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1.  Primary Open Angle Glaucoma is Associated with MR Biomarkers of Cerebral Small Vessel Disease 
Scientific Reports  2016;6:22160.
This prospective study tests the hypotheses that: 1) glaucoma is associated with evidence of cerebral small vessel disease; 2) that imaging biomarkers of cerebral small vessel disease in POAG and NTG will show different characteristics. 12 normal controls, 7 patients with primary open angle glaucoma (POAG) and 9 patients with normal tension glaucoma (NTG) were recruited. Ophthalmological clinical assessment and MR imaging of the brain were performed. MR imaging was used to quantify white matter lesion load, frequency of dilated perivascular spaces (PVS) and abnormalities in cerebral hydrodynamics. Patients with POAG had significantly greater white matter lesion load (p < 0.05), more PVS in the centrum semiovale (p < 0.05) and had higher overall PVS scores than controls (p < 0.05). In the POAG group, optic cup-to-disc ratio (CDR) was positively correlated with deep white matter hyperintensities (R2 = 0.928, p < 0.01). Mean deviation on the Humphrey visual field assessment was negatively correlated with deep white matter lesion load (R2 = −0.840, p < 0.01), total white matter lesion load (R2 = −0.928, p < 0.01) and total PVS (R2 = −0.820, p < 0.01). MR evidence of cerebral small vessel disease is strongly associated with a diagnosis of POAG and with the severity of abnormalities in CDR and visual field.
PMCID: PMC4770586  PMID: 26923106
2.  Quantifying anti-vascular effects of monoclonal antibodies to VEGF 
Little is known concerning the onset, duration and magnitude of direct therapeutic effects of anti-VEGF therapies. Such knowledge would help guide the rational development of targeted therapeutics from bench to bedside and optimize use of imaging technologies that quantify tumor function in early phase clinical trials.
Experimental design
Pre-clinical studies were performed using ex vivo micro-CT and in-vivo ultrasound imaging to characterize tumor vasculature in a human HM-7 colorectal xenograft model treated with the anti-VEGF antibody G6-31. Clinical evaluation was by quantitative MRI in ten patients with metastatic CRC treated with bevacizumab.
Micro-CT experiments demonstrated reduction in perfused vessels within 24-48 hours of G6-31 drug administration (p ≤ 0.005). Ultrasound imaging confirmed reduced tumor blood volume within the same time frame (p = 0.048). Consistent with the pre-clinical results, reductions in enhancing fraction and fractional plasma volume were detected in patient CRC metastases within 48 hours after a single dose of bevacizumab that persisted throughout one cycle of therapy. These effects were followed by resolution of edema (p = 0.0023) and tumor shrinkage in 9/26 tumors at day 12.
These data suggest that VEGF-specific inhibition induces rapid structural and functional effects with downstream significant anti-tumor activity within one cycle of therapy. This finding has important implications for the design of early phase clinical trials that incorporate physiological imaging. The study demonstrates how animal data help interpret clinical imaging data, an important step towards the validation of image biomarkers of tumor structure and function.
PMCID: PMC4688942  PMID: 19861458
angiogenesis; biomarker; imaging; VEGF
3.  Imaging Intratumor Heterogeneity: Role in Therapy Response, Resistance, and Clinical Outcome 
Tumors exhibit genomic and phenotypic heterogeneity which has prognostic significance and may influence response to therapy. Imaging can quantify the spatial variation in architecture and function of individual tumors through quantifying basic biophysical parameters such as density or MRI signal relaxation rate; through measurements of blood flow, hypoxia, metabolism, cell death and other phenotypic features; and through mapping the spatial distribution of biochemical pathways and cell signaling networks. These methods can establish whether one tumor is more or less heterogeneous than another and can identify sub-regions with differing biology. In this article we review the image analysis methods currently used to quantify spatial heterogeneity within tumors. We discuss how analysis of intratumor heterogeneity can provide benefit over more simple biomarkers such as tumor size and average function. We consider how imaging methods can be integrated with genomic and pathology data, rather than be developed in isolation. Finally, we identify the challenges that must be overcome before measurements of intratumoral heterogeneity can be used routinely to guide patient care.
PMCID: PMC4688961  PMID: 25421725
4.  Cut-off points for anthropometric indices of adiposity: differential classification in a large population of young women 
The British journal of nutrition  2008;101(3):424-430.
Anthropometric indices of adiposity include body mass index (BMI), waist circumference and waist-to-height ratio. In the recruitment phase of a prospective cohort study carried out between 1998 and 2002 we studied a population sample of 11 786 white Caucasian non-pregnant women in Southampton, UK aged 20-34 y, and explored the extent to which proposed cut-off points for the three indices identified the same or different women and how these indices related to adiposity. Height, weight and waist circumference were measured and body fat was estimated from skinfold thicknesses; fat mass index was calculated as fat mass/height1.65. 4 869 (42%) women were overweight (BMI ≥ 25) and 1 849 (16%) were obese (BMI ≥ 30). 890 (8%) were not overweight but had a waist circumference ≥ 80 cm and 748 (6%) were overweight but had a waist circumference < 80 cm (6%). 50% of the women had a BMI ≥ 25 or a waist circumference ≥ 80 cm or a waist-to-height ratio ≥ 0.5. 85% of the variation in fat mass index was explained by BMI, 76% by waist circumference and 75% by waist-to-height ratio. Our findings demonstrate that many women are differentially classified depending on which index of adiposity is used. As each index captures different aspects of size in terms of adiposity, there is the need to determine how the three indices relate to function and how they can be of use in defining risk of ill health in women.
PMCID: PMC4579544  PMID: 18634708
body mass index; waist circumference; waist-to-height ratio; young women; adiposity
5.  Vascular biomarkers derived from dynamic contrast-enhanced MRI predict response of vestibular schwannoma to antiangiogenic therapy in type 2 neurofibromatosis 
Neuro-Oncology  2015;18(2):275-282.
Antiangiogenic therapy of vestibular schwannoma (VS) in type 2 neurofibromatosis can produce tumor shrinkage with response rates of 40%–60%. This study examines the predictive value of parameter-derived MRI in this setting.
Twelve patients with 20 VSs were recruited. Each had at least one rapidly growing tumor. Patients were treated with bevacizumab, 5 mg/kg every 2 weeks. Patients with stable or reduced VS volume were maintained at 2.5–5 mg every 4 weeks after 6 months. Those who failed treatment had their bevacizumab discontinued. Dynamic contrast-enhanced (DCE) MRI performed prior to treatment using a high temporal resolution technique, and data were analyzed to allow measurement of contrast transfer coefficient (Ktrans), vascular fraction (vp), extravascular-extracellular fraction (ve). Relaxation rate (R1N) was measured using a variable flip angle technique. Apparent diffusional coefficient (ADC) was calculated from diffusion-weighted imaging. The predictive power of microvascular parameters and ADC were examined using logistic regression modeling.
Responding tumors were larger (P < .001), had lower R1N (P < .001), and higher Ktrans (P < .05) and ADC (P < .01). They showed increases in R1N (P < .01) and reduction of Ktrans (P < .01) and ADC (P < .01). Modeling to predict response demonstrated significant independent predictive power for R1N (Β = − 0.327, P < .001), and Ktrans (Β = 0.156, P < .05). Modeling to predict percentage change in tumor volume at 90 days identified baseline tumor volume (Β = 5.503, P < .05), R1N (Β = − 5.844, P < .05), and Ktrans (Β = 5.622, P < .05) as independent significant predictors.
In patients with type 2 neurofibromatosis, biomarkers from DCE-MRI are predictive of VS volume response to inhibition of vascular endothelial growth factor inhibition.
PMCID: PMC4724182  PMID: 26311690
bevacizumab; DCE-MRI; neurofibromatosis type 2; prediction; treatment response
6.  The Accuracy of ADC Measurements in Liver Is Improved by a Tailored and Computationally Efficient Local-Rigid Registration Algorithm 
PLoS ONE  2015;10(7):e0132554.
This study describes post-processing methodologies to reduce the effects of physiological motion in measurements of apparent diffusion coefficient (ADC) in the liver. The aims of the study are to improve the accuracy of ADC measurements in liver disease to support quantitative clinical characterisation and reduce the number of patients required for sequential studies of disease progression and therapeutic effects. Two motion correction methods are compared, one based on non-rigid registration (NRA) using freely available open source algorithms and the other a local-rigid registration (LRA) specifically designed for use with diffusion weighted magnetic resonance (DW-MR) data. Performance of these methods is evaluated using metrics computed from regional ADC histograms on abdominal image slices from healthy volunteers. While the non-rigid registration method has the advantages of being applicable on the whole volume and in a fully automatic fashion, the local-rigid registration method is faster while maintaining the integrity of the biological structures essential for analysis of tissue heterogeneity. Our findings also indicate that the averaging commonly applied to DW-MR images as part of the acquisition protocol should be avoided if possible.
PMCID: PMC4512673  PMID: 26204105
7.  The feasibility and acceptability of training volunteer mealtime assistants to help older acute hospital in-patients: the Southampton Mealtime Assistance Study 
Journal of clinical nursing  2014;23(0):3240-3249.
Aims and objectives
To determine the feasibility and acceptability of using trained volunteers as mealtime assistants for older hospital inpatients.
Poor nutrition among hospitalised older patients is common in many countries and associated with poor outcomes. Competing time pressures on nursing staff may make it difficult to prioritise mealtime assistance especially on wards where many patients need help.
Mixed methods evaluation of the introduction of trained volunteer mealtime assistants on an acute female Medicine for Older People ward in a teaching hospital in England.
A training programme was developed for volunteers who assisted female inpatients aged 70 years and over on weekday lunchtimes. The feasibility of using volunteers was determined by the proportion recruited, trained, and their activity and retention over 1 year. The acceptability of the training and of the volunteers’ role was obtained through interviews and focus groups with 12 volunteers, 9 patients and 17 nursing staff.
59 potential volunteers were identified: 38 attended a training session of whom 29 delivered mealtime assistance, including feeding, to 3,911 (76%) ward patients during the year (mean duration of assistance 5.5 months). The volunteers were positive about the practical aspects of training and on-going support provided. They were highly valued by patients and ward staff and have continued to volunteer.
Volunteers can be recruited and trained to help acutely unwell older female inpatients at mealtimes, including feeding. This assistance is sustainable and is valued.
Relevance to clinical practice
This paper describes a successful method for recruitment, training and retention of volunteer mealtime assistants. It includes a profile of those volunteers who provided the most assistance, details of the training programme and role of the volunteers, and could be replicated by nursing staff in other healthcare units.
PMCID: PMC4196922  PMID: 24666963
Nutrition; older; hospital; volunteer; mealtime assistance; nurses; nursing
8.  Improving women's diet quality preconceptionally and during gestation: effects on birth weight and prevalence of low birth weight—a randomized controlled efficacy trial in India (Mumbai Maternal Nutrition Project)12345 
Background: Low birth weight (LBW) is an important public health problem in undernourished populations.
Objective: We tested whether improving women's dietary micronutrient quality before conception and throughout pregnancy increases birth weight in a high-risk Indian population.
Design: The study was a nonblinded, individually randomized controlled trial. The intervention was a daily snack made from green leafy vegetables, fruit, and milk (treatment group) or low-micronutrient vegetables (potato and onion) (control group) from ≥90 d before pregnancy until delivery in addition to the usual diet. Treatment snacks contained 0.69 MJ of energy (controls: 0.37 MJ) and 10–23% of WHO Reference Nutrient Intakes of β-carotene, riboflavin, folate, vitamin B-12, calcium, and iron (controls: 0–7%). The primary outcome was birth weight.
Results: Of 6513 women randomly assigned, 2291 women became pregnant, 1962 women delivered live singleton newborns, and 1360 newborns were measured. In an intention-to-treat analysis, there was no overall increase in birth weight in the treatment group (+26 g; 95% CI: −15, 68 g; P = 0.22). There was an interaction (P < 0.001) between the allocation group and maternal prepregnant body mass index (BMI; in kg/m2) [birth-weight effect: −23, +34, and +96 g in lowest (<18.6), middle (18.6–21.8), and highest (>21.8) thirds of BMI, respectively]. In 1094 newborns whose mothers started supplementation ≥90 d before pregnancy (per-protocol analysis), birth weight was higher in the treatment group (+48 g; 95% CI: 1, 96 g; P = 0.046). Again, the effect increased with maternal BMI (−8, +79, and +113 g; P-interaction = 0.001). There were similar results for LBW (intention-to-treat OR: 0.83; 95% CI: 0.66, 1.05; P = 0.10; per-protocol OR = 0.76; 95% CI: 0.59, 0.98; P = 0.03) but no effect on gestational age in either analysis.
Conclusions: A daily snack providing additional green leafy vegetables, fruit, and milk before conception and throughout pregnancy had no overall effect on birth weight. Per-protocol and subgroup analyses indicated a possible increase in birth weight if the mother was supplemented ≥3 mo before conception and was not underweight. This trial was registered at as ISRCTN62811278.
PMCID: PMC4196482  PMID: 25332324
9.  Semi-Quantitative Parameter Analysis of DCE-MRI Revisited: Monte-Carlo Simulation, Clinical Comparisons, and Clinical Validation of Measurement Errors in Patients with Type 2 Neurofibromatosis 
PLoS ONE  2014;9(3):e90300.
To compare semi-quantitative (SQ) and pharmacokinetic (PK) parameters for analysis of dynamic contrast enhanced MR data (DCE-MRI) and investigate error-propagation in SQ parameters.
Clinical data was collected from five patients with type 2-neurofibromatosis (NF2) receiving anti-angiogenic therapy for rapidly growing vestibular schwannoma (VS). There were 7 VS and 5 meningiomas. Patients were scanned prior to therapy and at days 3 and 90 of treatment. Data was collected using a dual injection technique to permit direct comparison of SQ and PK parameters. Monte Carlo modeling was performed to assess potential measurement errors in SQ parameters in persistent, washout, and weakly enhancing tissues. The simulation predictions for five semi-quantitative parameters were tested using the clinical DCE-MRI data.
In VS, SQ parameters and Ktrans showed close correlation and demonstrated similar therapy induced reductions. In meningioma, only the denoised Signal Enhancement Ratio (Rse1/se2(DN)) showed a significant therapy induced reduction (p<0.05). Simulation demonstrated: 1) Precision of SQ metrics normalized to the pre-contrast-baseline values (MSErel and ∑MSErel) is improved by use of an averaged value from multiple baseline scans; 2) signal enhancement ratio Rmse1/mse2 shows considerable susceptibility to noise; 3) removal of outlier values to produce a new parameter, Rmse1/mse2(DN), improves precision and sensitivity to therapy induced changes. Direct comparison of in-vivo analysis with Monte Carlo simulation supported the simulation predicted error distributions of semi-quantitative metrics.
PK and SQ parameters showed similar sensitivity to anti-angiogenic therapy induced changes in VS. Modeling studies confirmed the benefits of averaging baseline signal from multiple images for normalized SQ metrics and demonstrated poor noise tolerance in the widely used signal enhancement ratio, which is corrected by removal of outlier values.
PMCID: PMC3942428  PMID: 24594707
10.  Early reduction in tumour [18F]fluorothymidine (FLT) uptake in patients with non-small cell lung cancer (NSCLC) treated with radiotherapy alone 
Changes in tumour 3′-deoxy-3′-[18F]fluorothymidine (FLT) uptake during concurrent chemo-radiotherapy in patients with non-small cell lung cancer (NSCLC) have been reported, at variable time points, in two pilot positron emission tomography (PET) studies. The aim of this study was to assess whether FLT changes occur early in response to radiotherapy (RT) without concurrent chemotherapy and whether such changes exceed test-retest variability.
Sixteen patients with NSCLC, scheduled to have radical RT, underwent FLT PET once/twice at baseline to assess reproducibility and/or after 5–11 RT fractions to evaluate response. Primary and nodal malignant lesions were manually delineated on CT and volume, mean and maximum standardized uptake values (SUVmean and SUVmax) estimated. Analysis included descriptive statistics and parameter fitting to a mixed-effects model accounting for patients having different numbers of evaluable lesions.
In all, 35 FLT PET scans from 7 patients with a total of 18 lesions and 12 patients with a total of 30 lesions were evaluated for reproducibility and response, respectively. SUVmean reproducibility in primary tumours (SD 8.9 %) was better than SUVmax reproducibility (SD 12.6 %). In nodes, SUVmean and SUVmax reproducibilities (SD 18.0 and 17.2 %) were comparable but worse than for primary tumours. After 5–11 RT fractions, primary tumour SUVmean decreased significantly by 25 % (p = 0.0001) in the absence of significant volumetric change, whereas metastatic nodes decreased in volume by 31 % (p = 0.020) with a larger SUVmean decrease of 40 % (p < 0.0001). Similar changes were found for SUVmax.
Across this group of NSCLC patients, RT induced an early, significant decrease in lesion FLT uptake exceeding test-retest variability. This effect is variable between patients, appears distinct between primary and metastatic nodal lesions, and in primary tumours is lower than previously reported for concurrent chemo-RT at a similar time point. These results confirm the potential for FLT PET to report early on radiation response and to enhance the clinical development of novel drug-radiation combinations by providing an interpretable, early pharmacodynamic end point.
Electronic supplementary material
The online version of this article (doi:10.1007/s00259-013-2632-3) contains supplementary material, which is available to authorized users.
PMCID: PMC3955141  PMID: 24504503
[18F]Fluorothymidine PET; Non-small cell lung cancer; Radiotherapy; Early response monitoring
11.  Impact of Gas Delivery Systems on Imaging Studies of Human Cerebral Blood Flow 
Purpose. To compare a semiopen breathing circuit with a non-rebreathing (Hudson mask) for MRI experiments involving gas delivery. Methods and Materials. Cerebral blood flow (CBF) was measured by quantitative phase contrast angiography of the internal carotid and basilar arteries in 18 volunteers (20–31 years). In 8 subjects, gases were delivered via a standard non-rebreathing (Hudson mask). In 10 subjects, gases were delivered using a modified “Mapleson A” semiopen anesthetic gas circuit and mouthpiece. All subjects were given 100% O2, medical air, and carbogen gas (95% O2 and 5% CO2) delivered at 15 L/min in a random order. Results. The Hudson mask group showed significant increases in CBF in response to increased FiCO2 compared to air (+9.8%). A small nonsignificant reduction in CBF (−2.4%) was seen in response to increased inspired concentrations of oxygen (FiO2). The Mapleson A group showed significantly larger changes in CBF in response to both increased inspired concentrations of carbon dioxide (FiCO2) (+32.2%, P < 0.05) and FiO2 (−14.6%, P < 0.01). Conclusions. The use of an anaesthetic gas delivery circuit avoids entrainment of room air and rebreathing effects that may otherwise adversely affect the experimental results.
PMCID: PMC3874307  PMID: 24392225
12.  Does living in a food insecure household impact on the diets and body composition of young children? Findings from the Southampton Women’s Survey 
Little is known about food insecurity in the UK. The aims of this study were to assess the prevalence and factors associated with food insecurity in a UK cohort, and to examine whether the diets, reported health and anthropometry of young food insecure children differed from those of other children.
The Southampton Women’s Survey is a prospective cohort study in which detailed information about the diet, lifestyle and body composition of 3000 women was collected before and during pregnancy. Between 2002-2006, 1618 families were followed up when the child was 3 years old. Food insecurity was determined using the Household Food Security scale. The child’s height and weight were measured; diet was assessed by food frequency questionnaire.
4.6% of the households were food insecure. Food insecurity was more common in families where the mothers were younger, smokers, of lower social class, in receipt of financial benefits, and who had a higher deprivation score (all p<0.05). In comparison with other 3-year-old children, those living in food insecure households were likely to have worse parent-reported health and to have a diet of poorer quality, characterised by greater consumption of white bread, processed meat and chips, and by a lower consumption of vegetables (all p<0.05). They did not differ in height or body mass index.
Our data suggest that there are significant numbers of food insecure families in the UK. The poorer reported health and diets of young food insecure children have important implications for their development and lifelong health.
PMCID: PMC3679518  PMID: 21652519
food insecurity; body composition; dietary quality; children
13.  [11C]-(R)PK11195 tracer kinetics in the brain of glioma patients and a comparison of two referencing approaches 
Translocator protein (TSPO) is a biomarker of neuroinflammation that can be imaged by PET using [11C]-(R)PK11195. We sought to characterize the [11C]-(R)PK11195 kinetics in gliomas of different histotypes and grades, and to compare two reference tissue input functions (supervised cluster analysis versus cerebellar grey matter) for the estimation of [11C]-(R)PK11195 binding in gliomas and surrounding brain structures.
Twenty-three glioma patients and ten age-matched controls underwent structural MRI and dynamic [11C]-(R)PK11195 PET scans. Tissue time–activity curves (TACs) were extracted from tumour regions as well as grey matter (GM) and white matter (WM) of the brains. Parametric maps of binding potential (BPND) were generated with the simplified reference tissue model using the two input functions, and were compared with each other. TSPO expression was assessed in tumour tissue sections by immunohistochemistry.
Three types of regional kinetics were observed in individual tumour TACs: GM-like kinetics (n = 6, clearance of the tracer similar to that in cerebellar GM), WM-like kinetics (n = 8, clearance of the tracer similar to that in cerebral WM) and a form of mixed kinetics (n = 9, intermediate rate of clearance). Such kinetic patterns differed between low-grade astrocytomas (WM-like kinetics) and oligodendrogliomas (GM-like and mixed kinetics), but were independent of tumour grade. There was good agreement between parametric maps of BPND derived from the two input functions in all controls and 10 of 23 glioma patients. In 13 of the 23 patients, BPND values derived from the supervised cluster input were systematically smaller than those using the cerebellar input. Immunohistochemistry confirmed that TSPO expression increased with tumour grade.
The three types of [11C]-(R)PK11195 kinetics in gliomas are determined in part by tracer delivery, and indicated that kinetic analysis is a valuable tool in the study of gliomas with the potential for in vivo discrimination between low-grade astrocytomas and oligodendrogliomas. Supervised cluster and cerebellar input functions produced consistent BPND estimates in approximately half of the gliomas investigated, but had a systematic difference in the remainder. The cerebellar input is preferred based on theoretical and practical considerations.
PMCID: PMC3738844  PMID: 23715902
Translocator protein; [11C]-(R)PK11195; Kinetic analysis; Reference tissue; Glioma; PET
14.  Role of Nuclear Factor-κB in Oxidative Stress Associated with Rabies Virus Infection of Adult Rat Dorsal Root Ganglion Neurons 
Journal of Virology  2012;86(15):8139-8146.
Recent studies in an experimental model of rabies showed major structural changes in the brain involving neuronal processes that are associated with severe clinical disease. Cultured adult rat dorsal root ganglion (DRG) neurons infected with the challenge virus standard-11 strain of rabies virus (CVS) showed axonal swellings and immunostaining for 4-hydroxy-2-nonenal (4-HNE), indicating evidence of lipid peroxidation associated with oxidative stress and reduced axonal growth compared to that of mock-infected DRG neurons. We have evaluated whether nuclear factor (NF)-κB might act as a critical bridge linking CVS infection and oxidative stress. On Western immunoblotting, CVS infection induced expression of the NF-κB p50 subunit compared to that of mock infection. Ciliary neurotrophic factor, a potent activator of NF-κB, had no effect on mock-infected rat DRG neurons and reduced the number of 4-HNE-labeled puncta. SN50, a peptide inhibitor of NF-κB, and CVS infection had an additive effect in producing axonal swellings, indicating that NF-κB is neuroprotective. The fluorescent signal for subunit p50 was quantitatively evaluated in the nucleus and cytoplasm of mock- and CVS-infected rat DRG neurons. At 24 h postinfection (p.i.), there was a significant increase in the nucleus/cytoplasm ratio, indicating increased transcriptional activity of NF-κB, perhaps as a response to stress. At both 48 and 72 h p.i., there was significantly reduced nuclear localization of NF-κB. CVS infection may induce oxidative stress by inhibiting nuclear activation of NF-κB. A rabies virus protein may directly inhibit NF-κB activity. Further investigations are needed to gain a better understanding of the basic mechanisms involved in the oxidative damage associated with rabies virus infection.
PMCID: PMC3421658  PMID: 22623795
15.  Southampton mealtime assistance study: design and methods 
BMC Geriatrics  2013;13:5.
Malnutrition is common in older people in hospital and is associated with adverse clinical outcomes including increased mortality, morbidity and length of stay. This has raised concerns about the nutrition and diet of hospital in-patients. A number of factors may contribute to low dietary intakes in hospital, including acute illness and cognitive impairment among in-patients. The extent to which other factors influence intake such as a lack of help at mealtimes, for patients who require assistance with eating, is uncertain. This study aims to evaluate the effectiveness of using trained volunteer mealtime assistants to help patients on an acute medical ward for older people at mealtimes.
The study design is quasi-experimental with a before (year one) and after (year two) comparison of patients on the intervention ward and parallel comparison with patients on a control ward in the same department. The intervention in the second year was the provision of trained volunteer mealtime assistance to patients in the intervention ward. There were three components of data collection that were repeated in both years on both wards. The first (primary) outcome was patients’ dietary intake, collected as individual patient records and as ward-level balance data over 24 hour periods. The second was clinical outcome data assessed on admission and discharge from both wards, and 6 and 12 months after discharge. Finally qualitative data on the views and experience of patients, carers, staff and volunteers was collected through interviews and focus groups in both years to allow a mixed-method evaluation of the intervention.
The study will describe the effect of provision of trained volunteer mealtime assistants on the dietary intake of older medical in-patients. The association between dietary intake and clinical outcomes including malnutrition risk, body composition, grip strength, length of hospital stay and mortality will also be determined. An important component of the study is the use of qualitative approaches to determine the views of patients, relatives, staff and volunteers on nutrition in hospital and the impact of mealtime assistance.
Trial registration
Trial registered with NCTO1647204
PMCID: PMC3547699  PMID: 23294981
Nutrition; Older; Volunteer; Mealtime assistance; Dietary intake; Hospital
16.  Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study 
Lancet  2012;379(9811):136-142.
Public objection to autopsy has led to a search for minimally invasive alternatives. Imaging has potential, but its accuracy is unknown. We aimed to identify the accuracy of post-mortem CT and MRI compared with full autopsy in a large series of adult deaths.
This study was undertaken at two UK centres in Manchester and Oxford between April, 2006, and November, 2008. We used whole-body CT and MRI followed by full autopsy to investigate a series of adult deaths that were reported to the coroner. CT and MRI scans were reported independently, each by two radiologists who were masked to the autopsy findings. All four radiologists then produced a consensus report based on both techniques, recorded their confidence in cause of death, and identified whether autopsy was needed.
We assessed 182 unselected cases. The major discrepancy rate between cause of death identified by radiology and autopsy was 32% (95% CI 26–40) for CT, 43% (36–50) for MRI, and 30% (24–37) for the consensus radiology report; 10% (3–17) lower for CT than for MRI. Radiologists indicated that autopsy was not needed in 62 (34%; 95% CI 28–41) of 182 cases for CT reports, 76 (42%; 35–49) of 182 cases for MRI reports, and 88 (48%; 41–56) of 182 cases for consensus reports. Of these cases, the major discrepancy rate compared with autopsy was 16% (95% CI 9–27), 21% (13–32), and 16% (10–25), respectively, which is significantly lower (p<0·0001) than for cases with no definite cause of death. The most common imaging errors in identification of cause of death were ischaemic heart disease (n=27), pulmonary embolism (11), pneumonia (13), and intra-abdominal lesions (16).
We found that, compared with traditional autopsy, CT was a more accurate imaging technique than MRI for providing a cause of death. The error rate when radiologists provided a confident cause of death was similar to that for clinical death certificates, and could therefore be acceptable for medicolegal purposes. However, common causes of sudden death are frequently missed on CT and MRI, and, unless these weaknesses are addressed, systematic errors in mortality statistics would result if imaging were to replace conventional autopsy.
Policy Research Programme, Department of Health, UK.
PMCID: PMC3262166  PMID: 22112684
19.  Role of Oxidative Stress in Rabies Virus Infection of Adult Mouse Dorsal Root Ganglion Neurons▿  
Journal of Virology  2010;84(9):4697-4705.
Rabies virus infection of dorsal root ganglia (DRG) was studied in vitro with cultured adult mouse DRG neurons. Recent in vivo studies of transgenic mice that express the yellow fluorescent protein indicate that neuronal process degeneration, involving both dendrites and axons, occurs in mice infected with the challenge virus standard (CVS) strain of rabies virus by footpad inoculation. Because of the similarities of the morphological changes in experimental rabies and in diabetic neuropathy and other diseases, we hypothesize that neuronal process degeneration occurs as a result of oxidative stress. DRG neurons were cultured from adult ICR mice. Two days after plating, they were infected with CVS. Immunostaining was evaluated with CVS- and mock-infected cultures for neuron specific β-tubulin, rabies virus antigen, and amino acid adducts of 4-hydroxy-2-nonenal (4-HNE) (marker of lipid peroxidation and hence oxidative stress). Neuronal viability (by trypan blue exclusion), terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling (TUNEL) staining, and axonal growth were also assessed with the cultures. CVS infected 33 to 54% of cultured DRG neurons. Levels of neuronal viability and TUNEL staining were similar in CVS- and mock-infected DRG neurons. There were significantly more 4-HNE-labeled puncta at 2 and 3 days postinfection in CVS-infected cultures than in mock-infected cultures, and axonal outgrowth was reduced at these time points in CVS infection. Axonal swellings with 4-HNE-labeled puncta were also associated with aggregations of actively respiring mitochondria. We have found evidence that rabies virus infection in vitro causes axonal injury of DRG neurons through oxidative stress. Oxidative stress may be important in vivo in rabies and may explain previous observations of the degeneration of neuronal processes.
PMCID: PMC2863745  PMID: 20181692
20.  Effect of physiological doses of oral vitamin B12 on plasma homocysteine – A randomized, placebo-controlled, double-blind trial in India 
Vitamin B12 (B12) deficiency is common in Indians and a major contributor to hyperhomocysteinemia, which may influence fetal growth, risk of type 2 diabetes and cardiovascular disease.
To study the effect of physiological doses of B12 and folic acid on plasma total homocysteine (tHcy).
A cluster randomized, placebo-controlled, double-blind, 2x3 factorial trial, using the family as the randomization unit. Vitamin B12 was given as 2 or 10 μg capsules, with or without 200 μg folic acid, forming six groups (B0F0, B2F0, B10F0, B0F200, B2F200, B10F200). Plasma tHcy was measured before and after 4 and 12 mo of supplementation.
Three hundred individuals from 119 families in the Pune Maternal Nutrition Study were randomised. There was no interaction between B12 and folic acid (P=0.14) in relation to tHcy change and their effects were analyzed separately: B0 vs. B2 vs. B10; and F0 vs. F200. At 12 mo, tHcy fell by a mean 5.9 (95% CI: −7.8, −4.1) μmol/L in B2, and by 7.1 (95% CI: −8.9, −5.4) μmol/L in B10, compared to non-significant rise of 1.2 (95% CI: −0.5, 2.9) μmol/L in B0. B2 and B10 did not differ significantly. In F200, tHcy fell by 4.8 (95% CI: −6.3, −3.3) μmol/L compared to 2.8 (95% CI: −4.3, −1.2) μmol/L in F0.
Daily oral supplementation with physiological doses of B12 is an effective community intervention to reduce tHcy. Folic acid (200 μg/d) showed no additional benefit, neither had any unfavourable effects.
PMCID: PMC2865445  PMID: 20216560
Cyanocobalamin; folic acid; homocysteine; randomised controlled trial; South Asian Indians; vitamin B12
21.  Magnetic resonance perfusion imaging in neuro-oncology 
Cancer Imaging  2008;8(1):186-199.
Recent advances in magnetic resonance imaging (MRI) have seen the development of techniques that allow quantitative imaging of a number of anatomical and physiological descriptors. These techniques have been increasingly applied to cancer imaging where they can provide some insight into tumour microvascular structure and physiology. This review details technical approaches and application of quantitative MRI, focusing particularly on perfusion imaging and its role in neuro-oncology.
PMCID: PMC2590875  PMID: 18980870
Magnetic resonance imaging (MRI); functional imaging; dynamic imaging; perfusion; permeability; glioma; meningioma; cerebral tumour
22.  Nutrition in early life, and risk of cancer and metabolic disease: alternative endings in an epigenetic tale? 
The British journal of nutrition  2008;101(5):619-630.
There is substantial evidence which shows that constraints in the early life environment is an important determinant of risk of metabolic and cardiovascular disease. There is emerging evidence that higher birth weight, which reflects a more abundant prenatal environment, is associated with increased risk of cancer, in particular breast cancer and childhood leukaemia. Using specific examples from epidemiology and experimental studies, this review discusses the hypothesis that increased susceptibility to cardiovascular, metabolic disease and cancer have a common origin in developmental changes induced in the developing fetus by aspects of the intra uterine environment including nutrition which involve stable changes to the epigenetic regulation of specific genes. However, the induction of specific disease risk is dependent upon the nature of the environmental challenge and interactions between the susceptibility set by the altered epigenome and the environment throughout the life course.
PMCID: PMC2649281  PMID: 19079817
23.  Feeding pregnant rats a protein-restricted diet persistently alters the methylation of specific cytosines in the hepatic PPARα promoter of the offspring 
The British journal of nutrition  2008;100(2):278-282.
Induction of an altered phenotype by prenatal under-nutrition involves changes in the epigenetic regulation of specific genes. We investigated the effect of feeding pregnant rats a protein-restricted (PR) diet with different amounts of folic acid on the methylation of individual CpG dinucleotides in the hepatic PPARα promoter in juvenile offspring, and the effect of the maternal PR diet on CpG methylation in adult offspring. Pregnant rats (n 5 / group) were fed 180g / kg casein (Control) or 90g / kg casein (PR) with 1mg / kg folic acid, or 90g / kg casein and 5 mg / kg folic acid (PRF). Offspring were killed on postnatal d34 (n 5 males and females / group) and d80 (n 5 males / group). Methylation of 16 CpG dinucleotides in the PPARα promoter was measured by pyrosequencing. Mean PPARα promoter methylation in the PR offspring (4.5%) was 26% lower than Controls (6.1%) due to specific reduction at CpG dinucleotides 2 (40%), 3 (43%), 4 (33%) and 16 (48 %) (P < 0.05). There was no significant difference in methylation at these CpGs between Control and PRF offspring. Methylation of CpGs 5 and 8 was higher (47% and 63%, respectively, P < 0.05) in the PRF offspring than Control or PR offspring. The methylation pattern in d80 PR offspring was comparable to d34 PR offspring. These data show for the first time that prenatal nutrition induces differential changes to the methylation of individual CpG dinucleotides in juvenile rats which persist in adults.
PMCID: PMC2564112  PMID: 18186951
Fetal programming; epigenetic; rat; PPARα
24.  The nature of the growth pattern and of the metabolic response to fasting in the rat are dependent upon the dietary protein and folic acid intakes of their pregnant dams and post-weaning fat consumption 
The British journal of nutrition  2007;99(3):540-549.
The nutritional cues which induce different phenotypes from a single genotype in developing offspring are poorly understood. How well prenatal nutrient availability before birth predicts that after birth may also determine the offspring's response to later metabolic challenge. We investigated the effect of feeding pregnant rats diets containing 180 g/ kg (Control) or 90 g/ kg (PR) protein and either 1 or 5 mg/kg folic acid on growth and metabolic response to fasting in their offspring, and also the effect of diets with different fat contents (40 g/kg (Fat4) or 100g/kg (Fat10) after weaning. Offspring of dams fed the PR diet with 5 mg/kg folic acid were significantly lighter than other offspring. The PR offspring fed the Fat4 diet had lower plasma triacylglycerol (TAG) than the Control offspring, but this relationship was reversed when offspring were fed Fat10. Increasing the folic acid content of the Control or PR maternal diets induced opposing effects on plasma TAG, non-esterified fatty acids, β-hydroxybutyrate and glucose concentrations in offspring fed Fat4. The effect was accentuated in offspring fed the Fat10 diet such that these metabolites were increased in the Control offspring, but reduced in the PR offspring. These data show for the first time that maternal dietary folic acid intake alters offspring phenotype depending upon dietary protein intake, and that this effect is modified by fat intake after weaning. Prevention by increased folic acid intake of an altered metabolic phenotype by maternal protein-restriction may be at the expense of somatic growth.
PMCID: PMC2493056  PMID: 17761015
Low protein diet; fetal programming; folic acid; Growth; Metabolism
25.  Structural Abnormalities in Neurons Are Sufficient To Explain the Clinical Disease and Fatal Outcome of Experimental Rabies in Yellow Fluorescent Protein-Expressing Transgenic Mice▿  
Journal of Virology  2007;82(1):513-521.
Under natural conditions and in some experimental models, rabies virus infection of the central nervous system causes relatively mild histopathological changes, without prominent evidence of neuronal death despite its lethality. In this study, the effects of rabies virus infection on the structure of neurons were investigated with experimentally infected transgenic mice expressing yellow fluorescent protein (YFP) in neuronal subpopulations. Six-week-old mice were inoculated in the hind-limb footpad with the CVS strain of fixed virus or were mock infected with vehicle (phosphate-buffered saline). Brain regions were subsequently examined by light, epifluorescent, and electron microscopy. In moribund CVS-infected mice, histopathological changes were minimal in paraffin-embedded tissue sections, although mild inflammatory changes were present. Terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling and caspase-3 immunostaining showed only a few apoptotic cells in the cerebral cortex and hippocampus. Silver staining demonstrated the preservation of cytoskeletal integrity in the cerebral cortex. However, fluorescence microscopy revealed marked beading and fragmentation of the dendrites and axons of layer V pyramidal neurons in the cerebral cortex, cerebellar mossy fibers, and axons in brainstem tracts. At an earlier time point, when mice displayed hind-limb paralysis, beading was observed in a few axons in the cerebellar commissure. Toluidine blue-stained resin-embedded sections from moribund YFP-expressing animals revealed vacuoles within the perikarya and proximal dendrites of pyramidal neurons in the cerebral cortex and hippocampus. These vacuoles corresponded with swollen mitochondria under electron microscopy. Vacuolation was also observed ultrastructurally in axons and in presynaptic nerve endings. We conclude that the observed structural changes are sufficient to explain the severe clinical disease with a fatal outcome in this experimental model of rabies.
PMCID: PMC2224401  PMID: 17942540

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