Vocational assessment: a review of the literature from an occupation-based perspective

The vast majority of the currently available vocational assessments are used to measure a worker's physical body functions and/or work capacity, while very few, if any, can be utilized to measure actual work performance. Within this research project, the authors conducted a brief review of the literature and synthesized the existing evidence related to some of the key vocational assessments that are utilized by occupational therapists. It was found that the current "gold standard" of vocational assessment is the Functional Capacity Evaluation, yet the evidence does not fully support its reliability and validity in determining an employee's ability to safely return to work. Alternative assessment options were explored, emphasizing the utilization of occupation-focused, performance-based assessment strategies. It is concluded that occupational therapists need to take action to develop and promote the use of performance-based measures of actual work ability. Occupational therapists must capitalize on their unique strengths of evaluating occupational performance and take the lead to develop standardized means of assessing, measuring, and predicting work performance and work status.

Mechanisms of U46619-induced contraction of rat pulmonary arteries in the presence and absence of the endothelium

BACKGROUND AND PURPOSE

Thromboxane A(2) and endothelial dysfunction are implicated in the development of pulmonary hypertension. The receptor-transduction pathway for U46619 (9,11-dideoxy-9 alpha, 11 alpha-methanoepoxy prostaglandin F(2 alpha))-induced contraction was examined in endothelium-intact (E+) and denuded (E-) rat pulmonary artery rings.

EXPERIMENTAL APPROACH

Artery rings were mounted on a wire myograph under a tension of 7-7.5 mN at 37 degrees C and gassed with 95% O(2)/5% CO(2). Isometric recording was made by using Powerlab data collection and Chart 5 software.

KEY RESULTS

Both E+ and E- contractile responses were sensitive to Rho-kinase inhibition and the chloride channel blocker NPPB [5-nitro-2-(3-phenylpropylamino)benzoic acid]. The E+ response was sensitive to the store-operated calcium channel blockers SKF-96365 {1-[B-[3-(4-methoxyphenyl)propoxy]-4-methoxy-phenethyl]-1H-imidazole hydrochloride} and 2-APB (2-amino ethoxy diphenylborate) (75-100 micromol x L(-1)). The E- response was sensitive to 2-APB (10-30 micromol x L(-1)), a putative IP(3) receptor antagonist, and the calcium and chloride channel blockers nifedipine, DIDS (4,4'-diisothiocyanostilbene-2,2'-disulphonic acid) and niflumic acid but was insensitive to SKF-96365. Inhibiting K(V) with 4-AP in E+ rings exposed a contraction sensitive to nifedipine, DIDS and niflumic acid, whereas inhibiting BK(Ca) exposed a contraction sensitive to mibefradil, DIDS and niflumic acid. This indicates that removal of the endothelium allows the TP receptor to inhibit K(V), which may involve coupling to phospholipase C, because inhibition of phospholipase C with U73122 (1-[6-[[(17beta)-3-methoxyestra-1,3,5(10)-trien-17-y]amino]hexyl]- 1H-pyrrole-2,5-dione) switched the E- pathway to the E+ pathway.

CONCLUSIONS AND IMPLICATIONS

The results from this study indicate that distinct transduction pathways can be employed by the TP receptor to produce contraction and that the endothelium is able to influence the coupling of the TP receptor.

Long-term compliance with a novel vitamin and mineral supplement in older people with PKU

BACKGROUND

The long-term efficacy of vitamin and mineral preparations in dietary-treated adult patients with phenylketonuria (PKU) is unreported.

AIM

In an open, intervention trial, the acceptability, safety and impact on biochemical and haematological micronutrient status of a new vitamin and mineral tablet (Phlexy Vits, SHS International) was investigated.

METHODS

Fifteen subjects with PKU (median age 21 years, range 8-33 years) on low-phenylalanine diet from two PKU centres were recruited. No vitamins or minerals were added to their protein substitute and for 12 months they took their full daily requirements of vitamin and minerals from Phlexy Vits (5 tablets/daily). All but two subjects had taken alternative vitamin and mineral supplements before the trial. Fasting bloods were taken at baseline (week -2 and at week 0), 4 and 12 months for a range of biochemical and nutritional measurements.

RESULTS

By 4 months, serum vitamin B(12) (p = 0.003), serum manganese (p=0.03) and plasma (p=0.03) and red blood cell (p=0.004) glutathionine peroxidase (GSHPx) all significantly increased but remained within normal reference ranges. By 12 months, serum vitamin B(12) (p<0.05) and plasma GSHPx (p<0.05) remained increased. The Phlexy Vits tablets scored better than conventional vitamin and mineral supplements for overall acceptability (p<0.05), and ease of swallowing (p=0.1) at 4 months, although swallowing score deteriorated by 12 months (p<0.05). There was a small but significant deterioration in compliance with taking the vitamin and mineral supplements between 4 and 12 months (p<0.05).

CONCLUSION

In the long term, these comprehensive vitamin and mineral tablets appeared acceptable and improved biochemical nutritional status, although there were long-term compliance and swallowing issues.

Psoriasis: advances in pathophysiology and management

Psoriasis is an inflammatory skin disease that affects 1-3% of Caucasian populations and may be persistent, disfiguring and stigmatizing. There is a range of severity, but even when the affected body surface area is relatively limited the impact on day-to-day activities and social interactions may be significant. An understanding of the psychological burden and an appreciation that many patients are currently dissatisfied with their management has driven the development of more effective treatment. In recent years psoriasis has been the focus of intense investigation resulting in an improved understanding of the immunopathogenesis, and the development of new, targeted biological treatments.

Home enteral tube feeding in patients with inherited metabolic disorders: safety issues

BACKGROUND

Many children with inherited metabolic disorders (IMD), at risk of hypoglycaemia and metabolic decompensation, are dependent on long-term home overnight enteral tube feeding but its safety issues have not been evaluated.

OBJECTIVE

To identify common safety issues and carer pressures for patients with IMD on home enteral tube feeds (HETF).

METHODS

Thirty-four patients (53% male; median age 4.1, range: 1.2-15.8 years), with IMD on home continuous overnight tube feeds were recruited. They were all following specialized feeding regimens. A questionnaire, administered by face-to-face interview with carers identified family members involved in feeding, training they received; child safety issues; equipment reliability and carer night time disturbance.

RESULTS

The principal problems were: carer sleep disturbance (100%); tube entanglement (71%); untrained secondary carers (71%); faulty pumps (50%); tube blockages (45%); faulty equipment (32%); and child tampering with pumps and feeding equipment (29%).

CONCLUSIONS

Significant risks for children on HETF with IMD were identified, potentially leading to metabolic decompensation and hospitalization. The safety of feeding equipment, lack of training of extended family members and practical support for carers requires urgent attention.

Impact of nutrient density of nocturnal enteral feeds on appetite: a prospective, randomised crossover study

OBJECTIVE

To determine whether the energy density of isocaloric nocturnal enteral feeds (NEF) influences daily nutrient intake in children.

METHOD

In a 6 week, randomised, crossover trial, the impact on spontaneous nutrient intake of manipulating the energy density of two isocaloric overnight feeds (1.0 kcal/ml and 1.5 kcal/ml) was compared in a group of 32 children aged 1-10 years (or 8-25 kg body weight) on long term, overnight enteral feeding at home. Total daily oral energy, protein, fat and carbohydrate intake were assessed using 3 day food diaries. Anthropometric data were also recorded during the study.

RESULTS

Spontaneous intakes of energy, protein, fat and carbohydrate from food were 20-30% greater when receiving the lower nutrient density feed (1 kcal/ml). This was due to a gender effect; males consumed twice as much protein from food than females and had slightly higher (but not significant) energy and fat intakes when on the larger volume feed. All children increased in weight, height and mid-upper arm circumference in the 6 week period.

CONCLUSIONS

Children appear to tolerate and grow equally well, irrespective of the nutrient density and volume of NEF taken. However, it appears that children will consume a more energy and nutrient dense oral diet when given their NEF as a higher volume/lower nutrient density feed. This is particularly so for boys, while for girls the volume of NEF or feed concentration appeared to have no impact on quantity of oral diet taken. However, further blinded studies with larger subject numbers would be useful to support these findings.

Mechanisms of U46619- and 5-HT-induced contraction of bovine pulmonary arteries: role of chloride ions

BACKGROUND AND PURPOSE

Thromboxane A(2) and 5-hydroxytryptamine (5-HT) are implicated in pulmonary hypertension. The involvement of chloride, voltage-operated calcium channels (VOCCs), store-operated calcium channels (SOCCs) and the Rho kinase in the contractile response of bovine pulmonary arteries (BPA) to the thromboxane A(2) mimetic U46619 and 5-HT was investigated.

EXPERIMENTAL APPROACH

Endothelium-intact ring segments of BPA were mounted in Krebs/Henseleit buffer (37 degrees C) under a tension of 2g and gassed with 95%O(2)/5%CO(2).

KEY RESULTS

Depletion or removal of extracellular chloride, inhibition of chloride and SOCC, Na:K:2Cl, Cl/HCO(3), Rho kinase inhibited contractions to U46619. Combining Rho kinase inhibition and chloride channel blockade (with NPPB) almost abolished the contractions to U46619. In contrast 5-HT-induced contraction was inhibited by verapamil and mibefradil. Depletion of stored calcium with caffeine almost abolished the response to U46619 but not 5-HT. The contraction by the sarco(endo)plasmic reticulum Ca(2+)-ATPase inhibitor CPA was abolished by SOCC and chloride channel blockade (with NPPB) and by chloride depletion.

CONCLUSIONS AND IMPLICATIONS

This study suggests that the contractile response of BPA to U46619 involves Rho kinase together with a chloride-sensitive mechanism, which does not involve VOCC but may have a role in calcium release and calcium entry via SOCC. In contrast contraction of the BPA by 5-HT appears to involve verapamil- and mibefradil-sensitive VOCC. This study may indicate that the use of calcium channel blockers in the management of pulmonary hypertension may not always be effective and that Rho kinase and chloride channels may be targets for the development of new therapies.

A qualitative study to identify factors influencing COXIB prescribed by family physicians for musculoskeletal disorders

INTRODUCTION

Cyclo-oxygenase-2 inhibiting (COXIB) anti-inflammatories have been the drug class prescribed for a large number of cases of musculoskeletal (MSK) disorders in Canada over the past 5 years. The Alberta Improvements for MSK Disorders (AIMS) initiative sought to better understand the COXIB prescribing situation by funding several studies. The objective of this qualitative study was to determine the factors underlying primary care physicians' medication prescribing behaviour during an office visit for an MSK disorder, with particular emphasis on the prescribing of COXIBs.

METHODS

The target respondents were Alberta primary care physicians chosen from a stratified random sample to meet a wide range of characteristics. Individual, semi-structured interviews were used to assess decision pathways in four real cases chosen by the physician. A total of 19 interviews were conducted and analysed using an analytic inductive approach.

RESULTS

Factors judged as being important to decision pathways in relation to COXIB prescribing for MSK disease included safety, patient characteristics, affordability to patients, availability of samples, drug company marketing practices, habit formation, time contstraints, previous clinical experience of doctors and/or patient with certain drugs and doctors' perception of absolute versus relative risk. Interpretation. Most physicians preferentially prescribed COXIBs subsequent to a complicated, multifactorial, but essentially patient-centred, decision-making process.

Home delivery of dietary products in inherited metabolic disorders reduces prescription and dispensing errors

In the UK, for patients with inherited metabolic disorders (IMD) the traditional system for acquiring essential dietary products [patient prompted prescriptions generated by a medical general practitioner (GP) and dispensed by a chemist] is problematic.

OBJECTIVE

To investigate the efficacy of a home delivery service (HDS) for essential dietary products (EDP) (i.e. protein substitutes, milk replacements, energy and vitamin and mineral supplements) for subjects with IMD, particularly examining any prescription and dispensing errors, metabolic control and consumer satisfaction.

METHODS

A prospective, controlled, home delivery trial for EDP was conducted in patients with IMD for 12 months. Sixty-two patients with IMD [50 with phenylketonuria (PKU); 12 with other IMD: aged 6 months-30 years] were recruited. Thirty subjects used a monthly HDS (Homeward: Nutricia) to receive EDP, 32 remained on the traditional system. Each month, the HDS checked home stock levels of EDP, obtained their prescriptions directly from GP's, and then delivered them to the subjects' homes. An independent researcher completed monthly telephone interviews with patients/parents about any EDP prescription errors or delay in receipt.

RESULTS

Incorrect protein substitute was dispensed once by the HDS compared with nine subjects who had 12 errors in the control group (P = 0.01); incorrect flavours of protein substitute were dispensed to the home delivery group once compared with eight subjects getting 11 errors via the chemist (P = 0.03). The HDS delayed delivery of protein substitute for one subject on three occasions compared with 39 occasions in 16 subjects via the chemist (P = 0.001). In patients with PKU, plasma phenylalanine control deteriorated in the control group (P < 0.05) but not in the HDS group.

CONCLUSIONS

The long-term use of a HDS for EDP in IMD is safer, effective and more reliable than conventional systems.

'Ready to drink' protein substitute is easier is for people with phenylketonuria

In phenylketonuria (PKU), compliance with taking protein substitute is an issue in teenage and older patients. A 'ready to drink' protein substitute may overcome many of the practical issues associated with its administration.

OBJECTIVE

To investigate the efficacy of a liquid protein substitute in a 6-week, three-part, randomized, crossover, controlled study.

METHODS

27 subjects (15 female; 12 male) with PKU with a median age of 30 years (range 8-49 years) were recruited. One subject withdrew from the study. Their median daily dose of protein equivalent was 60 g (range 45-75 g). In parts 1 and 2, subjects were randomized to either a liquid or a powder protein substitute with the same nutritional composition per unit (each 130 ml liquid pouch or 25 g powder sachet contained 15 g protein equivalent). In part 3, subjects chose liquid, powder or a combination of both. Weekly blood phenylalanine (Phe) concentrations were estimated, and during weeks 2, 4 and 6 subjects completed a daily questionnaire on administration issues.

RESULTS

All but one of 26 subjects chose the liquid in part 3 as either their sole (69%, n = 18) or partial source (28%, n = 7) of protein substitute. Blood Phe concentrations were significantly better on the liquid (p = 0.03). With the liquid protein substitute, subjects were less self-consciousness (p = 0.003) and found it easier to take away from home (p = 0.001). Overall, the liquid was easier (p < 0.0001), more convenient (p = 0.002) and resulted in less wastage of protein substitute (p = 0.001).

CONCLUSION

Liquid protein substitute was popular and efficacious, reduced self-consciousness and overall improved compliance of teenagers and adults with PKU.

Protein substitute dosage in PKU: how much do young patients need?

BACKGROUND

The optimal dose of protein substitute has not been determined in children with phenylketonuria (PKU).

AIM

To determine if a lower dose of protein substitute could achieve the same or better degree of blood phenylalanine control when compared to the dosage recommended by the UK MRC.(1)

METHODS

In a six week randomised, crossover study, two doses of protein substitute (Protocol A: 2 g/kg/day of protein equivalent; Protocol B: 1.2 g/kg/day protein equivalent) were compared in 25 children with well controlled PKU aged 2-10 years (median 6 years). Each dose of protein substitute was taken for 14 days, with a 14 day washout period in between. Twice daily blood samples (fasting pre-breakfast and evening, at standard times) for plasma phenylalanine were taken on day 8-14 of each protocol. The median usual dose of protein substitute was 2.2 g/kg/day (range 1.5-3.1 g/kg/day).

RESULTS

When compared with control values, median plasma phenylalanine on the low dose of protein substitute increased at pre-breakfast by 301 mumol/l (95% CI 215 to 386) and in the evening by 337 micromol/l (95% CI 248 to 431). On the high dose of protein substitute, plasma phenylalanine concentrations remained unchanged when compared to control values. However, wide variability was seen between subjects.

CONCLUSIONS

A higher dosage of protein substitute appeared to contribute to lower blood phenylalanine concentrations in PKU, but it did have a variable and individual impact and may have been influenced by the carbohydrate (+/- fat) content of the protein substitute.

Breast feeding in IMD

Breast feeding has proven benefits for many infants with inherited metabolic disorders (IMDs) but, with the exception of phenylketonuria, there are few reports in other conditions. A questionnaire, completed by dietitians and clinicians from 27 IMD centres from 15 countries (caring for a total of over 8000 patients with IMDs on diet) identified breast feeding experience in IMD. Successful, demand breast feeding (in combination with an infant amino acid formula free of precursor amino acids) was reported in 17 infants with MSUD, 14 with tyrosinaemia type I, and 5 with homocystinuria. Eighty-nine per cent were still breast fed at 16 weeks. Fewer infants with organic acidaemias were demand breast fed (7 with propionic acidaemia; 6 with methylmalonic acidaemia and 13 with isovaleric acidaemia) (usually preceded by complementary feeds of a protein-free infant formula or infant amino acid formula free of precursor amino acids). Only 12 infants with urea cycle disorders were given demand breast feeds, but this was unsuccessful beyond 8 days in CPS deficiency. Further work is needed in developing guidelines for feeding and for clinical and biochemical monitoring for breast-fed infants with IMDs.

An audit of the management of melanoma patients at Glasgow Royal Infirmary 1998-2003

BACKGROUND

Melanoma is an important cause of morbidity and mortality. Recently published Scottish Intercollegiate Guideline Network (SIGN) guidelines outline standard management for melanoma patients in Scotland.

METHODS

We audited the management of consecutive patients diagnosed with melanoma in Glasgow Royal Infirmary (1998-2003), using the SIGN guidelines as a gold standard.

RESULTS

Of 102 patients, 41% were male and 59% were female. The mean ages of men and women were 58 and 50 years respectively. Fifty five per cent of all patients had a superficial spreading melanoma, and the median Breslow thickness was 0.64 mm. The most commonly affected site was the head and neck (29%). Most patients (87%) were referred by their general practitioner, but only 30% were marked as urgent by the referrer, and accordingly the median time to first appointment varied between 20 days (1998) and 52 days (2001). The most frequently noted suspicious feature was irregular pigmentation. The median time to biopsy was 6 days. Seventy-one per cent of patients had an excision biopsy, and of those who did not, most (71%) had lesions on the head and neck. There was poor recording of surgical margins (13%) and histological margins were used to determine the need for re-excision. The SIGN guidelines for re-excision and sentinel lymph node biopsy were closely followed.

CONCLUSION

The SIGN guidelines for melanoma have been adhered to in our department, although time to first appointment exceeded national recommendations.

Home enteral feeding audit 1 year post-initiation

OBJECTIVE To determine the practical problems that families of children on home enteral tube feeds (HETF) experience in the first year post-hospital discharge. METHODS Thirty parents/carers of children (0-16 years) completed a multiple choice/short answer questionnaire by interview 12 months after discharge from hospital. Issues addressed included: home delivery of feed and equipment; pump usage; tube changes; and overnight feeding.

RESULTS

The main problems identified were: sleep disturbance (75%); frequent tube dislodgement (46%); tube blockages (41%); inability of some home delivery companies (HDC) to provide all the paediatric special feeds required (43%); and pump inaccuracy (23%). Conclusions Children on long-term HETF and their families experience significant problems with sleep disturbance, tube dislodgement and tube blockage. In addition, accuracy of pumps and obtaining feed and equipment was a source of stress. Dietitians and community nurses urgently need to explore solutions to the common problems associated with overnight feeding. Furthermore, regular home reviews are necessary in long-term HETF to continue to identify and minimize problems.

Nutritional deficiencies and the skin

Malnutrition states are relatively uncommon in the UK but we have seen two recent cases which have heightened our awareness of both dermatological manifestations of malnutrition and of nutritional sequelae of a dermatological problem. Case 1 is a patient with anorexia nervosa presenting with features of pellagra. This condition is due to deficiency of niacin and responds rapidly to replacement therapy. Classical presentation is an erythematous rash on photoexposed sites, often related to heat or friction. There are three reported cases of pellagra occurring in patients with anorexia nervosa. Case 2 is an adult atopic with sensitizations to multiple foodstuffs. A self-imposed restriction diet caused multiple nutritional deficiencies. Restriction diets in adult atopics are not particularly common in the UK, but there is some evidence to suggest that they may cause significant nutritional deficiency. A nutrition screen may be indicated more frequently than is currently recognized.

Prolonged Skin Allograft Survival in Scid Mice Reconstituted With Isogeneic Bone Marrow Stem Cell Antigen-1-Positive Cells and Thymus Tissue

INTRODUCTION

Many studies indicate that tolerance induction is much more dependent on the maturation status of lymphocytes than the age of the animal. We hypothesized that direct persistent contact of bone marrow stem cells with graft alloantigen will result in tolerance to that antigen in the adult animal.

MATERIAL AND METHODS

Severe combined immunodeficient mice (CB-17-Scid, H-2b) were reconstituted with isogeneic bone marrow stem cell antigen-1 (Sca-1)-positive cells and grafted with fetal thymus (BMSC-T), followed by transplant of allogeneic skin grafts from C57BL/6 (H-2d) mice. The control group include CB-17 non-Scid mice, CB-17-Scid mice, and CB-17 Scid mice pretransplanted with nonmodified isogeneic bone marrow cells and fetal thymus (BMC-T).

RESULTS AND DISCUSSION

Skin allograft survival was significantly prolonged in the group pretransplanted with isogeneic BMSC-T compared the group of non-Scid mice and the group of Scid mice pretransplanted with BMC-T (59.6 days vs 7.1 days vs 11.7 days). In 2 of 10 mice pretransplanted with BMSC-T, the skin allografts transplanted immediately after BMSC-T survived for more than 100 days, but the third-party skin allografts transplanted at 100 days after BMSC-T transplant were rejected. The results suggest direct persistent contact of bone marrow Sca-1-positive cells with graft alloantigen may be a feasible approach to prolong allograft survival and induce tolerance in a small fraction of adult animals.

Is fibre supplementation in paediatric sip feeds beneficial?

The usefulness of a paediatric fibre containing sip feeds specifically formulated for paediatrics has not been evaluated. In an open, prospective, parallel study the efficacy, safety and tolerance of a paediatric fibre-containing sip feed designed for children weighing 8-20 kg (1-6 years) was compared with a fibre-free sip feed in 60 children with chronic illness. The subjects either received a trial sip feed containing 150 kcal (100 ml)(-1) and 2.0 g (100 ml)(-1) of fibre or a fibre-free equivalent control sip feed for 12 weeks. Blood biochemistry, haematology, anthropometry, tolerance and food intake data were estimated during week 1 and 12. The fibre intake was higher (P < 0.0001) and laxative usage decreased in the fibre-containing sip feed group. The sip feed provided almost 50% of fibre intake in the trial group. There were no differences in sip feed tolerance, anthropometry, nutritional biochemistry or haematology between the two groups. Sip feeds provide an important source of fibre for sick children with normal gut function requiring nutritional support.

Can a genetic signature for metastatic head and neck squamous cell carcinoma be characterised by comparative genomic hybridisation?

Survival from head and neck squamous cell carcinoma (HNSCC) has remained static for the last 20 years. The development of lymph node metastasis (LNM) significantly reduces the 5-year survival rate, thus the ability to identify tumours with the potential to metastasise would allow more aggressive treatment regimes to be directed at these patients regardless of negative clinical and radiological findings at the time of presentation. Comparative genomic hybridisation (CGH) can identify chromosomal aberrations that may lead to metastasis. DNA from 23-paired specimens of primary tumour (PT) and LNM were analysed. Nonrandom copy number changes were identified in all paired samples. Similar numbers of aberrations were identified on PT and LNM samples. The most common aberrations were 3q (90%), 8q (65%), 1q (50%), 5p (43%), 2q (41%) and 11q (41%) and deletions 3p (57%), 1p (54%), 4p (48%), 13q (48%), 11q (41%) and 10q (37%). A number of differences were also detected. No aberration was found to be preferentially associated with the LNM, although gains on 6q (48 vs 22%) and 22q (26 vs 9%) were found at higher frequencies. Clonality studies demonstrated that LNM develop from the dominant population of cells in the PT. These results were compared with two similar publications. No combination of chromosomal aberrations, as detected by CGH, was associated with metastatic progression in HNSCC.

Transanal endoscopic microsurgery: a viable operative alternative in selected patients with rectal lesions

BACKGROUND

Local excision of rectal lesions is being increasingly undertaken, especially in those unfit for major surgery. The traditional transanal approach is often cumbersome and limited to low and mid rectal lesions. Transanal endoscopic microsurgery (TEMS) is being used to excise both benign and malignant rectal lesions, including those in the upper rectum.

METHODS

Prospective analysis of all patients undergoing a TEMS excision between January 1997 and December 2000 in a specialized colorectal unit.

RESULTS

Forty patients underwent a TEMS resection, with a mean age of 72 years (SD, 10 years). The mean distance of the lesions from the anal verge was 9.8 cm (SD, 3.1 cm). In 24 patients, the lesion was located >or=10 cm from the anal verge, making them unsuitable for traditional transanal resection. The mean operative time was 91 minutes (SD, 34 minutes), and the mean postoperative stay was 3 days (SD, 1.5 days). No mortality was associated with the procedure, and there was minimal morbidity in 15%. There has been no recurrence in the 18 patients who had a malignant lesion excised.

CONCLUSIONS

The TEMS operating system provides the surgeon with a suitable alternative for the resection of benign and malignant rectal neoplasms in selected patients. It has the advantage of providing visual clarity of the operative field, allowing more precise dissection and a minimally invasive approach to mid and upper rectal lesions. There has been no mortality and minimal morbidity. We advocate its inclusion as part of a colorectal surgeon's operative armamentarium for these selected cases.

Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs

In March 2000 the Plastic Surgery Unit of our 600-bedded district general hospital agreed to be the pilot ward for the introduction of a new standard of hand hygiene, emphasizing the use of alcohol gel on socially clean hands between clinical contact with patients. Hand hygiene practice of healthcare workers (HCWs) was observed using Formic forms. The data from completed forms were scanned into an Excel database, and results fed back to HCWs in graphical form. The case notes of patients newly affected by methicillin-resistant Staphylococcus aureus (MRSA), likely to have been acquired as inpatients, were reviewed for one year before and after this performance feedback of hand hygiene. The cost of teicoplanin use (for MRSA infections) was also determined for the two periods. There was a significant reduction in the number of patients newly affected by MRSA (P<0.05), and in the use of teicoplanin, suggesting that performance feedback of hand hygiene reduces nosocomial MRSA infection rates and antibiotic use.

A new, low-volume protein substitute for teenagers and adults with phenylketonuria

Some older patients with phenylketonuria (PKU) fail to consume their protein substitute (with or without vitamin and mineral supplements) in prescribed amounts, which contributes to poor blood phenylalanine control. PKU Express (Vitaflo), is a new low-volume (amino acids 72 g/100 g), low-carbohydrate, phenylalanine-free protein substitute with added vitamins and minerals designed for people with PKU over 8 years of age. In an open intervention study, the aim was to investigate its acceptability and effectiveness in a group of teenagers and adults with PKU. Twenty-three subjects (15 female; 8 male) with PKU, who had a median age of 17 years (range 8-37 years) took the substitute for 8 weeks. A 3-day prospective diet diary, height, weight, plasma amino acids, biochemical and haematological nutritional analytes were measured at weeks 0 and 8. Skin-puncture bloods for plasma phenylalanine were collected every 2 weeks. The median weight of protein substitute (with or without vitamin and mineral supplements) consumed decreased by 33% from 150 g (range 140-180) daily to 100 g (range 100-125) daily ( p <0.001). Median change in energy intake decreased by a median of 10% (95% CI 2.0 to 18.0) when compared to intake on original protein substitute. On PKU Express, the intakes of all nutrients exceeded the dietary reference values but none was excessively high. Blood phenylalanine decreased by a mean of 37 micromol/L (95% CI-27 to 102) during the trial. Body mass index decreased in 40% of subjects. Changes in blood phenylalanine or body mass index were not statistically significant. Most of the nutritional, haematological and biochemical indices stayed within normal reference ranges for the analytes studied. Sixteen (70%) of the subjects had low plasma selenium at the start, but only 13 (57%) at the study end. Plasma vitamin B12 was high in 8 subjects at the start of the study and 9 at the end. Twenty-one subjects (96%) stated that the product was convenient and easy to prepare. However, 7 (32%) described the smell and 9 (46%) the texture as the same as or worse than those of previous protein substitutes. Because of the use of the premeasured sachets, some subjects were able to prepare their own protein substitute for the first time. PKU Express is a safe, efficacious, protein substitute that significantly reduces the daily volume of prescribed protein substitute.

Pilot study: quality of life assessment of postnatal fatigue and other physical morbidity

Postnatal morbidity is increasingly recognized, but standard assessments may not capture what is most important to the woman with such morbidity in terms of her quality of life. The Mother-Generated Index (MGI) is a proposed postnatal quality-of-life instrument which allows the mother to determine both content and scoring. In this pilot study we found that although a degree of psychological and physical morbidity (including tiredness) is common, and may be very significant, for most women these factors are low-grade, and other aspects of their lives are more important. A quality-of-life approach allows the mother to determine her own postnatal assessment, and encourages practitioners to view her more holistically.

Genetic and functional analyses of FH mutations in multiple cutaneous and uterine leiomyomatosis, hereditary leiomyomatosis and renal cancer, and fumarate hydratase deficiency

Germline mutations of the fumarate hydratase (FH, fumarase) gene are found in the recessive FH deficiency syndrome and in dominantly inherited susceptibility to multiple cutaneous and uterine leiomyomatosis (MCUL). We have previously reported a number of germline FH mutations from MCUL patients. In this study, we report additional FH mutations in MCUL and FH deficiency patients. Mutations can readily be found in about 75% of MCUL cases and most cases of FH deficiency. Some of the more common FH mutations are probably derived from founding individuals. Protein-truncating FH mutations are functionally null alleles. Disease-associated missense FH changes map to highly conserved residues, mostly in or around the enzyme's active site or activation site; we predict that these mutations severely compromise enzyme function. The mutation spectra in FH deficiency and MCUL are similar, although in the latter mutations tend to occur earlier in the gene and, perhaps, are more likely to result in a truncated or absent protein. We have found that not all mutation-carrier parents of FH deficiency children have a strong predisposition to leiomyomata. We have confirmed that renal carcinoma is sometimes part of MCUL, as part of the variant hereditary leiomyomatosis and renal cancer (HLRCC) syndrome, and have shown that these cancers may have either type II papillary or collecting duct morphology. We have found no association between the type or site of FH mutation and any aspect of the MCUL phenotype. Biochemical assay for reduced FH functional activity in the germline of MCUL patients can indicate carriers of FH mutations with high sensitivity and specificity, and can detect reduced FH activity in some patients without detectable FH mutations. We conclude that MCUL is probably a genetically homogeneous tumour predisposition syndrome, primarily resulting from absent or severely reduced fumarase activity, with currently unknown functional consequences for the smooth muscle or kidney cell.

Are tablets a practical source of protein substitute in phenylketonuria?

BACKGROUND

A phenylalanine-free amino acid based protein substitute is necessary to provide the major source of protein in phenylketonuria (PKU). Protein substitutes in PKU are usually given as drinks. These are unpalatable and compliance is often poor. Tablets containing a suitable mixture of phenylalanine-free amino acids (Aminogran Food Supplement, UCB) are now available.

AIMS

To compare the effectiveness and acceptability of these tablets with conventional protein substitute drinks.

METHODS

Twenty one subjects with PKU, aged 8-25 years, participated in a randomised crossover study. During one phase, subjects received at least 40% of their protein substitute requirements from the amino acid tablets and the rest from their usual protein substitute tablets. During the other phase, they received their usual protein substitute. Each period lasted 12 weeks. Blood phenylalanine concentrations were measured at least once every two weeks and other plasma amino acids were measured at the beginning, at crossover, and at the end of the study. The subjects kept a diary of all protein substitute taken.

RESULTS

Compliance appeared to be better with the new tablets than with patients' usual protein substitutes. Ninety per cent (18/20) recorded that they took the tablets as prescribed, compared with 65% (13/20) fully compliant with their usual protein substitute. Moreover, plasma phenyalanine was lower on the amino acid tablets, and the median difference in blood concentrations between the two groups was 46 micro mol/l (95% CI 14.8 to 89.0, p = 0.02). Tyrosine increased by a median of 16 micro mol/l daily on the amino acid tablets (95% CI 7.1 to 40.5, p = 0.01). Most subjects (70%) preferred incorporating the new tablets into their usual protein substitute regimen.

CONCLUSIONS

Amino acid tablets are an effective and relatively popular protein substitute in older children, teenagers, and adults with PKU.

Administration of protein substitute and quality of control in phenylketonuria: a randomized study

Uneven administration of an L-amino acid protein substitute is an important contributing factor in variability in plasma phenylalanine concentrations over the 24-hour period in patients with phenylketonuria under treatment. The aim of this study was to determine whether manipulating the timing of protein substitution would reduce variability in plasma phenylalanine over 24 h. Sixteen children (aged 1-11 years) with well-controlled phenylketonuria were entered into a randomized crossover study in which four protocols of the same daily dose of protein substitute administration were compared. In protocol A, three equal, divided doses were given with meals over 10 h; in protocol B, three equal doses over 14 h; in protocol C, four equal doses over 14 h; and in protocol D, six equal doses over 24 h (3 subjects only). Four-hourly skin puncture blood specimens were collected for 48 h in each study protocol. In protocols A, B and C, but not in protocol D, there was wide variability in 24 h plasma phenylalanine. The median daily differences (micromol/L) between highest and lowest phenylalanine concentrations were: for protocol A, 140; for protocol B, 100; for protocol C, 120; and for protocol D, 40. In protocol D, 97% of all phenylalanine concentrations were below 120 micromol/L and no concentration fell below 40 micromol/L. Administration of protein substitute overnight as well as during daytime produces stable and lower plasma phenylalanine concentrations and may lead to improved dietary phenylalanine tolerance.

Free use of fruits and vegetables in phenylketonuria

This study aimed to evaluate systematically the effect of the free use of fruits and vegetables containing an intermediate amount of phenylalanine (51-100 mg/100 g) on the biochemical control in children with phenylketonuria (PKU). Fifteen subjects with PKU, with a median age of 6 years (range 1-24 years) were studied. In a three-part prospective 15-week study, subjects sequentially ate fruits and vegetables containing phenylalanine 0-50 mg/100 g for weeks 1 to 3; 51-75 mg/100 g for weeks 4 to 8; and 76-100 mg/100 g for weeks 9 to 15. Plasma phenylalanine concentrations were measured twice daily for three consecutive days in weeks 1, 3, 6, 8, 11, 13 and 15. A standard menu was followed on the blood sampling days. Daily dietary records of fruits and vegetables under study were kept throughout the trial. Control of phenylalanine concentrations was not adversely affected by the free use of fruits and vegetables containing 51-100 mg/100 g. Pre-breakfast median plasma concentrations were: weeks 1 to 3, 260 micromol/L (range 90-890); weeks 4 to 8, 255 micromol/L (range 130-920); and weeks 9 to 15, 278 micromol/L (range 30-880). Pre-evening meal median plasma phenylalanine concentrations were: weeks 1 to 3, 240 micromol/L (range 30-820); weeks 4 to 8, 210 micromol/L (40-880); and weeks 9 to 15, 238 micromol/L (range 20-880). These data suggest that free use of fruits and vegetables containing 51-75 mg/100 g poses no problem for children with PKU.

Involvement of gap junctions in bradykinin-induced relaxation of bovine pulmonary supernumerary arteries before and after inhibition of nitric oxide/guanylate cyclase

This study evaluated the possible contribution of gap junctions to the nitric oxide (NO)- and endothelium-derived hyperpolarizing factor (EDHF)-mediated responses elicited by bradykinin in bovine pulmonary supernumerary arteries. In artery rings with an intact endothelium and treated with the cyclo-oxygenase inhibitor indomethacin (10 microM), bradykinin (100 pM-1 microM) produced a concentration-dependent relaxation [-logEC(50) (pEC(50)), 9.6+/-0.2; maximum relaxation ( R (max)), 89.7+/-14.8%; n =6]. The NO synthase inhibitor N (G)-nitro-L-arginine methyl ester (L-NAME; 100 microM) and the NO scavenger hydroxocobalamin (200 microM) each produced a rightward shift in the bradykinin concentration-response curve [pEC(50): L-NAME, 8.9+/-0.1 ( n =6; P <0.01); hydroxocobalamin, 8.3+/-0.2, ( n =6; P <0.001)]. However, the soluble guanylate cyclase inhibitor ODQ (1H-[1,2,4]oxadiazolo[4,3-a]quinoxalin-1-one; 10 microM) did not significantly alter the response to bradykinin (pEC(50) 9.4+/-0.2; n =9). The gap junction inhibitor carbenoxolone (100 microM) did not affect the relaxation produced by bradykinin (pEC(50), 9.7+/-0.1; R (max), 100+/-3.2%; n =6), but it significantly depressed R (max) when L-NAME, hydroxocobalamin or ODQ was present. Further, carbenoxolone produced a rightward shift in the bradykinin concentration-response curve in the presence of ODQ (8.4+/-0.1; n =6, P <0.01). The data suggest that, in bovine pulmonary supernumerary arteries, gap junctions may, in part, facilitate the EDHF-mediated response, but not the NO-mediated response, to bradykinin. However, the additional involvement of an unidentified endothelial relaxing factor cannot be excluded.

Relaxation to bradykinin in bovine pulmonary supernumerary arteries can be mediated by both a nitric oxide-dependent and -independent mechanism

1. The aim of the present study was to determine the relative contribution of prostanoids, nitric oxide and K(+) channels in the bradykinin-induced relaxation of bovine pulmonary supernumerary arteries. 2. In endothelium-intact, but not denuded rings, bradykinin produced a concentration-dependent relaxation (pEC(50), 9.6+/-0.1), which was unaffected by the cyclo-oxygenase inhibitor indomethacin. The nitric oxide scavenger hydroxocobalamin (200 micro M, pEC(50), 8.5+/-0.2) and the nitric oxide synthase inhibitor L-NAME (100 micro M, pEC(50), 8.9+/-0.1) and the combination of L-NAME and hydroxocobalamin (pEC(50), 8.1+/-0.2) produced rightward shifts in the bradykinin concentration response curve. 3. The guanylyl cyclase inhibitor ODQ (10 micro M, pEC(50), 9.6+/-0.4) did not affect the response to bradykinin. 4. Elevating the extracellular [K(+)] to 30 mM did not affect the response to bradykinin but abolished the response when ODQ or L-NAME was present. 5. The K(+) channel blocker apamin (100 nM), combined with charybdotoxin (100 nM), produced a small reduction in the maximum response to bradykinin but they abolished the response to bradykinin when ODQ, L-NAME or hydroxocobalamin were present. Apamin (100 nM) combined with iberiotoxin (100 nM) also reduced the response to bradykinin in the presence of hydroxocobalamin or L-NAME. 6. The concentration response curve for sodium nitroprusside-induced relaxation was abolished by ODQ (10 micro M) and shifted to the right by apamin and charybdotoxin. 7. These studies suggest that in bovine pulmonary supernumerary arteries bradykinin can stimulate the formation of nitric oxide and activate an EDHF-like mechanism and that either of these pathways alone can mediate the bradykinin-induced relaxation. In addition nitric oxide, acting through guanylyl cyclase, can activate an apamin/charbydotoxin-sensitive K(+) channel in this tissue.

How practical are recommendations for dietary control in phenylketonuria?

In patients with phenylketonuria, blood phenylalanine concentration during childhood is the major determinant of cognitive outcome. Guidelines provide age-related recommendations for treatment. To ascertain the extent to which these aims are achievable, we audited results from four centres for the years 1994-2000. The median proportion of samples with phenylalanine concentrations above those recommended was less than 30% for those younger than age 10 years but almost 80% for those aged 15 years and older. Similarly, the median frequency of blood sampling, expressed as a proportion of that recommended, was more than 80% for patients younger than 10 years but less than 50% by age 15 years. Our results indicate the difficulty of maintaining control in phenylketonuria, especially in older rather than younger children.

The measurement of engagement in the homeless mentally ill: the Homeless Engagement and Acceptance Scale--HEAS

BACKGROUND

Much of the difficulty in helping the homeless mentally ill arises as a consequence of their resistance to engagement. A refused intervention can seldom influence a client's problems and engagement status can be argued as being an important independent predictor of outcome. No instrument could be identified which systematically measured the factors involved. This paper describes the development and psychometric properties of a new scale, the Homeless Engagement and Acceptance Scale (HEAS).

METHOD

Staff from an established project for the homeless mentally ill helped to identify relevant questions used to develop a five-item rating scale for completion by an informant. After piloting, the instrument was tested in a study in which subjects were assessed twice over 12 months by informants. Item analysis was undertaken and predictive validity was assessed.

RESULTS

Item analysis indicated a good facility index signifying all items were able to differentiate subjects according to the characteristic being measured, and a high discrimination index demonstrating that all items were measuring the same concept. Predictive validity and internal consistency coefficients were both good. The 3 month HEAS score was found to be a significant predictor of accommodation status and adequacy of a support network at 12 months.

CONCLUSIONS

The good psychometric properties and predictive validity of the scale suggest the HEAS is likely to be a useful tool in assessing engagement status. One of the five questions (Q4) can be omitted for those who are not homeless and the scale termed the Engagement and Acceptance Scale (EAS).

An observational study to evaluate micronutrient status during enteral feeding

BACKGROUND

There are few data on the optimal micronutrient composition of paediatric enteral feeds. The recent European Directive on Foods for Special Medical Purposes (1999/21/EC) did not distinguish between the composition of adult and paediatric feeds.

AIMS

To evaluate, in an open, observational study, the long term nutritional biochemistry of 12 children aged 1-6 years and/or 8-20 kg.

METHODS

The children were receiving at least 50% of their estimated average requirement (EAR) for energy from paediatric enteral formulae: 1.0 kcal/ml (Nutrison Paediatric Standard) or 1.5 kcal/ml (Nutrison Paediatric Energy Plus). Venous blood samples for trace elements, vitamins, and minerals were taken at study entry and six months later. Parents kept three day food and feed records every month.

RESULTS

Despite a median energy intake of only 75% EAR (range 52-158%), 67% (n = 8) achieved their reference nutrient intake (RNI) for all micronutrients. No significant micronutrient deficiencies were seen on blood analysis after six months. Eighty three per cent (n = 10) had vitamin B(12) and 92% (n = 11) had copper intake >150% RNI. Fifty eight per cent (n = 7) had high plasma B(12) (>733 micromol/l) and 75% (n = 9) had high serum copper (>22 micromol/l) concentrations.

CONCLUSIONS

Children without excess losses maintain adequate micronutrient status on long term enteral feeding. Subjects had high blood concentrations of vitamin B(12) and copper, and had high dietary intakes of these micronutrients. We suggest that the maximum nutrient guidelines for paediatric enteral feeds should be more clearly defined.

Improving tolerability of immunosuppressive regimens

CNIs and corticosteroids are associated with adverse effects that can diminish quality of life and detrimentally affect long-term allograft and patient survival. Nephrotoxicity is the major side effect of CNI therapy. A search has been ongoing for improved immunosuppressive regimens that will provide adequate protection against acute allograft rejection, while decreasing the nephrotoxic and other effects associated with CNIs. This paper reviewed the immunosuppressive agent sirolimus as a potential new option in transplantation, focusing on its mechanism of action and clinical efficacy as well as potential antiproliferative and antineoplastic properties. The findings and lessons learned from key clinical studies in which sirolimus was used to augment or replace CNIs and/or corticosteroids were highlighted, and the importance of clinical pharmacokinetics and therapeutic drug monitoring in these regimens were discussed. Preliminary studies of combination therapy with sirolimus and tacrolimus in solid organ transplantation indicate that sirolimus/tacrolimus combination therapy may provide strong protection against acute rejection and diminish the nephrotoxicity associated with CNI-based therapy. Other studies suggest that sirolimus can be used as base immunosuppressive therapy, thereby completely avoiding the nephrotoxicity associated with CNI-based therapies, while continuing to provide powerful protection against rejection. With patients surviving longer with functional allografts, quality of life is becoming an increasing important clinical endpoint in transplantation. The studies reviewed here suggest that sirolimus might be used to improve quality of life significantly without increasing the risk of allograft rejection or shortening patient survival.