Should UK emergency physicians undertake diagnostic ultrasound examinations?

From the published evidence there is no doubt that emergency physicians in America can undertake focused ultrasound examinations and that, by extrapolation, this would also be the case for UK emergency physicians. If this skill is to become part of the diagnostic armamentarium of the emergency physician, however, it needs to be demonstrated to be cost effective compared with the alternatives already available to the hospital. Trials to test for this benefit should adopt a hospital and not an emergency department perspective if the results are to influence health policy and specialty training.

Persistent "haematoma"

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Clearing the cervical spine of adult victims of trauma

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Point of care testing in the accident and emergency department: a cost analysis and exploration of financial incentives to use the technology within the hospital

OBJECTIVES

To compare the costs of current arrangements for testing emergency blood samples from patients attending an accident and emergency (A&E) department in a large teaching hospital in England with point of care testing (POCT).

METHODS

Estimates were made of the fixed and variable costs of two options: a supplemental option, in which POCT was introduced to A&E only; and a replacement option, in which POCT was introduced to A&E and the intensive therapy unit (ITU), thereby entirely replacing an existing process.

RESULTS

For the supplemental option, current arrangements cost 68,466 Pounds in total per year; average costs per test were 5.53 Pounds (venous in the central laboratory) and 3.60 Pounds (arterial on the ITU). Introducing POCT would increase total hospital costs by 35,929 Pounds, and average costs per test would be 5.32 Pounds (venous) and 4.28 Pounds (arterial). For the replacement option, current arrangements cost 132,630 Pounds in total, and average cost per test (for all tests) was 4.06 Pounds. Introducing POCT would make hospital savings ranging from 8332 Pounds to 20,000 Pounds, and average cost per test would be 3.78 Pounds.

CONCLUSIONS

Introducing POCT results in lower average costs per test. The supplemental option will result in significantly increased costs to the hospital. The replacement option can lead to significant savings. The internal cross-charging arrangements between departments that exist in this hospital may mean that supplemental implementation of POCT could be potentially 'profitable' for the A&E department, but would result in higher expenditure for the hospital as a whole.

Meiosis: step-by-step through sporulation

A transcription factor, Ndt80p, has been identified that has a critical role in the pathway that controls meiosis--sporulation--in budding yeast. Ndt80p coordinately controls genes that mediate spore formation and progression through the two meiotic divisions; it may also be a target of a checkpoint control.

The S. cerevisiae nitrogen starvation-induced Yvh1p and Ptp2p phosphatases play a role in control of sporulation

Starvation for nitrogen in the absence of a fermentable carbon source causes diploid Saccharomyces cerevisiae cells to leave vegetative growth, enter meiosis, and sporulare; the former nutritional condition also induces expression of the YVH1 gene that encodes a protein phosphatase. This correlation prompted us to determine whether the Yvh1p phosphatase was a participant in the network that controls the onset of meiosis and sporulation. We found that expression of the IME2 gene, encoding a protein kinase homologue required for meiosis- and sporulation-specific gene expression, is decreased in a yvh1 disrupted strain. We also observed a decrease, albeit a smaller one, in the expression of IME1 which encodes an activator protein required for IME2 expression. Under identical experimental conditions, expression of the MCKI and IME4 genes (which promote sporulation but do not require Ime1p for expression) was not affected. These results demonstrate the specificity of the yvh1 disruption phenotype. They suggest that decreased steady-state levels of IME1 and IME2 mRNA were not merely the result of non-specific adverse affects on nucleic acid metabolism caused by the yvh1 disruption. Sporulation of a homozygous yvh1 disruption mutant was delayed and less efficient overall compared to an isogenic wild-type strain, a result which correlates with decreased IME1 and IME2 gene expression. We also observed that expression of the PTP2 tyrosine phosphatase gene (a negative regulator of the osmosensing MAP kinase cascade), but not the PTP1 gene (also encoding a tyrosine phosphatase) was induced by nitrogen-starvation. Although disruption of PTP2 alone did not demonstrably affect sporulation or IME2 gene expression, sporulation was decreased more in a yvh1, ptp2 double mutant than in a yvh1 single mutant; it was nearly abolished in the double mutant. These data suggest that the YVH1 and PTP2 encoded phosphatases likely participate in the control network regulating meiosis and sporulation. Expression of YVH1 and PTP2 was not affected by nitrogen source quality (asparagine compared to proline) suggesting that nitrogen starvation-induced YVH1 and PTP2 expression and sensitivity to nitrogen catabolite repression are on two different branches of the nitrogen regulatory network.

Changes in stroke distance in response to haemorrhage in a swine model

OBJECTIVE

To determine, using an animal model of blood loss, (1) if stroke distance, derived non-invasively from the time integral of the maximum velocity of red cells in the aorta, changed to a greater extent than heart rate and mean arterial pressure (MAP), which are recognised to be unreliable indicators of blood loss; (2) if changes in stroke distance reflected changes in stroke volume derived from thermodilution cardiac output measurements.

METHODS

Eight anaesthetised swine had baseline measurements of heart rate, MAP, stroke volume, and stroke distance and were then exsanguinated at a rate of 1 ml/kg/min. Percentage changes from baseline of heart rate, MAP, stroke volume, and stroke distance were compared after 10, 20, and 30 ml/kg blood loss. The animal's blood was then reinfused at the rate of 2 ml/kg/min for 15 min, followed by normal saline 1 ml/kg/min. Percentage changes from baseline measurement of stroke volume and stroke distance over the whole experiment were evaluated by regression analysis.

RESULTS

Heart rate, MAP, and stroke distance changed +7.9%, -22.5%, and -18.1% respectively (from baseline values) after 10 ml/kg blood loss; +23.2%, -44.0%, and -47.4% after 20 ml/kg blood loss; and +55.7%, -62.0%, and -69.8% after 30 ml/kg blood loss. Regression analysis of percentage changes in stroke volume and stroke distance from their baseline values at experimental time zero is stroke volume = 1.014 x stroke distance -2.156, r = 0.92, n = 54, P < 0.0001.

CONCLUSIONS

(1) At maximal blood loss, stroke distance changes to a greater extent than heart rate and MAP. (2) Changes in stroke distance reflected changes in stroke volume but with less variability at lower values. Stroke distance may be a more useful measure of blood loss than heart rate and MAP.

Volumetric flow estimation in vivo and in vitro using pulsed-Doppler ultrasound

The measurement of volumetric blood flow in small vessels in vitro and in vivo poses a significant technological challenge. In this study, two pulsatile flow models were developed, one with a 3.2-mm lumen diameter and one with a 12.7-mm lumen diameter, to assess the accuracy of volumetric flow estimation of two pulsed-Doppler devices, a Crystal Biotech VF1 20-MHz system with either a cuff-mounted or a needle-mounted probe and an Advanced Technology Laboratories Ultramark 9 High Definition Imaging system with a 5-MHz linear array transducer. The VF1 volumetric flow error was measured in the 3.2-mm phantom over a variety of pulsatile and continuous waveforms. The accuracy of the VF1 was also tested in porcine femoral and renal arteries. VF1 volumetric flow error ranged from 4.8% to 54.3% in the in vivo studies. The ATL demonstrated similar volumetric flow errors in the porcine femoral artery (approximately 3.2 mm diameter), but these errors were reduced to < or = 17.4% in the 12.7-mm-diameter in vitro flow model.

The SPR3 gene encodes a sporulation-specific homologue of the yeast CDC3/10/11/12 family of bud neck microfilaments and is regulated by ABFI

The SPR3 gene is selectively activated only during the sporulation phase of the Saccharomyces cerevisiae (Sc) life cycle. The predicted amino acid (aa) sequence has homology to microfilament proteins that are involved in cytokinesis and other proteins of unknown function. These include the products of Sc cell division cycle (CDC) genes involved in bud formation (Cdc3p, Cdc10p, Cdc11p and Cdc12p), Candida albicans proteins that accumulate in the hyphal phase (CaCdc3p and CaCdc10p), mouse brain-specific (H5p) and lymphocyte (Diff6p) proteins, Drosophila melanogaster (Dm) protein Pnutp (which is localized to the cleavage furrow of dividing cells), a Diff6p homologue (DmDiff6p), and the Sc septin protein (Sep1hp), a homologue of the 10-nm filament proteins of Sc. One strongly conserved region contains a potential ATP-GTP-binding domain. Primer extension analysis revealed six major transcription start points (tsp) beginning at -142 relative to the ATG start codon. The sequence immediately upstream from the tsp contains consensus binding sites for the HAP2/3/4 and ABFI transcription factors, a T-rich sequence and two putative novel elements for mid to late sporulation, termed SPR3 and PAL. Electrophoretic mobility shift assay (EMSA) and footprint analyses demonstrated that the ABFI protein binds to a region containing the putative ABFI site in vitro, and site-directed mutagenesis showed that the ABFI motif is essential for expression of SPR3 at the appropriate stage in sporulating cells.

The use of ultrasound in the non-invasive detection of changes in the renal circulation in response to blood loss using an animal model

Using a continuous haemorrhage model, 8 anaesthetised swine were bled 1 ml/kg per min for 30 min. The resistance index (RI) of the main renal artery, interlobar and arcuate vessels all significantly increased. Cortical Doppler signals were lost in 4 animals at a mean arterial pressure of 26 mmHg. After reinfusion of blood and normal saline only the RI of the interlobar vessels was significantly different from baseline readings. Ultrasound demonstrated non-invasively changes in regional blood flow within the kidney in response to hypovolaemic shock.

Pneumatic anti-shock garment--does it have a future?

A total of 100 accident and emergency (A&E) departments in the UK responded to a questionnaire about their use of the pneumatic anti-shock garment (PASG). Less than one in 10 departments used PASG in their prehospital care system, less than one in five departments used PASG during in-patient care, and there was wide variation in PASG usage in those situations for which their use is recommended by the Advanced Trauma Life Support (ATLS) course.

The effect of audit and feedback on data recording in the accident and emergency department

Thirteen newly appointed senior house officers (SHOs) at two hospitals were assessed in the recording of two variables: Glasgow Coma Scale (GCS) and diagnostic coding at Hospital A, and GCS at Hospital B. At Hospitals A and B baseline recordings of these variables were established. Active feedback (in the form of data presentation and discussion) was given at 6 and 11 weeks and a final 4-week audit was performed on GCS recordings at 20 weeks. Analysis of GCS recordings of head injuries at Hospitals A and B showed an increase from baseline values of 162/401 (40%) to 336/420 (80%) after feedback 1, and after feedback 2 recordings increased to 379/429 (88%). This was maintained in the last 4-week audit which showed recordings of 220/244 (90%). Further analysis of Hospital A's data showed the SHOs recorded diagnostic coding in 1335/4406 (30%) of cases. After feedback 1, recordings increased to 2550/3327 (77%). After feedback 2 there was no change in recording 2712/3530 (77%). Active feedback improves data recording. The first feedback has a greater impact than the second. Two feedbacks produce a sustained effect in 6 months.

IME4, a gene that mediates MAT and nutritional control of meiosis in Saccharomyces cerevisiae

In the yeast Saccharomyces cerevisiae, sporulation occurs in response to nutritional and genetic signals. The process is initiated when nutrient availability limits mitotic growth, but only in MATa/MAT alpha diploid cells. Under these conditions, the cells express an activator of meiosis (IME1), which is required for the expression of early sporulation-specific genes. We describe a new gene, IME4, whose activity is essential for IME1 transcript accumulation and sporulation. The IME4 transcript was induced in starved MATa/MAT alpha diploids but not in other cell types. In addition, excess IME4 promoted sporulation in mat-insufficient cells. Thus, IME4 appears to activate IME1 in response to cell type and nutritional signals. We have also explored the interactions between IME4 and two genes that are known to regulate IME1 expression. Normally, cells that lack complete MAT information cannot sporulate; when such strains lack RME1 activity or contain the semidominant RES1-1 mutation, however, they can express IME1 and sporulate to low levels. Our results show that mat-insufficient strains containing rme1::LEU2 or RES1-1 bypass mutations still retain MAT control of IME4 expression. Even though IME4 levels remained low, the rme1::LEU2 and RES1-1 mutations allowed IME1 accumulation, implying that these mutations do not require IME4 to exert their effects. In accord with this interpretation, the RES1-1 mutation allowed IME1 accumulation in MATa/MAT alpha strains that contain ime4::LEU2 alleles. These strains still sporulated poorly, suggesting that IME4 plays a role in sporulation in addition to promoting IME1 transcript accumulation. IME4 is located between ADE5 and LYS5 on chromosome VII.

A study of the eye care provided by an accident and emergency department

The eye care provided by an Accident and Emergency (A&E) Department was prospectively studied over a 2-month period. Six out of a total of 506 patients were deemed to have been treated unsatisfactorily by the A&E Department. None of these patients suffered serious sequelae. Approximately one in three of those patients seen solely by A&E staff failed to have their visual acuity recorded.

An RME1-independent pathway for sporulation control in Saccharomyces cerevisiae acts through IME1 transcript accumulation

The RES1-1 mutation was isolated on the basis of its ability to allow MATa/MAT alpha diploid Saccharomyces cerevisiae cells to express a late sporulation-regulated gene, SPR3, in the presence of excess copies of RME1. RME1 is a repressor of meiosis that is normally expressed in cells that lack the a1/alpha 2 repressor encoded by MAT. The RES1-1 mutation also supports sporulation in mat-insufficient diploids. This phenotype does not result from a failure to express RME1 and is not due to activation of the silent copies of mating type information. RES1-1 activates sporulation by allowing IME1 accumulation in all cell types, irrespective of the presence of the MAT products. IME1 is still responsive to RME1 in RES1-1 cells, since double mutants (rme1 RES1-1) that are deficient at MAT can sporulate better than either single mutant. RES1-1 is not an allele of IME1.