ATP site-directed inhibitors of protein kinase CK2: an update

CK2 denotes a pleiotropic, constitutively active protein kinase whose abnormally high level in many cancer cells is held as an example of "non oncogene addiction". A wide spectrum of cell permeable, fairly specific ATP site-directed CK2 inhibitors are currently available which are proving useful to dissect its biological functions and which share the property of inducing apoptosis of cancer cells with no comparable effect on their "normal" counterparts. One of these, CX-4945, has recently entered clinical trials for the treatment of advanced solid tumors, Castelman's disease and multiple myeloma. The solution of a wide range of 3D structures of inhibitors bound to the catalytic subunits of CK2 reveals that their efficacy substantially relies on hydrophobic interactions within a cavity which is smaller than in other protein kinases. Accordingly the potency of tetra-halogenated benzimidazoles increases upon replacement of chlorine by bromine and, even more, by iodine, and decreases if two unique bulky side chains on CK2 (Val66 and Ile174) are mutated to alanines. Many CK2 inhibitors have been tested on a panel of more than 60 kinases providing Promiscuity Scores useful to evaluate their selectivity, the lowest value (9.47), denoting highest selectivity, being displayed by quinalizarin. The observation that CK2 inhibitors with medium/high promiscuity scores share the ability to inhibit a group of protein kinases as effectively as CK2 discloses the possibility of using their scaffolds for the rational development of selective inhibitors of these kinases, with special reference to PIMs, DYRKs, HIPK2, PKD and ERK8.

Functional testosterone: biochemical assessment of hypogonadism in men--report from a multidisciplinary workshop hosted by the Ontario Society of Clinical Chemists

OBJECTIVES

In 2004, the Ontario Society of Clinical Chemists (OSCC) held an invitational multidisciplinary workshop to establish the most reliable, cost-effective approach to the biochemical assessment of hypogonadism in men.

METHODS

Specialists across Canada in clinical biochemistry, endocrinology, family medicine and urology were invited to participate in this workshop which included individual presentations and a consensus component addressing two challenge statements: 1) 'Determinations for total testosterone (TT) are equivalent to those for bioavailable testosterone (BAT) or calculated BAT (cBAT) or free testosterone (FT) (by analogue radioimmunoassay or equilibrium dialysis) or calculated FT (cFT)'; 2) 'There is no good evidence that borderline low testosterone concentrations in men should be treated'. The main outcomes were to identify what agreement exists in Canada, what issues were still controversial, and what research remains to be addressed.

RESULTS

Six recommendations based on expert opinion addressed these main themes: investigate with morning total testosterone (TT) followed by repetition and reflexive testing of sex hormone binding globulin (SHBG) if testosterone is 8-15 nmol/L with automatic calculation of cBAT; discontinue the use of analogue free testosterone assays; and definitive methods and standards must be available to ensure standardized results.

CONCLUSIONS

Total testosterone is a reliable marker for the initial investigation of men presenting with symptoms of hypogonadism; cBAT is a reasonable follow-up test in patients with equivocal biochemical or consistent symptomatic findings.

Role of sex steroids in modulating tumor necrosis factor alpha-induced changes in vascular function and blood pressure

BACKGROUND

We previously showed that the infusion of tumor necrosis factor alpha (TNF-alpha) induces hypertension and vascular dysfunction in late pregnant but not virgin rats. In the present study, we tested the hypothesis that levels of ovarian hormones to mimic pregnancy are required for TNF-alpha-induced changes in vascular function and blood pressure in rats.

METHODS

Twenty-one-day-release pellets containing 17beta-estradiol, progesterone, or both were implanted in ovariectomized (OVX) rats. Sham OVX rats were used as controls. Twelve days after implantation, TNF-alpha or vehicle was infused via osmotic minipumps (days 12 to 17). On day 18, mean arterial pressure was measured, and animals were sacrificed to assess vascular function.

RESULTS

Average estrogen and progesterone levels across all groups were 106 +/- 6 pg/mL and 88 +/- 5 ng/mL, respectively. The level of TNF-alpha was 41 +/- 7 pg/mL compared with OVX rats infused with vehicle (4 +/- 1 pg/mL). The results show that TNF-alpha did not cause elevated mean arterial pressure in OVX rats with increased estrogen, progesterone, or both. Vascular responses to the endothelium-dependent and independent agonists, acetylcholine and sodium nitroprusside, were also unchanged. Phenylephrine-induced contraction was moderately but significantly increased at the highest concentrations (10(-4) M) only in TNF-alpha-infused rats.

CONCLUSIONS

These data suggest that increased ovarian hormones to the levels observed during pregnancy are not sufficient to promote TNF-alpha-induced increases in blood pressure or vascular dysfunction.

Characterization of a protein kinase B inhibitor in vitro and in insulin-treated liver cells

OBJECTIVE

Abnormal expression of the hepatic gluconeogenic genes (glucose-6-phosphatase [G6Pase] and PEPCK) contributes to hyperglycemia. These genes are repressed by insulin, but this process is defective in diabetic subjects. Protein kinase B (PKB) is implicated in this action of insulin. An inhibitor of PKB, Akt inhibitor (Akti)-1/2, was recently reported; however, the specificity and efficacy against insulin-induced PKB was not reported. Our aim was to characterize the specificity and efficacy of Akti-1/2 in cells exposed to insulin and then establish whether inhibition of PKB is sufficient to prevent regulation of hepatic gene expression by insulin.

RESEARCH DESIGN AND METHODS

Akti-1/2 was assayed against 70 kinases in vitro and its ability to block PKB activation in cells exposed to insulin fully characterized.

RESULTS

Akti-1/2 exhibits high selectivity toward PKBalpha and PKBbeta. Complete inhibition of PKB activity is achieved in liver cells incubated with 1-10 mumol/l Akti-1/2, and this blocks insulin regulation of PEPCK and G6Pase expression. Our data demonstrate that only 5-10% of maximal insulin-induced PKB is required to fully repress PEPCK and G6Pase expression. Finally, we demonstrate reduced insulin sensitivity of these gene promoters in cells exposed to submaximal concentrations of Akti-1/2; however, full repression of the genes can still be achieved by high concentrations of insulin.

CONCLUSIONS

This work establishes the requirement for PKB activity in the insulin regulation of PEPCK, G6Pase, and a third insulin-regulated gene, IGF-binding protein-1 (IGFBP1); suggests a high degree of functional reserve; and identifies Akti-1/2 as a useful tool to delineate PKB function in the liver.

BI-D1870 is a specific inhibitor of the p90 RSK (ribosomal S6 kinase) isoforms in vitro and in vivo

Hormones and growth factors induce the activation of a number of protein kinases that belong to the AGC subfamily, including isoforms of PKA, protein kinase B (also known as Akt), PKC, S6K p70 (ribosomal S6 kinase), RSK (p90 ribosomal S6 kinase) and MSK (mitogen- and stress-activated protein kinase), which then mediate many of the physiological processes that are regulated by these extracellular agonists. It can be difficult to assess the individual functions of each AGC kinase because their substrate specificities are similar. Here we describe the small molecule BI-D1870, which inhibits RSK1, RSK2, RSK3 and RSK4 in vitro with an IC(50) of 10-30 nM, but does not signi-ficantly inhibit ten other AGC kinase members and over 40 other protein kinases tested at 100-fold higher concentrations. BI-D1870 is cell permeant and prevents the RSK-mediated phorbol ester- and EGF (epidermal growth factor)-induced phosphoryl-ation of glycogen synthase kinase-3beta and LKB1 in human embry-onic kidney 293 cells and Rat-2 cells. In contrast, BI-D1870 does not affect the agonist-triggered phosphorylation of substrates for six other AGC kinases. Moreover, BI-D1870 does not suppress the phorbol ester- or EGF-induced phosphorylation of CREB (cAMP-response-element-binding protein), consistent with the genetic evidence indicating that MSK, and not RSK, isoforms mediate the mitogen-induced phosphorylation of this transcription factor.

Enhanced Endothelin Synthesis by Endothelial Cells Exposed to Sera From Pregnant Rats With Decreased Uterine Perfusion

The initiating event in preeclampsia is thought be to reduced uteroplacental perfusion. Although we have reported previously that chronic reductions in uterine perfusion pressure (RUPP) in pregnant rats results in hypertension and enhanced endothelin production, the factors linking placental ischemia and endothelial cell activation remain unclear. The purpose of this study was to determine the role of angiotensin II type-1 (AT1) receptor activation on endothelin production induced by serum from pregnant rats exposed to reductions in uterine perfusion. To achieve this goal, human umbilical vein endothelial cells were exposed to sera collected from RUPP rats or normal pregnant rats. Arterial pressure was significantly higher in RUPP rats (135+/-2 mm Hg) than in pregnant rats (106+/-1 mm Hg). Six hours after exposure to RUPP serum (n=17), cell media endothelin concentration was 18.4+/-2.7 pg/mL as compared with 9.22+/-1.3 pg/mL from cells exposed to serum from normal pregnant rats (n=9). Eighteen hours after exposure to RUPP serum (n=7), endothelin concentration was 30.5+/-3.8 pg/mL as compared with 12.8+/-5.3 pg/mL from cells exposed to normal pregnant rat serum (n=6). In contrast, serum from RUPP rats did not increase endothelin production in human umbilical vein endothelial cells pretreated with an AT1 receptor antagonist, losartan (15 micromol/L). Eighteen hours after exposure to RUPP serum and losartan (n=14), endothelin concentration was 21.3+/-2.2 pg/mL as compared with 16.4+/-3.3 pg/mL from cells exposed to normal pregnant rat serum and losartan (n=10). These data indicate that serum from pregnant rats exposed to reductions in uterine perfusion enhances endothelin production by endothelial cells via by AT1 receptor activation.

Interactions of LY333531 and other bisindolyl maleimide inhibitors with PDK1

LY333531, BIM-1, BIM-2, BIM-3, and BIM-8 are bisindolyl maleimide-based, nanomolar protein kinase C inhibitors. LY333531, a PKCbeta-specific inhibitor, is in clinical trials against diabetes and cardiac ventricular hypertrophy complications. Specificity analysis with a panel of 29 protein kinases reveals that these bisindolyl maleimide inhibitors also inhibit PDK1, a key kinase from the insulin signaling pathway, albeit in the lower microM range. To understand the molecular basis of inhibition, the PDK1 kinase domain was cocrystallized with these bisindolyl maleimide inhibitors. The inhibitor complexes represent the first structural description of this class of compounds, revealing their unusual nonplanar conformation within the ATP binding site and also explaining the higher inhibitory potential of LY33331 compared to the BIM compounds toward PDK1. A combination of site-directed mutagenesis and essential dynamics analysis gives further insight into PDK1 and also PKC inhibition by these compounds, and may aid inhibitor design.

Structural basis for UCN-01 (7-hydroxystaurosporine) specificity and PDK1 (3-phosphoinositide-dependent protein kinase-1) inhibition

PDK1 (3-phosphoinositide-dependent protein kinase-1) is a member of the AGC (cAMP-dependent, cGMP-dependent, protein kinase C) family of protein kinases, and has a key role in insulin and growth-factor signalling through phosphorylation and subsequent activation of a number of other AGC kinase family members, such as protein kinase B. The staurosporine derivative UCN-01 (7-hydroxystaurosporine) has been reported to be a potent inhibitor for PDK1, and is currently undergoing clinical trials for the treatment of cancer. Here, we report the crystal structures of staurosporine and UCN-01 in complex with the kinase domain of PDK1. We show that, although staurosporine and UCN-01 interact with the PDK1 active site in an overall similar manner, the UCN-01 7-hydroxy group, which is not present in staurosporine, generates direct and water-mediated hydrogen bonds with active-site residues. Inhibition data from UCN-01 tested against a panel of 29 different kinases show a different pattern of inhibition compared with staurosporine. We discuss how these differences in inhibition could be attributed to specific interactions with the additional 7-hydroxy group, as well as the size of the 7-hydroxy-group-binding pocket. This information could lead to opportunities for structure-based optimization of PDK1 inhibitors.

Regulation of breast cancer cell chemotaxis by the phosphoinositide 3-kinase p110delta

Class IA phosphoinositide 3'-kinases (PI3Ks) regulate many cellular processes downstream of tyrosine kinases and Ras. Despite a clear implication of PI3K in cancer, little is known about the distribution of the different PI3K isoforms in malignant cells. We screened a large panel of tissues and cell lines for expression of class IA PI3Ks, and document a ubiquitous expression of the p110alpha and p110beta isoforms but a variable and more restricted tissue distribution of the p110delta isoform. Originally found in WBCs, p110delta was also detected in some nonhematopoietic cell types especially those of breast or melanocytic origin, both in the untransformed and transformed state. Isoform-specific neutralization of PI3K isoforms in breast cancer cell lines (by PI3K antibody microinjection or a p110delta-selective pharmacological inhibitor) demonstrated that p110delta is the most important class IA PI3K in the regulation of epidermal growth factor-driven motility in vitro, controlling the directionality and, to a lesser extent, the speed of migration. In contrast, p110beta was required for the direction but not the speed of migration, whereas p110alpha did not impact on either of these parameters. These results show a nonredundant function of PI3K isoforms downstream of the epidermal growth factor receptor and indicate that the presence of p110delta may confer breast cancer cells with selective migratory capacities. The potential clinical implications of p110delta expression in non-WBC-derived tumors are discussed.

A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care

BACKGROUND

Despite evidence that uncomplicated lower respiratory tract infection (cough) does not respond appreciably to antibiotics and that bacterial resistance is increasing, general practitioners (GPs) still prescribe frequently.

AIM

To assess delayed antibiotic prescribing as a strategy for reducing the unnecessary use of antibiotics for cough in primary care.

DESIGN OF STUDY

Open randomised controlled trial of delayed versus immediate prescribing of antibiotics.

SETTING

One hundred and ninety-one adult patients with uncomplicated cough in 22 Scottish practices who would have received antibiotics under the GP's usual practice were randomised to receive either an immediate prescription (92 patients) or a delayed prescription (99 patients).

METHOD

Delayed subjects were asked to wait a week before deciding whether to collect their prescription. Outcome measures included symptom duration, prescription uptake, patient satisfaction, patient enablement, and subsequent consultation rates. The 48 GPs who recruited patients were surveyed six months after the trial to see whether they used delayed prescribing as a part of their normal practice.

RESULTS

Study and control groups were similar at baseline. Of the subjects in the delayed arm, 55% did not pick up their prescription. Although most patients were satisfied, more patients in the immediate arm were very satisfied with the treatment (P = 0.001) and the consultation (P = 0.03). The patients in the immediate arm were also more enabled (3.3 versus 2.4; P = 0.04), although more of them intended to consult for similar complaints in the future (85% versus 69%, P = 0.02). We were unable to detect any difference in actual consulting behaviour in the follow-up period (mean = 15 months [SD = 5 months]). Subsequently, 68% of GPs used delayed prescribing at least monthly; all gave the prescription to the patient.

CONCLUSION

Delayed prescribing is effective at reducing the use of antibiotics for self-limiting cough; however, patients are less satisfied and enabled as a result. Patients may be deterred from consulting rather than becoming enabled.

Treatment of acute otitis media: are children entered into clinical trials representative?

This study involved a meta-analysis of randomised control studies of the treatment of acute otitis media and judged the characteristics of these trials on the basis of methods, age groups, interventions, and outcomes. An investigation of the eight trials reported in the meta-analysis of clinical trials revealed that the number of children entered per doctor in all practices was low and that the recruitment rate was probably lower than 44%. Low recruitment rates indicate that the type of children entered into trials may only relate to those with mild to moderate symptoms and signs, which could explain why the results of these trials show that antibiotics are not essential in treating acute otitis media.

Andropause. Testosterone replacement therapy for aging men

OBJECTIVE

To review the rationale for treating symptomatic aging men whose testosterone levels are mildly reduced or low-normal with testosterone replacement therapy.

QUALITY OF EVIDENCE

Large-scale multicentre prospective studies on the value of treating andropausal men with hormone therapy do not exist because the whole area of hormone therapy is barely 10 years old. Evidence presented is based on physiologic studies, particularly studies in which treatment has been assessed. These were largely uncontrolled open studies. Studies to date report positive responses to testosterone treatment with very few serious side effects.

MAIN MESSAGE

Physicians should consider hypoandrogenism if male patients complain of loss of libido, erectile dysfunction, weakness, fatigue, lethargy, loss of motivation, or mood swings. Less obvious associations with reduced levels of testosterone are anemia and osteoporosis. The main cause of reduced testosterone production is primary gonadal insufficiency, but secondary causes, such as hypothalamic-pituitary disease, should be considered. Evidence shows that most men treated with testosterone will feel better about themselves and their lives.

CONCLUSION

Andropause is a term of convenience describing a complex of symptoms in aging men who have low testosterone levels. Physicians should be aware of its existence, should consider ordering tests for men who have symptoms, and should treat carefully selected patients whose serum testosterone levels are low.

Mothers' ability to identify infants' communicative acts consistently

A mother's ability to identify consistently what she perceives to be communicatively salient behaviours is considered to be fundamental to the process of responding sensitively to prelinguistic infants. The present study investigated the ability of 35 mothers to identify consistently what they perceived to be communicative acts by infants at three ages (0;6, 0;9, and 1;0). Each mother coded the same videotape of her infant's behaviour on two occasions, three months apart, and observed measures of agreement (consistency) between coded records were obtained. A randomization procedure was used to provide distributions of chance levels of agreement between coded records with which observed measures were compared. Comparisons of the mothers' coded records indicated that they were able to identify infants' communicative acts consistently at each age.

A study of clerics who commit sexual offenses: are they different from other sex offenders?

OBJECTIVE

The goal of this study was to determine if cleric-sex offenders differed significantly from other sex offenders when compared to a control group and assessed with standard instruments that examine the major factors important in sexual offenses.

METHOD

Twenty-four male clerics accused of sexual offenses were compared to 24 male sex offender controls, matched on offense type, age, education, and marital status. Both groups were compared to a general sample of sex offenders (n = 2125) matched only for offense type. The three groups were compared on sexual history and preference, substance abuse, mental illness and personality, history of crime and violence, neuropsychological impairment, and endocrine abnormalities, using reliable and valid measures.

RESULTS

The clerics in this study formed a statistically significant highly educated, older, and predominantly single subgroup of sex offenders. The majority of cleric-sex offenders suffered from a sexual disorder (70.8%), predominantly homosexual pedophilia, as measured by phallometric testing, but did not differ from the control groups in this respect. The clerics were comparable to the other two groups in most respects, but tended to show less antisocial personality disorders and somewhat more endocrine disorders. The most noteworthy features differentiating the clerics from highly educated matched controls were that clerics had a longer delay before criminal charges were laid, or lacked criminal charges altogether, and they tended to use force more often in their offenses.

CONCLUSIONS

In spite of differences in age, education, and occupation between cleric-sex offenders and sex offenders in general, the same procedures should be used in the assessment of this group as for the sex offender population in general. Hypotheses about reduced sexual outlet and increased sexual abuse of clerics in childhood were not supported. Assessment and treatment of cleric-sex offenders should focus especially on sexual deviance, substance abuse, and endocrine disorders.

Physicians who commit sexual offences: are they different from other sex offenders?

OBJECTIVE

To determine if physician sex offenders differ significantly from other sex offenders by using a control group and assessing both groups with reliable and valid instruments.

METHOD

Nineteen male physician sex offenders were compared with 19 male sex offender control subjects, matched on offence type, age, education, and marital status. Both groups were compared with a general sample of sex offenders (n = 2125). The 3 groups were compared on sexual history and preference, substance abuse, mental illness, personality, history of crime and violence, neuropsychological impairment, and endocrine abnormalities.

RESULTS

Physicians in this study were highly educated and older, forming a statistically significant subgroup of sex offenders. The majority of physician sex offenders suffered from a sexual disorder (68.4%), as did the other 2 groups. Physicians showed more neuropsychological impairment and endocrine abnormalities and less antisocial behaviour than did the general sample of sex offenders but did not differ from the matched control group. Physician offenders who sexually assaulted their patients did not differ from those who had nonpatient victims.

CONCLUSIONS

Despite differences in age, education, and occupation between physician sex offenders and sex offenders in general, the same assessment procedures can be recommended for examining both groups. Although the sample size is small, results suggest that physicians who commit sexual offences should be scrutinized by phallometric assessment of sexual deviance and especially for neurological and endocrine abnormalities.

Day surgery in Scotland: patient satisfaction and outcomes

OBJECTIVE

To evaluate patients' views on the process and outcome of day surgery in Scotland, and to study patients' satisfaction with care in a range of specific procedures.

DESIGN

Questionnaires completed by a census of day case surgery patients within a band of 25 procedures under the umbrella of five broad groups: (1) general surgery; (2) urology; (3) gynaecology; (4) orthopaedics; (5) ear, nose, and throat; ophthalmology.

SETTING

13 hospitals in six health board areas in Scotland.

SUBJECTS

During the period 1995-6, 5069 day case patients were asked to complete a questionnaire within two weeks of their operation and discharge from hospital.

MAIN OUTCOME MEASURES

Arrangements before admission; immediate postoperative symptoms and complications; problems experienced after discharge; readmission after discharge.

RESULTS

A response rate of 68% was obtained from 13 sites ranging from 43% to 82%. The overall satisfaction score was 85. A total of 894 patients (26%) experienced pain after surgery and 783 (23%) had relatively minor medical problems after discharge. In total, 265 (7.8%) patients were readmitted to hospital after discharge. Few notable differences existed between specialties or hospitals in terms of satisfaction scores, although notable pain was experienced more frequently in gynaecology and general surgery patients. Readmission was more common for urological procedures.

CONCLUSION

Overall, patient satisfaction with day case surgery was high. Dissatisfaction was largely related to waiting times between admission, operation, and discharge. The amount of pain experienced also had a notable impact on the level of patient satisfaction. Day surgery is not without complications, with 26% of patients experiencing notable degrees of pain; 23% having minor medical problems after discharge; and 8% of respondents having to reattend hospital with problems relating to their original operations.

Repeat dispensing by community pharmacists: advantages for patients and practitioners

Repeat prescribing is an appreciable chore for general practitioners (GPs), and often lacks rigorous clinical control. This paper reports on a pilot repeat dispensing system, which employed community pharmacists to streamline the process and provide clinical supervision. The system described operated within the current regulations, was popular, and worked well for patients on stable treatment regimes.

Relationship between new and return consultations and workload in general practice

General practitioners (GPs) in Tayside, with higher weekly surgery workloads, tended to have a greater proportion of return consultations compared with GPs with smaller workloads. By reducing the number of return consultations, GPs could have a notable effect on their workload and alleviate the, oft-quoted, stress induced by the perceived increase in demand for patient care.

Hospital doctors, general practitioners and dentists learning together

The design, implementation and evaluation of an innovative course on education for a group of hospital doctors, general practitioners and dentists is described. It took place over five 2-day modules spread over 21 months. There were 33 participants and several tutors and external resources. The course was designed around group work and used a learner-centred agenda. Evaluation was by use of the nominal group technique during the course and by open questionnaires after 18 months. The course was successful in stimulating a number of activities and in developing the skills and confidence of the participants. Problem areas centred around the tension between the learner-centred agenda and the participants' need for structure. Courses such as this require good administration, as cohesive and supportive tutors' group, a clear statement of aims, even within a learner-centred framework, and the establishment of clear ground rules to allow the participants to feel safe. Without safety it is arguable that less challenging learning will occur.

The Dundee out-of-hours cooperative: preliminary outcomes for the first year of operation

The Dundee out-of-hours cooperative (DDOC) was the first of its kind to be developed in a city in Scotland. In its first year of operation, the key features of the cooperative were that (a) two doctors could deal with the large majority of out-of-hours calls for a population of just under 100,000 patients, (b) only one third of calls required a home visit, (c) most calls were handled within a period of time acceptable to patients, (d) seven out of 10 patients rated the service equal to or better than previous services, and (e) there were extended opportunities for general practitioners (GPs) involved in the scheme to meet with other colleagues during out-of-hours work.

Community hospitals and general practice: extended attachments for medical students

The first year experience of an innovative experiment in undergraduate medical education is described. The study investigated the educational effectiveness of prolonged clinical attachments for medical undergraduates in community hospital-based general practice. It has also assessed the ability of students to take some responsibility for their own learning in a clinically challenging environment. A retrospective evaluation of the experience obtained during the 3 month attachments for a self-selected group of fourth year Dundee medical school undergraduates was made. These undergraduates were placed in 10 mainly rural Scottish general practices with attached community hospitals providing a wide spectrum of inpatient and outpatient medical and surgical care. Students were assessed on the satisfactory completion of a portfolio of learning experiences and a practical clinical skills list. They were also required to submit a clinical project based on some aspect of their work during the attachment. The initial results showed a high degree of student and tutor satisfaction with the attachments. The assessment of all 10 of the students' educational achievements in their attachment were regarded as satisfactory and two were assessed as outstanding. Tutor assessment confirmed the validity of the initiative. Prolonged attachments in community hospital-based general practice for medical undergraduates have proved educationally valid and popular with both students and tutors. The development and dissemination of this model on a wider scale has resource issues which require to be addressed.