniques, was that considerable modification of the prototype method and a process of 'biological optimisation' was required to achieve good results in terms of conservation of bioactivity. Biological optimisation has not, as far as we are aware, been systematically applied by other groups working in PEGylation. It is the term we use to describe an iterative process for examining and refining all the steps in the PEGylation process, including manufacturing the activated polymer, in order to achieve the best possible conservation of bioactivity and other beneficial features of the method. The application of this biologically optimised PEGylation technique, using tresyl monomethoxy PEG (TMPEG), to a variety of target proteins reveals, as outlined in this review, an exceptional ability to conserve biological activity of the target. This, and the benefit of adding nothing other than PEG itself (which has an excellent safety record), to the protein, as well as other manufacturing and practical advantages, makes the method ideal for the modification of cytokines and other therapeutic proteins.

Animals↗

Cloning of two candidate tumor suppressor genes within a 10 kb region on chromosome 13q14, frequently deleted in chronic lymphocytic leukemia.

Previous studies have indicated the presence of a putative tumor suppressor gene on chromosome 13q14, commonly deleted in patients with B-cell chronic lymphocytic leukemia (B-CLL). We have previously defined a minimally deleted region of 130 kb centromeric to the marker D13S272, and constructed a PAC and cosmid contig encompassing this area. In the present study we have made a detailed restriction and transcriptional map of the region of interest. Using these tools we have screened a panel of 206 primary CLL clones and three cell lines. In five CLL cases we found limited deletions defining the region of interest to an area of no more than 10 kb. Two adjacent genes, termed Leu1 and Leu2 (leukemia-associated gene 1 and 2), were mapped to the minimally deleted region, with several patients showing deletion borders within these genes. The Leu1 and Leu2 genes show little homology to previously published genes at the nucleotide and expected translated amino acid sequence level. Mutational analysis of the Leu1 and 2 genes in 170 CLL samples revealed no small intragenic mutations or point mutations. However, in all cases of 13q14 loss examined, the first exon of both genes, which are only 300 bp apart, were deleted. We conclude that the Leu1 and Leu2 genes are strong candidates as tumor suppressor gene(s) involved in B-CLL leukemogenesis.

Amino Acid Sequence↗

Structural abnormalities of chromosome 7q in chronic lymphoproliferative disorders.

Structural abnormalities of 7q are common in myeloid malignancies but rarely reported in chronic lymphoproliferative disorders. 7q abnormalities were found in 29 of 796 patients (3.6%) with chronic lymphoid malignancies. The most common association was found in splenic lymphoma with villous lymphocytes (SLVL) in which 8 of 31 cases (26%) has one or more abnormalities of 7q. The most common abnormalities were deletions involving 7q32 and deletions or translocation of 7q22. There was no correlation between the type of lymphoid disorder or clinical course and specific structural abnormalities. We postulate that genes important in the pathogenesis of SLVL may reside on 7q22 and/or 7q32.

Aged↗

Trisomy 12 and structural abnormalities of 13q14 occurring in the same clone in chronic lymphocytic leukaemia.

Trisomy 12 and deletions or translocations of 13q14 are the commonest cytogenetic abnormalities in chronic lymphocytic leukaemia but rarely co-exist in the same patient. We describe eight patients from a series of > 400 patients with CLL in whom trisomy 12 and t or del 13 occur in the same clone. Using FISH we have identified clones with trisomy 12 alone, t or del 13q14 alone and both abnormalities, in each of the patients studied. This implies that neither trisomy 12 nor t or del 13q14 is the initiating event in leukaemogenesis, but does not exclude the possibility of a submicroscopic abnormality of 13q14 occurring as an early event.

Aged↗

Frequent homozygous deletions of the D13S25 locus in chromosome region 13q14 defines the location of a gene critical in leukaemogenesis in chronic B-cell lymphocytic leukaemia.

Cytogenetic studies of B-cell chronic lymphocytic leukaemia show structural abnormalities involving the 13q14 chromosome region as the only karyotypic change in a significant proportion of tumours. This observation suggests the location of a gene important in leukaemogenesis. A series of 68 BCLL tumours have been analysed for allele loss using a series of probes from 13q14. Using intragenic polymorphic markers from the retinoblastoma predisposition gene LOH was observed in 25% of tumours including 3/6 showing cytogenetically obvious deletions of the 13q14 region and 3/6 showing translocations involving 13q14. However, three deletions with proximal breakpoints in 13q14 did not show allele loss, demonstrating that the breakpoint lay distal to RB1. Using the D13S25 locus, which lies 1.6 cM distal to RB1, allele loss was seen in 90% of tumours with structural rearrangements of 13q14 and 75% of tumours with an apparently normal karyotype. 50% of these tumours showed homozygous loss of D13S25, suggesting that a 'tumour suppressor gene' lies in this region. The more distal D13S31 locus, 1 cM distal to D13S25, was infrequently involved in allele loss demonstrating that the minimum region of overlap for homozygous deletions is approximately 1 Mbp around the D13S25 locus.

Alleles↗