Construction of the Azacyclic Core of Tabernaemontanine-Related Alkaloids via Tandem Reformatsky-Aza-Claisen Rearrangement

A divergent synthetic methodology for a tabernaemontanine-related alkaloid was developed. The synthetic route features practical improvements in the Pictet-Spengler cyclization for the tetrahydro-β-carboline intermediate and an unprecedented tandem Reformatsky-aza-Claisen rearrangement to create the core carbon skeleton and stereochemistries of tabernaemontanine-related alkaloids.

Divergent synthetic route to new cyclopenta[c]pyran iridoids: syntheses of jatamanin A, F, G and J, gastrolactone and nepetalactone

Six natural iridoids including jatamanin A, F, G and J, gastrolactone and nepetalactone have been synthesized via the efficient transformation of a core cyclopenta[c]pyran intermediate. Key features of the syntheses include the stereoselective construction of the core cyclopenta[c]pyran skeleton of the iridoid lactones via a Pd(0)-catalyzed intramolecular allylic alkylation, and the facile transformation of the common intermediate into natural iridoids.

Health status, late effects and long-term survivorship of allogeneic bone marrow transplantation: a retrospective study

BACKGROUND

Survival after allogeneic haemopoietic stem cell transplantation (allo-HSCT) has improved because of advancements in allo-HSCT. Allo-HSCT has been performed in Australia since the late 1970s. However, there are few published data about health problems of allo-HSCT survivors in Australia.

AIMS

Identify health issues in long-term survivors of allo-HSCT in an Australian centre to manage better and prevent long-term complications.

METHODS

The health records of all patients of allo-HSCT in a single centre from January 2000 to December 2007 and survived beyond 2 years were assessed.

RESULTS

Ninety-nine of the 200 allo-HSCT patients survived beyond 2 years, and the median time from allo-HSCT was 74 months. Twenty-eight per cent died at a median of 37 months after allo-HSCT because of relapsed malignancy (12%), stroke (1%), infection (3%), chronic graft versus host disease (9%), secondary malignancy (2%) and unknown cause (1%). Ninety-one per cent reported one or more chronic health conditions. Health issues were chronic graft versus host disease (70%); respiratory (66%), ophthalmic (40%), bone (33%), and renal (26%) problems; and malignancies (14% skin, 3% solid organ). Seventy-nine per cent resumed vocation at full or reduced capacity 2 years after allo-HSCT. Clinicians identified 40% with quality of life (QOL) issues, but survivors' self-reported QOL was comparable with the general Australian population.

CONCLUSION

This study shows that allo-HSCT patients are living with high burdens of chronic diseases that warrant lifelong surveillance and engagement with healthcare. Structured, multi-disciplinary care as recommended by published guidelines for allo-HSCT survivors may reduce long-term effects and improve their outcomes.

Total synthesis of (−)-deguelin via an iterative pyran-ring formation strategy

Asymmetric synthesis of (−)-deguelin has been accomplished via iterative pyran-ring formation of the O- and C-arylation precursor prepared by an anionic addition of a chromene unit to aryloxy alkyl aldehyde.

Effects of single-dose dexmedetomidine on the quality of recovery after modified radical mastectomy: a randomised controlled trial

BACKGROUND

Dexmedetomidine is a highly selective α2 agonist with analgesic, anxiolytic, and anti-inflammatory properties. We investigated the effect of a single dose of dexmedetomidine on patient-perceived quality of recovery and clinical recovery variables after modified radical mastectomy under general anesthesia in this randomized, double-blind, placebo-controlled study.

METHODS

After Institutional Review Board approval, ninety two female patients were randomly allocated to receive intravenously either saline (Group C, N.=46) or 0.5 μg/kg of dexmedetomidine (Group D, N.=46) five min before the end of surgery. The quality of recovery was assessed using a 40-item quality-of-recovery scoring system (QoR-40) preoperatively and 24 h after surgery. Pain intensity, rescue analgesics, and postoperative nausea and vomiting (PONV) were assessed at postanesthesia care unit (PACU), 1-6 h, and 6-24 h after surgery.

RESULTS

Postoperative global QoR-40 scores were higher in Group D compared with Group C (181 [175-187] vs. 174 [154.5-181.5], P=0.004); postoperative QoR-40 scores were improved in the dimensions of emotional state, physical comfort, and psychological support. Total amount of tramadol during 24 h after surgery was significantly lower in Group D than in Group C (54 vs. 76 mg, P=0.006). The incidence of PONV was lower in Group D than in Group C in PACU (21% vs. 43%, P=0.026) and 6-24 h period after surgery (10% vs. 41%, P=0.012). Heart rate and mean blood pressure were significantly lower in Group D as compared with Group C at 5 min after administration of dexmedetomidine, 1 min after extubation, and 20 min after arrival in PACU.

CONCLUSION

The use of a single dose dexmedetomidine improved the quality of recovery and reduced analgesic requirements and the incidence of PONV in the early postoperative period after modified radical mastectomy.

Evaluation of acid-base status in brain dead donors and the impact of metabolic acidosis on organ retrieval

BACKGROUND

Pathophysiologic changes after brain death can lead to acid-base disturbances. The primary aim of this study was to clarify the acid-base state and its source in brain dead donors using Stewart's approach. Additionally, we investigated whether the presence of metabolic acidosis affected the number of organs retrieved from donors.

METHODS

A retrospective review of electronic medical records was performed for brain dead donors who had undergone organ harvesting during the past 5 years in a tertiary medical center. The parameters related to acid-base disturbance and the number of organs retrieved from the donors was assessed.

RESULTS

Sixty one brain dead donors were evaluated in this study. Twenty three (37.7%) of these patients had metabolic acidosis at the initial diagnosis of brain death. Metabolic acidosis resulted from hyperchloremia and a large strong ion gap. The severity of metabolic acidosis was masked by hypernatremia and hypoalbuminemia. In addition, donors without metabolic acidosis also showed mixed acid-base disturbances in which metabolic acidosis induced by significant hyperchloremia was combined with metabolic alkalosis caused by hypoalbuminemia and hypernatremia. Although more organs were retrieved from the donors without metabolic acidosis than those with metabolic acidosis (P=0.012), serum albumin level (P=0.010) and donor age (P<0.001), rather than metabolic acid-base disturbances, significantly correlated with the number of organs retrieved in multivariate regression analysis.

CONCLUSION

Most brain dead donors exhibited metabolic acid-base disturbances. However, rather than metabolic acidosis, serum albumin level and donor age were well correlated with the number of organs retrieved.

Distinctiveness of long-term pain that does not interfere with life: an observational cohort study

BACKGROUND

Reporting of pain that does not interfere with life is common in the older population but little is known about people with such long-term non-interfering pain.

OBJECTIVES

To assess whether non-interfering pain can be a long-term state, and to compare this group with those who continuously report no pain, and with those with chronic pain that interferes with life.

METHODS

This was a prospective general population cohort study set within the North Staffordshire Osteoarthritis Project (NorStOP). People aged 50 plus were sent baseline, 3-year and 6-year questionnaires. Those who reported the same pain status (no pain, non-interfering pain, interfering pain) at each time point were compared on pain intensity, widespread pain and medication, and on sociodemographic and co-morbid characteristics at 6 years.

RESULTS

Forty percent of responders reported the same pain status at each time point; 12% reported long-term non-interfering pain. Fifty-nine percent of those with non-interfering pain reported at least one site of high pain intensity, 33% reported widespread pain, and 90% had used pain medication in the past 4 weeks. This group was similar to the no-pain group but distinct on sociodemographic and co-morbid measures from those with pain that interfered.

CONCLUSIONS

Long-term non-interfering pain is common, but despite often suffering from high pain intensity and widespread pain, those within this group seem to be able to control their pain without allowing it to affect their everyday lives. Future work is needed to assess how people with long-term pain ensure it does not cause interference with life.

Obstetric Care of New European Migrants in Scotland: an audit of antenatal care, obstetric outcomes and communication

Background and Aims

There has been a twelve-fold increase in the number of New European migrants giving birth in Lothian between 2004 and 2007. The objective of this study was to audit obstetric care standards in Lothian for new migrants and recommend service improvements.

Methods

A retrospective audit of 114/136 (84%) obstetric case records of new European migrants giving birth in Lothian hospitals in 2006 was conducted. Assessment was against care standards for antenatal booking, antenatal attendance and interpretation. Obstetric outcomes were audited against the general population.

Results

Eighty percent were primiparous. Fifty five percent had booked by the end of week 14. Mean birth weights and lengths of stay were similar to the general population. Intervention rates were 23% for Caesarean Sections (C/S) and 17% for instrumental deliveries (versus 27% and 19% respectively in the general population). Epidural or spinal anaesthesia was used for 57% compared to 50% of the general population. The interpretation services (ITS) were used infrequently.

Conclusions

Full compliance with antenatal and interpretation standards was not achieved for this population. ITS was most commonly used to meet the needs of healthcare professionals, rather than as a routine. While there were no significant differences in maternity outcomes, poor communication did affect care.

A study to compare chest X-ray reports on overseas nursing recruits

This study was carried out to assess if there was a difference in the Chest X- ray (CXR) report on recruited nurses carried out overseas and later repeated in Ireland. This study was carried out in two Irish teaching hospitals. The subjects of this study comprised all overseas nurses recruited in each of the two hospitals within the defined period. The total number of subjects recruited from the 2 two centres was 84. Only nurses that had a repeat CXR were included in this study. 6/84 (7%) of the CXR that were initially reported as normal were subsequently reported as abnormal and were later diagnosed as Latent TB. 2/84(2%) of the CXR that were reported as abnormal were subsequently reported as normal. The data collected in this study has demonstrated that there was a significant difference in the CXR report from overseas and the CXR report in Ireland.

Etiology of hemoptysis in children: a single institutional series of 40 cases

Purpose

The aim of this study was to determine the causes of hemoptysis in a pediatric age group.

Methods

We conducted a retrospective chart review of all patients who were admitted to Samsung Medical Center between 1996 and 2008 with a chief complaint of hemoptysis. Patients with trauma or underlying bleeding tendency such as leukemia were excluded. Patients were divided into three groups according to age (0 to 5 yr, 6 to 10 yr, and 11 to 18 yr). The amount of hemoptysis was classified as mild (≤20 mL/day), moderate (20-100 mL/day), or massive (>100 mL/day). Causes and duration of hemoptysis, disease course, and mortality were also investigated.

Results

A total of 40 patients (18 males and 22 females) were identified. Their median age was 6.3 yr (range, 10 months to 18 yr). Twenty-five patients manifested mild hemoptysis; moderate and massive hemoptysis were found in nine and six patients, respectively. Respiratory tract infection was the most common cause of hemoptysis. Other causes included congenital heart disease, Heiner syndrome, neoplasm in the airway, vasculitis syndrome, and bronchiectasis. In most patients (87.5%), hemoptysis disappeared during medical treatment that included antibiotics or transfusion. Hemoptysis recurred in 12 patients, and the overall mortality rate was 5%.

Conclusions

The most common cause of hemoptysis in children was respiratory tract infection. Most cases had a benign course, but recurrence and mortality occurred in a minority of patients. An accurate diagnosis of the underlying etiology is essential for treatment.

An economic evaluation of three physiotherapy treatments for non-specific neck disorders alongside a randomized trial

OBJECTIVES

Cost-effectiveness and cost-utility analyses were conducted to compare advice and exercise plus manual therapy (MT) and advice and exercise plus pulsed shortwave diathermy (PSWD) with advice and exercise alone (A&E) in the treatment of non-specific neck disorders by experienced physiotherapists.

METHODS

Between July 2000 and June 2002, 350 participants with neck disorders from 15 physiotherapy departments were randomized to: A&E (n = 115); MT (n = 114) and PSWD (n = 121). Outcome and resource-use data were collected using physiotherapist case report forms and participant self-complete questionnaires. Outcome measures were the Northwick Park Neck Pain Questionnaire (NPQ) and EuroQoL EQ-5D [used to derive quality-adjusted-life-year (QALY) utility scores]. Two economic viewpoints were considered (health care and societal). Cost-effectiveness acceptability curves were used to assess the probabilities of the interventions being cost-effective at different willingness-to-pay threshold values.

RESULTS

Mean improvement in NPQ at 6 months was 11.5 in the A&E group, 10.2 in the MT group and 10.3 in the PSWD group; mean QALY scores were 0.362, 0.342 and 0.360, respectively. Mean health care costs were pound sterling105, pound sterling119 and pound sterling123 in the A&E, MT and PSWD groups, respectively. Mean societal costs were pound sterling373, pound sterling303 and pound sterling 338 in each group, respectively. Depending on the viewpoint and the outcome measure, A&E or MT were most likely to be the cost-effective interventions. PSWD was consistently the least cost-effective intervention.

CONCLUSIONS

The cost-effective intervention is likely to be A&E or MT, depending on the economic perspective and preferred outcome, but not PSWD.

Tender point count and total myalgic score in fibromyalgia: changes over a 28-day period

Tender point count (TPC) is central to fibromyalgia syndrome (FMS), and with total myalgic score (TMS) is often used to monitor the patient's condition. This study aimed to determine the stability of TPC and TMS over time, and to examine how well these measures reflected patients' perceptions of their condition. Twenty-four patients with FMS completed the Fibromyalgia Impact Questionnaire (FIQ) and a visual analogue scale (VAS) measuring well-being, at entrance into the study, and 7 and 28 days later. There was no significant change in TPC (P = 0.074), FIQ score (P = 0.291) or VAS (P = 0.079) of well-being with time. However, mean TMS score did change over time (P = 0.021). There was no correlation between total FIQ score and the other measures (all P-values > 0.05). The significant change in TMS over time may reflect the natural fluctuation in the clinical presentation of FMS.

A systematic review on the efficacy of repeat hepatectomy for recurrent liver metastases from colorectal carcinoma

14506

Background: Liver recurrence after hepatectomy for colorectal liver metastases (CRLM) is common and associated with a reduced survival if not treated aggressively. The objectives of this systematic were to critically appraise the quantity and quality of current clinical evidence and demonstrate the efficacy of repeat hepatectomy for CRLM. Methods: Electronic searches for relevant studies published in peer-reviewed medical journals on repeat hepatectomy for recurrent CRLM prior to September 2006 were performed on six databases. The reference lists of all retrieved articles were manually searched for further identification of potentially relevant studies. All relevant articles identified were assessed with application of selection criteria. The quality of each included study was assessed. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies. Results: Seventeen studies with more than 20 patients were included for quality appraisal and data extraction. These 17 studies consisted of two multi- institutional, one bi-institutional and 14 single-center observational studies. The overall perioperative morbidity rate ranged from 7–30% and mortality rate varied from 0–5%. The rates of intra-abdominal abscess, wound infection, bile leak, hepatic failure and pleural effusion ranged from 2.4–23%, 2.4–11%, 0.8–10%, 0–4.5% and 2.4–9.5%, respectively. The overall median survival since initial hepatectomy was 26 to 73 months. The overall median survival since the repeat hepatectomy ranged from 23 to 56 months, with 3- and 5-year survival of 24–68% and 21–49%, respectively. The median disease-free survival ranged from 9 to 52 months, with 3- and 5-year disease-free survival of 16–68% and 16–48%, respectively. After repeat hepatectomy the rates of disease recurrence in the liver and at an extra-hepatic site were 15–67% and 27–64%, respectively. Conclusions: The current literature suggests that repeat hepatectomy is associated with a prolonged survival for recurrent CRLM. Although all studies were observational case series, repeat hepatectomy is justified in selected patients, as there is a lack of evidence for alternative treatment.

No significant financial relationships to disclose.

FCMAC-Yager: A Novel Yager-Inference-Scheme-Based Fuzzy CMAC

The cerebellum is a brain region important for a number of motor and cognitive functions. It is able to generate error correction signals to drive learning and for the acquisition of memory skills. The cerebellar model articulation controller (CMAC) is a neural network inspired by the neurophysiologic theory of the cerebellum and is recognized for its localized generalization and rapid algorithmic computation capabilities. The main deficiencies in the basic CMAC structure are: (1) it is difficult to interpret the internal operations of the CMAC network and (2) the resolution (quantization) problem arising from the partitioning of the input training space. These limitations lead to the synthesis of a fuzzy quantization technique and the mapping of a fuzzy inference scheme onto the CMAC structure. The discrete incremental clustering (DIC) technique is employed to alleviate the quantization problem in the CMAC structure, resulting in the fuzzy CMAC (FCMAC) network. The Yager inference scheme (Yager), which possesses firm fuzzy logic foundation and maps closely to the logical implication operations in the classical (binary) logic framework, is subsequently mapped onto the FCMAC structure. This results in a novel fuzzy neural architecture known as thefuzzy cerebellar model articulation controller-Yager (FCMAC-Yager) system. The proposed FCMAC-Yager network exhibits learning and memory capabilities of the cerebellum through the CMAC structure while emulating the human way of reasoning through the Yager. The new FCMAC-Yager network employs a two-phase training algorithm consisting of structural learning based on the DIC technique and parameter learning using hebbian learning (associative long-term potentiation). The proposed FCMAC-Yager architecture is evaluated using an extensive suite of real-life applications such as highway traffic-trend modeling and prediction and performing as an early warning system for bank failure classification and medical diagnosis of breast cancer. The experimental results are encouraging.

Glucose and diabetes: effects on podocyte and glomerular p38MAPK, heat shock protein 25, and actin cytoskeleton

Phosphorylated p38 (pp38) mitogen-activated protein kinase (MAPK) regulates heat shock protein 25 (HSP25), stabilizing fibrillar actin (FA) and preventing cleavage to G-actin (GA). Cultured podocytes (Pods) were exposed to glucose (5.5-50 mM)+/-p38MAPK inhibitor SB202190 (SB) or control SB202474 to assess the effects on FA/GA and Pod structure. The relationship of p38MAPK with in vivo Pod structure and albuminuria (Ualb) was assessed in rats with streptozotocin (SZ)-induced diabetes (DM) for 1 week, 1 month, and 4 months. High glucose induced concentration-dependent increases in pp38MAPK and phosphorylated HSP25 (pHSP25) maintained actin cytoskeleton. Inhibition by SB diminished pp38MAPK and pHSP25, decreased FA/GA, and altered FA and GA immunohistochemical appearance. In SZ-DM, glomerular pp38MAPK and biphosphorylated HSP25 were increased after 1 week, declining at 1 month, and at or below C values at 4 months. Glomerular FA/GA in DM was normal at 1 week, declining at 1 month, and low at 4 months. Ualb/creatinine was similar in DM vs C at 1 week, and increased at 1 and 4 months. Morphometry demonstrated progressively diminishing slit pore density in DM over time, denoting evolving effacement. There were strong correlations between slit membrane density and both glomerular biphosphorylated HSP25 and ln Ualb/cr ratio. The data suggest that increased pp38MAPK and pHSP25 comprise an acute adaptation to glycemic stress. Later depletion of DM may contribute to Pod structural alterations and Ualb.

The relationship between hand paraesthesia and occupational factors: results from a population study

OBJECTIVES

To investigate the association of occupational factors, both physical and psychosocial, with hand paraesthesia, and whether any such associations differ according to the concurrent presence of neck and upper limb pain (NULP).

METHODS

A questionnaire was mailed to an age-stratified random sample of 9596 adults. All subjects were asked about hand paraesthesia in the past 4 weeks. Information was obtained on respondents' main job (the job held for the longest time), whether this job involved any of six neck or upper limb activities on most or all days of the working week, and questions on the psychosocial aspects of the work environment. The questionnaire also asked about NULP according to a preshaded manikin.

RESULTS

A total of 5133 people replied to the survey (adjusted response 53.5%). Of these, 1592 reported abnormal feelings in the hands (prevalence of 31.9%). Prolonged gripping, prolonged bending of the neck forwards, working with arms at/above shoulder height, low job control, many changes in tasks and low job support were independently associated with hand paraesthesia. Among responders also reporting NULP, working with arms at/above shoulder height and many changes in tasks were independently associated with hand paraesthesia; prolonged gripping was linked to hand paraesthesia in the absence of NULP.

CONCLUSIONS

Hand paraesthesia is associated with physical and psychosocial workplace factors, although different work-related factors were associated with hand paraesthesia according to the concurrent presence of NULP, suggesting that these symptoms may not always be mediated in the same way.

Comparison of physical treatments versus a brief pain-management programme for back pain in primary care: a randomised clinical trial in physiotherapy practice

BACKGROUND

Recommendations for the management of low back pain in primary care emphasise the importance of recognising and addressing psychosocial factors at an early stage. We compared the effectiveness of a brief pain-management programme with physiotherapy incorporating manual therapy for the reduction of disability at 12 months in patients consulting primary care with subacute low back pain.

METHODS

For this pragmatic, multicentre, randomised clinical trial, eligible participants consulted primary care with non-specific low back pain of less than 12 weeks' duration. They were randomly assigned either a programme of pain management (n=201) or manual therapy (n=201). The primary outcome was change in the score on the Roland and Morris disability questionnaire at 12 months. Analysis was by intention to treat.

FINDINGS

Of 544 patients assessed for eligibility, 402 were recruited (mean age 40.6 years) and 329 (82%) reached 12-month follow-up. Mean disability scores were 13.8 (SD 4.8) for the pain-management group and 13.3 (4.9) for the manual-therapy group. The mean decreases in disability scores were 8.8 (6.4) and 8.8 (6.1) at 12 months (difference 0 [95% CI -1.3 to 1.4], p=0.99), and median numbers of physiotherapy visits per patient were three (IQR one to five) and four (two to five), respectively (p=0.001). One adverse reaction (an exacerbation of pain after the initial assessment) was recorded.

INTERPRETATION

Brief pain management techniques delivered by appropriately trained clinicians offer an alternative to physiotherapy incorporating manual therapy and could provide a more efficient first-line approach for management of non-specific subacute low back pain in primary care.

Reliability and validity of measures taken during the Chester step test to predict aerobic power and to prescribe aerobic exercise

OBJECTIVES

To evaluate the reliability and validity of measures taken during the Chester step test (CST) used to predict VO(2)max and prescribe subsequent exercise.

METHODS

The CST was performed twice on separate days by 7 males and 6 females aged 22.4 (SD 4.6) years. Heart rate (HR), ratings of perceived exertion (RPE), and oxygen uptake (VO(2)) were measured at each stage of the CST.

RESULTS

RPE, HR, and actual VO(2) were the same at each stage for both trials but each of these measures was significantly different between CST stages (p<0.0005). Intertrial bias +/-95% limits of agreement (95% LoA) of HR reached acceptable limits at CST stage IV (-2+/-10 beats/min) and for RPE at stages III (0.2+/-1.4) and IV (0.5+/-1.9). Age estimated HRmax significantly overestimated actual HRmax of 5 beats/min (p = 0.016) and the 95% LoA showed that this error could range from an underestimation of 17 beats/min to an overestimation of 7 beats/min. Estimated versus actual VO(2) at each CST stage during both trials showed errors ranging between 11% and 19%. Trial 1 underestimated actual VO(2)max by 2.8 ml/kg/min (p = 0.006) and trial 2 by 1.6 ml/kg/min (not significant). The intertrial agreement in predicted VO(2)max was relatively narrow with a bias +/-95% LoA of -0.8+/-3.7 ml/kg/min. The RPE and %HRmax (actual) correlation improved with a second trial. At all CST stages in trial 2 RPE:%HRmax coefficients were significant with the highest correlations at CST stages III (r = 0.78) and IV (r = 0.84).

CONCLUSION

CST VO(2)max prediction validity is questioned but the CST is reliable on a test-retest basis. VO(2)max prediction error is due more to VO(2) estimation error at each CST stage compared with error in age estimated HRmax. The HR/RPE relation at >50% VO(2)max reliably represents the recommended intensity for developing cardiorespiratory fitness, but only when a practice trial of the CST is first performed.