Functional characterization of alpha1-adrenoceptor subtypes in human subcutaneous resistance arteries

The functional characteristics of the alpha1-adrenoceptor subtypes in human resistance arteries are still not clear. We recently reported that the alpha1A-adrenoceptor predominantly mediates contraction to norepinephrine in human skeletal muscle resistance arteries. In this study we extended these investigations to human subcutaneous resistance arteries. Arterial segments were isolated from the inguinal subcutaneous fat and mounted on a small vessel wire myograph. Potencies of agonists and antagonists were examined. N-[5-(4,5-dihydro-1H-imidazol-2yl)-2-hydroxy-5,6,7,8-tetrahydronaphthalen-1-yl]methanesulphonamide (A-61603) was found to be 10- and 54-fold more potent than norepinephrine and phenylephrine, respectively. Brimonidine (UK 14304) evoked significantly smaller contractile responses than norepinephrine and phenylephrine, showing the presence of a small population of alpha2-adrenoceptors in these arteries, and this was confirmed by the studies with selective alpha1- and alpha2-adrenoceptor antagonists prazosin and (8aR,12aS,13aS)-5,8,8a,9,10,11,12,12a,13a-decahydro-3-methoxyl-12-(ethylsulphonyl)-6H-isoquino[2,1-g][1,6]-naphthyridine (RS 79948). Prazosin, 5-methyl-urapidil, and 2-[2,6-dimethoxyphenoxyethyl]aminomethyl)-1,4-benzodioxane (WB 4101) shifted the potency of norepinephrine concentration dependently giving pA2 values of 9.4, 8.9, and 10.1, respectively, showing the presence of the alpha1A-subtype in these arteries. Pretreatment with 1 and 10 microM chloroethylclonidine did not affect the potency of and maximum responses to norepinephrine, ruling out the presence of the alpha1B-subtype in these arteries. 8-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-8-azaspiro[4.5]decane-7,9-dione (BMY 7378, 10 and 100 nM) did not affect the potency of norepinephrine but a small shift was observed by 1 microM BMY 7378, giving a pK(B) value of 7.1, much less than that reported for the alpha1D-subtype. These results suggest the predominant involvement of alpha1A-adrenoceptor in the contractile responses to norepinephrine in these arteries. The physiological role of this subtype in the maintenance of peripheral arterial resistance is yet to be confirmed.

Insulin-mediated vasorelaxation in pregnancy

OBJECTIVE

To investigate insulin-mediated vasorelaxation in pregnancy, and the role of nitric oxide in this response.

DESIGN

In vitro study of isolated subcutaneous resistance arteries from pregnant and non-pregnant women.

METHODS

Small arteries (mean vessel diameter <300 microm) were isolated from biopsies of subcutaneous fat from 14 pregnant and seven non-pregnant women. Insulin-mediated attenuation of the vasoconstriction response to noradrenaline, before and after nitric oxide synthase inhibition, was studied in isolated arteries using wire myography. Vessel responses to noradrenaline following incubation with insulin were also tested after endothelial denudation. Maximum responses were compared using one-way ANOVA and Bonferroni's post hoc test for multiple comparisons.

RESULTS

In pregnancy, the maximum vasoconstriction produced by noradrenaline was increased (P < 0.01). Insulin significantly reduced this response in pregnant women (P < 0.01), while inhibition of nitric oxide synthase with Nomega-nitro-L-arginine methyl ester (L-NAME) resulted in potentiation (P < 0.05). Following inhibition of nitric oxide synthase with L-NAME, addition of the insulin was still able to produce a significant attenuation in maximum vasoconstriction to noradrenaline in pregnant women (P < 0.01). Furthermore, the absence of functioning endothelium did not abolish the attenuating effect of the insulin on noradrenaline-induced vasoconstriction in pregnant women (P < 0.01).

CONCLUSIONS

The vasodilatory effect of insulin is not diminished in pregnancy, despite the development of insulin resistance. Furthermore, the attenuation of vasoconstrictor tone is via an endothelium-independent mechanism. This suggests that the vascular dysfunction associated with diabetes mellitus does not occur with physiological insulin resistance.

The alpha(1A)-adrenoceptor subtype mediates contraction in rat femoral resistance arteries

In this study, alpha(1)-adrenoceptor subtypes were characterised in rat femoral resistance arteries mounted on a small vessel myograph. A-61603 was found to be more potent than noradrenaline and phenylephrine in these arteries. Brimonidine (UK 14304) could not evoke any contractile responses and the sensitivity to noradrenaline and phenylephrine was not affected by (8aR,12aS,13aS)-5,8,8a,9,10,11,12,12a,13a-decahydro-3-methoxy-12-(ethylsulphonyl)-6H-isoquino[2,1-g][1,6]-naphthyridine (RS 79948), ruling out the presence of alpha(2)-adrenoceptors. Prazosin, 5-methyl-urapidil and 2-([2,6-dimethoxyphenoxyethyl]aminomethyl)-1,4-benzodioxane (WB 4101) produced rightward shifts in the sensitivity to noradrenaline, giving pA(2) values of 9.6, 9.4 and 10.4, respectively, in agreement with the presence of alpha(1A)-adrenoceptors. (8-[2-[4-(2-Methoxyphenyl)-1-piperazinyl]ethyl]-8-azaspiro[4.5]decane-7,9-dione (BMY 7378; 1 microM) produced a small shift in the sensitivity of noradrenaline giving a pK(B) of 7.2. In the presence of 300 nM 5-methyl-urapidil, sensitivity to noradrenaline was not further shifted by 1 microM BMY 7378. Responses to noradrenaline were unaffected by the alpha(1B)-adrenoceptor alkylating agent chloroethylclonidine (1 microM). These results suggest alpha(1A)-adrenoceptors mediate contractile responses to noradrenaline in rat femoral resistance arteries.

Selective deficits in prefrontal cortex function in medication-naive patients with schizophrenia

BACKGROUND

Previously we proposed that dorsolateral prefrontal cortex (PFC) supports a specific working memory (WM) subcomponent: the ability to represent and maintain context information necessary to guide appropriate task behavior. By context, we mean prior task-relevant information represented in such a form that it supports selection of the appropriate behavioral response. Furthermore, we hypothesized that WM deficits in schizophrenia reflect impaired context processing due to a disturbance in dorsolateral PFC. We use functional magnetic resonance imaging to examine PFC activation in medication-naive, first-episode patients with schizophrenia during a WM, task-isolating context processing.

METHODS

Fourteen first-episode, medication-naive patients with schizophrenia and 12 controls similar in age, sex, and parental education underwent functional magnetic resonance imaging during performance of an A-X version of the Continuous Performance Test.

RESULTS

Patients with schizophrenia demonstrated deficits in dorsolateral PFC activation in task conditions requiring context processing but showed intact activation of posterior and inferior PFC. In addition, patients demonstrated intact activation of the primary motor and somatosensory cortex in response to stimulus processing demands.

CONCLUSIONS

These results demonstrate selectivity in dorsolateral PFC dysfunction among medication-naive first-episode patients with schizophrenia, suggesting that a specific deficit in PFC function is present at illness onset, prior to the administration of medication or the most confounding effects of illness duration. Furthermore, these results are consistent with the hypothesis that WM deficits in patients with schizophrenia reflect an impairment in context processing due to a disturbance in dorsolateral PFC function.

Role of the 5-HT(2A)receptor and alpha(1)-adrenoceptor in the contractile response of rat pulmonary artery to 5-HT in the presence and absence of nitric oxide

This study investigated the role of 5-HT(2A)receptors and alpha(1)-adrenoceptors in the contractile response to 5-HT in the first branch pulmonary artery of the rat and their interaction with endogenous nitric oxide. 5-HT and phenylephrine induced concentration-dependent contractions. The alpha(1)-adrenoceptor antagonists prazosin, HV723 and phentolamine produced concentration-dependent rightward shifts of the 5-HT concentration-response curves (CRC) consistent with an action at alpha(1)-adrenoceptors. The 5-HT(2)receptor antagonists ritanserin, ketanserin and methysergide produced rightward shifts that were less than would have been predicted for an action solely at 5-HT(2A)receptors. 5-HT and phenylephrine CRCs were shifted to the left by l -NAME. Endothelium denudation also increased the tissue sensitivity to 5-HT. In the presence of l -NAME, ketanserin produced greater antagonism of the 5-HT CRC but not the phenylephrine CRC. Ketanserin also produced greater antagonism of the 5-HT CRC in endothelium denuded rings compared with endothelium intact rings. These findings indicate (a) that both the alpha(1)-adrenoceptor class and the 5-HT(2A)receptor is involved in the contractile response to 5-HT; (b) in the presence of endogenous nitric oxide the contractile response to 5-HT is mediated predominently by alpha(1)-adrenoceptors; (c) inhibition of endogenous nitric oxide potentiates the 5-HT(2A)receptor-mediated component of the contraction.

Lipogranulomatous adenopathy: a characteristic but under-recognized presentation of Whipple's disease

A50-year-old Caucasian male was admitted with a left popliteal vein thrombosis confirmed on Doppler ultrasound scanning. He was previously well and there was no obvious precipitating cause for his venous thrombosis. Apart from pallor and the swollen left calf there were no abnormal findings on routine examination and he was anticoagulated with heparin followed by warfarin.

Investigations revealed a hypochromic microcytic anaemia (haemoglobin 8.3 g) and a marginally raised serum alkaline phosphatase. Other investigations including a myeloma screen, autoimmune profile and neutrophil cytoplasmic antibodies were negative. An intra-abdominal malignancy was suspected although faecal occult bloods were negative on three occasions and tumour markers (carcinoembryonic antigen (CEA) and CA 19.9) were normal. Upper gastrointestinal endoscopy demonstrated mild gastritis and a normal-looking duodenum only. Computed tomographic (CT) scanning of the abdomen and thorax revealed massive retroperitoneal and retrocrural adenopathy extending down to the small intestinal mesentery (Figure 1). The abdominal viscera were otherwise normal and there was no mediastinal Iymphadenopathy.

Small bowel Iymphoma was suspected and he underwent first a laparoscopic biopsy of the mesenteric Iymph nodes and subsequently a laparotomy. There were no abnormal findings apart from the retroperitoneal Iymphadenopathy. On both occasions the histological appearances of the Iymph nodes were the same: the Iymph node architecture was destroyed by large lipid-containing spaces. There was also infiltration by numerous lipid containing macrophages, and occasional multinucleate giant cells (Figure 2). No cause for these changes could be recognized clinically or pathologically.

Three months after his initial presentation he developed weight loss, mild diarrhoea, vague abdominal pain and a rash on his legs. A systemic vasculitis was suspected but a skin biopsy showed non-specific changes only. However, 1 week later he died suddenly at home, apparently having been markedly dyspnoeic for the preceding 48 hours.

At postmortem he was found to have a severe constrictive pericarditis, which was felt to be the probable cause of his death. There was no evidence of pulmonary embolism. The liver showed congestive ‘nutmeg’ changes. There was evidence of a panserositis with inflammation of pericardium, pleura and peritoneum. Bowel histology was not performed because of autolysis. However, the histology of the mesenteric Iymph nodes was reviewed and on this occasion stained with periodic acid Schiff. This was taken up by bacilliary organisms in the macrophages found in the Iymph nodes. The features were considered diagnostic of Whipple's disease.

An inter-disciplinary approach to swallowing problems in acute stroke

Many speech and language therapy (SLT) departments are in danger of being swamped with dysphagia referrals, often to the detriment of other work. At the same time surveys have shown that large numbers of patients with acute stroke have swallowing problems which are poorly managed during the critical early phase, not referred or missed altogether. The Collaborative Dysphagia Audit (CODA) study, carried out in six British hospitals, showed that nurses could quickly be trained to carry out basic screening assessments for dysphagia and that implementation of a co-ordinated inter-disciplinary dysphagia management policy (DMP) could substantially improve the proportion of dysphagic patients in whom appropriate feeding precautions were taken. These early DMPs were limited by the need for ward staff to keep all patients with suspected swallowing impairment nil by mouth until assessed by SLT, so in some acute stroke units nurses have been trained to a higher level which allows them to manage most routine transient swallowing problems, leaving only complex or persistent cases for referral to SLT. This approach has been used successfully in our unit in Gateshead, where a dysphagia nurse specialist post has been set up to act as a link between ward staff and SLTs, to ensure that the necessary training levels are maintained and to co-ordinate the DMP.

Increased alpha(1)- and alpha(2)-adrenoceptor-mediated contractile responses of human skeletal muscle resistance arteries in chronic limb ischemia

OBJECTIVE

Recently, we have shown augmented contractile responses of skeletal muscle resistance arteries to noradrenaline in patients with critical limb ischemia. We investigated whether this increased sensitivity in skeletal muscle resistance arteries is due to either alpha(1)- or alpha(2)-adrenoceptor-mediated responses or both.

METHODS

Skeletal muscle resistance arteries were isolated from the proximal (non-ischemic) and distal (ischemic) parts of limbs amputated for critical limb ischemia and mounted on a small vessel wire myograph. Cumulative concentration response curves of the vessel segments to noradrenaline, phenylephrine and brimonidine were obtained in the presence or the absence of the selective antagonists, prazosin and RS79948.

RESULTS

Noradrenaline and phenylephrine produced almost equal maximal contractile responses. Brimonidine responses were smaller and were almost abolished by 0.1 microM RS 79948 while those of phenylephrine and noradrenaline were not affected. Prazosin reduced the maximum responses to brimonidine, shifted the concentration response curves of noradrenaline and phenylephrine rightwards giving pK(B) values of 9.86 and 9.33, respectively. Maximum responses produced by all three agonists in distal vessels were significantly higher than those obtained in proximal vessels.

CONCLUSIONS

Noradrenaline contractile responses in skeletal muscle resistance arteries are predominantly mediated by alpha(1)-adrenoceptors. Both alpha(1)- and alpha(2)-adrenoceptor-mediated responses are increased in the arteries from ischemic regions that may aggravate the decreased blood flow to the limbs due to arterial occlusion.

Regulation of sensitivity to 5-hydroxytryptamine in pulmonary supernumerary but not conventional arteries by a 5-HT(1D)-like receptor

Bovine pulmonary supernumerary arteries are more sensitive to 5-hydroxtryptamine (5-HT) (pD(2) 6.43+/-0.25) than conventional arteries (pD(2) 5.32+/-0.16). This study investigated receptors for 5-HT in ring segments of these arteries. The 5-HT(2) receptor agonist, 2,5 dimethoxy-4-iodoamphetamine hydrobromide (DOI) constricts both arteries. The selective 5-HT(2) receptor antagonist ritanserin produced insurmountable antagonism of 5-HT concentration-response curves in both arteries, whereas the 5-HT(1B/1D) receptor antagonist N-[4-methoxy-3-(4-methyl-1-piperazinyl)phenyl]-2'-methyl-4'(5-methyl- 1,2,4-oxadiazol-3-yl[1,1,-biphenyl]-4-carboxamide hydrochloride (GR127935) produced much greater antagonism in supernumerary arteries. In rings preconstricted with 9,11-dideoxy-9, 11-methanoepoxy prostalagdin F(2alpha) (U46619) and relaxed with the adenylyl cyclase activator forskolin, the selective 5-HT(ID) receptor agonist 2-[5-[3-(4-methylsulphonylamino) benzyl-1,2, 4-oxadiazol-5-yl]-1H-indole-3-yl] ethylamine (L694247) reversed the relaxation. Concentration-response curves for L694247-induced reversal of forskolin-relaxation were antagonised by GR127935 in supernumerary (pK(B) 8.6) and conventional (pK(B) 8.4) arteries, whereas concentration-response curves to 5-HT-were less sensitive to antagonism by GR127935T and this was more obvious in conventional (pK(B) 7.6) than supernumerary (pK(B) 8.1) arteries. Neither the selective 5-HT(1D) receptor antagonist (1-(3-chlorophenyl)-4-[3, 3-diphenyl (2-(S,R) hydroxypropanyl)piperazine] hydrochloride (BRL15572) nor the 5-HT(1B) receptor antagonist (2,3,6, 7-tetrahydro-1'-methyl-5-[2'methyl-4'5-(methyl-1,2,4-oxadiazol-3-y l) biphenyl-4-carbonyl]furo[2,3-f]indole-3-spiro-4'-piperidine hydrochloride (SB224289) antagonised concentration-response curves induced by 5-HT or 5-HT(1)-receptor-selective agonists. In addition to the 5-HT(2A) receptor, 5-HT activates a GR127935-sensitive and a GR127935-insensitive receptor in these arteries. Supernumerary arteries have a greater proportion of GR127935-sensitive receptors, which display only some of the pharmacological characteristics of the cloned 5-HT(ID) receptor. It is possible that the GR127935-sensitive receptor could be a species homologue of the human 5-HT(1B) receptor that is insensitive to SB224289.

Fluid collections detected by ultrasound following uncomplicated colorectal surgery

The aim of the study was to assess the incidence and site of intraperitoneal fluid collections following uncomplicated colorectal surgery and to identify factors relating to the presence of such collections. 38 patients (22 males) with a mean age of 67 years (range 38-85 years) undergoing uncomplicated colorectal procedures were studied prospectively. Patients underwent abdominal and pelvic ultrasound on Day 3 and Day 7 following surgery. The number, site and volume of collections were recorded. Ultrasound-detected fluid collections were present in 26% on Day 3 and 25% on Day 7 following laparotomy. The presence of a collection was not related to the amount of residual volume after peritoneal lavage with normal saline prior to operative closure, to intraoperative blood loss or to the presence of drains. The right upper quadrant was the commonest site of intraperitoneal collections. In the absence of additional clinical signs, the presence of such collections is not an indication for intervention.

Diet and compliance in phenylketonuria

In phenylketonuria, compliance and diet is a difficult issue; it is hard to quantify and is under-researched. It is influenced by many factors. Failure to consume prescribed quantity of protein substitute has been commonly reported and is probably affected by their acceptability, format and timing of administration. There are few reports documenting actual phenylalanine intake and blood phenylalanine control, but it is possible that the more rigorous systems for allocation of phenylalanine are associated with worse compliance. The dry, hard and insipid nature of many low protein products may lead to their under usage and consequent boredom and hunger. The diet becomes increasingly harder to maintain as children grow older and seek fewer constraints in their meals.

CONCLUSION

In phenylketonuria, encouraging adherence to diet requires continual education, reinforcement and support from the family and professionals within the support team.

The relationship of genotype to cognitive outcome in galactosaemia

AIMS

To evaluate the cognitive outcome of a cohort of children with galactosaemia in relation to genotype.

METHODS

The cohort was drawn from children notified to the British Paediatric Surveillance Unit galactosaemia study which ran from 1988 to 1990. Cognitive outcome was assessed using the Wechsler Intelligence Scale for Children or the Wechsler Preschool and Primary Scale of Intelligence. Parents completed a questionnaire detailing educational status, and the attending paediatrician returned a questionnaire regarding age at diagnosis and biochemical outcome over the previous two years.

RESULTS

A total of 45 children were genotyped: 30 were homoallelic for the Q188R mutation, the remainder being heteroallelic for Q188R with K285N (n = 4), L195P (n = 4), or other mutations (n = 7). Psychometric evaluation was available in 34 cases: mean full scale IQ was 79, verbal quotient 79, and performance quotient 82. Genotype was not related to galactose-1-phosphate (Gal-1-P) concentrations. However, children homoallelic for the Q188R mutation had significantly lower IQ scores than those who were heteroallelic (73. 6 v 94.8). This difference was independent of social and demographic influences and Gal-1-P concentrations over the previous two years.

CONCLUSIONS

In children with galactosaemia, cognitive outcome appears to relate to genotype rather than metabolic control, as reflected by Gal-1-P concentrations. The value of measuring Gal-1-P concentrations routinely once successfully established on a galactosaemia diet is questionable as concentrations do not appear to affect outcome. In the UK population, homozygosity for the Q188R mutation is invariably associated with a poor outcome, and there is evidence that variability in neurocognitive outcome is at least part dependent on allelic heterogeneity.

Clinical pharmacokinetics and therapeutic drug monitoring of sirolimus

BACKGROUND

Sirolimus is a novel macrocyclic antibiotic that has an immunosuppressive mechanism of action distinct from that of cyclosporine and tacrolimus.

OBJECTIVE

The objective of this report is to provide an overview of the clinical development of sirolimus with emphasis on the mechanism of immunosuppressive activity, prevention of acute renal allograft rejection, clinical pharmacokinetics, concentration-effect relationships, and therapeutic drug monitoring (TDM).

RESULTS

Pharmacokinetic studies in adult renal transplant patients have shown that sirolimus may be characterized as a drug with rapid absorption (t(max) = 1 to 2 hours), low systemic availability (F = 14%), linear dose proportionality (2 to 24 mg), extensive partitioning into formed blood elements (B/P = 36), large apparent volume of distribution (1.7 L/kg), prolonged terminal half-life (62 hours), and large intersubject (CV = 52%) and intrasubject (CV = 26%) variability in oral-dose clearance. Results from phase 111 pivotal trials showed that sirolimus (2 or 5 mg/d) reduced acute renal graft rejection (generally, P < 0.01) without TDM. Although TDM may not be required for a regimen consisting of full-dose cyclosporine and corticosteroids with sirolimus 2 mg/d (4 hours after cyclosporine), it may be warranted in patients (1) with hepatic impairment, (2) who are young children, (3) who are receiving concurrent doses of strong CYP3A/p-glycoprotein inhibitors or inducers, (4) in whom cyclosporine dosing is markedly reduced or discontinued, and (5) who are at a high risk for rejection. A whole-blood sirolimus therapeutic window of 5 to 15 ng/mL (measured by microparticle enzyme immunoassay) is recommended for patients at standard risk of rejection. The large intrapatient variability observed in trough sirolimus concentrations indicates that dose adjustments should be optimally based on more than a single trough sample. Because of the time required to reach steady state, sirolimus dose adjustments would optimally be based on trough levels obtained >5 to 7 days after a dose change.

CONCLUSIONS

The effective use of sirolimus in an immunosuppressive regimen for the prevention of acute renal allograft rejection requires an understanding of the drug's clinical pharmacokinetics, concentration/adverse-effect relationship, concentration-efficacy relationship, and TDM.

Parkinson's disease and aided AAC: some evidence from practice

Clinical observation that people with Parkinson's disease (PD) seem to have different training needs from other adult client-groups in developing effective use of aided augmentative and alternative communication (AAC) was the catalyst for this study. There is little good-quality research evidence available on the effectiveness (or lack of effectiveness) of aided AAC use by those with PD. One of the main aims of this preliminary study, therefore, was to elicit the experiences and attitudes of speech and language therapists in this specific area of their practice as the basis for future efficacy research and clinical practice. Thirty speech and language therapists were questioned about their experience of introducing low- and high-tech AAC devices to this client-group. Of particular interest was the discovery of the factors identified by the therapists as influencing their introduction of aided AAC to someone with PD and affecting implementation and successful use. The factors reported were both disease-specific (e.g. motor problems) and more general factors (e.g. carer support) relevant to the process of introducing aided AAC to other adult client-groups. Implications for future research and practice are discussed. Some research questions are posed and the inclusion of people with PD and their carers in practice development is promoted.

Role of endothelium/nitric oxide in atypical beta-adrenoceptor-mediated relaxation in rat isolated aorta

The role of endothelium in the modulation of classical and atypical beta-adrenoceptor-mediated vasorelaxation was investigated in ring preparations of rat isolated thoracic aorta. Rings were pre-constricted with a sub-maximal concentration of noradrenaline (1 microM) and relaxant responses to cumulative concentrations of beta-adrenoceptor agonists obtained. Endothelium removal or pretreatment with N(G)-nitro-L-arginine methyl ester (L-NAME, 100 microM) or 1H-[1,2,4] oxadiazolol[4,3,-a] quinoxalin-1-one (ODQ, 10 microM) significantly reduced the relaxant effects of isoprenaline, but had less effect on relaxant responses to the atypical beta-adrenoceptor agonist, (+/-)-4-(3-t-butylamino-2-hydroxypropoxy)-benzimidazol-2-one hydrochloride (CGP 12177A). Sodium nitroprusside (3 nM) shifted the isoprenaline concentration-response curve to the left and restored the attenuated responses in the presence of L-NAME back to control levels. Sodium nitroprusside had little effect on the CGP 12177A concentration-response curve. The results show that the endothelium/nitric oxide (NO) pathway modulates beta-adrenoceptor-mediated vasorelaxation in rat aorta and that classical beta-adrenoceptors are modulated to a greater extent than atypical beta-adrenoceptors.

Cerebrovascular accident clinical pathway

The cerebrovascular accident (CVA) clinical pathway project was selected to complement the work already underway within the West Moreton Health Services District such as the development of a continuum of care model, revision of work practices to complement the new hospital redevelopment and encouraging team and evidence-based approaches to problem solving. Specific objectives were set for the project along with a detailed evaluation plan. A steering group was convened to run the project and a full time project officer was appointed. At the end of the 12 month period all the objectives were met. Specific achievements included a reduction in the overall average length of stay for those patients who experience CVA, improved clinical outcomes and a more effective use of resources. Quality of care has been improved through the preparation of specialized clinical pathway documentation, education packages, patient surveys, focus groups, independent reviews and benchmarking. Complementing these measures has been a series of process changes and environmental modifications. Furthermore, good working relationships have been established with private sector providers of health care and other external bodies. The development of the CVA clinical pathway at the Ipswich Hospital has meant timely referrals and a streamlined assessment and referral process to get patients into rehabilitation sooner. It has promoted good communication between, and recognition of, the professional roles of various team members and has put the patient back at the centre of the care process.

Angiographic embolization for major haemorrhage after upper gastrointestinal surgery

AIMS: Severe postoperative haemorrhage after upper gastrointestinal surgery is a serious complication. This study examined the effectiveness of selective mesenteric angiography (SMA) in localizing a bleeding point and the ability of angiographic haemostatic methods to control bleeding. METHODS: The case notes of a consecutive series of nine patients undergoing urgent SMA during 1996-1998 were analysed. Examination of angiography suite records confirmed the accuracy of patient identification. SMA was performed 18 times with 13 embolizations in nine individuals (seven men; median age 54 (27-73) years). Patients underwent the following operations: Whipple pancreaticoduodenectomy (four patients), pancreatic necrosectomy (two), total gastrectomy (one), cholecystectomy (one) and splenectomy (one). The median interval from surgery to haemorrhage was 15 (2-49) days. Six patients presented with haematemesis/melaena and three with bleeding from drains. Seven had evidence of shock (systolic blood pressure less than 100 mmHg, pulse more than 100 per min); the mean preprocedure haemoglobin concentration was 59 g/l. A median of 8 (4-14) units of blood were transfused before embolization and 4 (2-9) units after. Ten initial endoscopies were performed in six patients, seven of which revealed a source of bleeding. Endoscopic haemostasis was attempted in five and achieved temporary control of bleeding in two. RESULTS: Angiography revealed a discrete bleeding point in 13 of 18 procedures in eight patients. Where a bleeding point was identified, angiographic embolization using 3-8-mm stainless steel coils (ten) or a combination of coils and gelatin sponge (three) achieved radiological evidence of haemostasis in all cases. Periprocedural complications occurred in one patient with unintentional partial embolization of the right hepatic artery during embolization of an actively bleeding left hepatic artery pseudoaneurysm. Rebleeding occurred in six patients within 48 h. Three rebleeds were successfully managed with repeat SMA and embolization (one patient required a third embolization); the remaining three required surgery. Definitive radiological haemostasis was achieved in six patients. Five of the nine patients died in hospital, two of whom had been successfully embolized. CONCLUSIONS: In this group of patients, endoscopy contributed relatively little to treatment of postoperative haemorrhage. In contrast, SMA identified a bleeding point in eight of nine patients and achieved definitive control of bleeding in six. SMA and embolization appears to have a useful role in patients with this infrequent but potentially lethal complication.

Dietary practices and use of the ketogenic diet in the UK

With the introduction of Internet communications, parental interest has increased in the use of the ketogenic diet for epilepsy. It was decided to audit current practice in the use of the ketogenic diet in the UK. All paediatric dietitians who were members of the Paediatric Group of the British Dietetic Association were surveyed by a postal questionnaire. There was a 51% response rate. Twenty-two hospitals (17%) used the ketogenic diet with 101 patients being treated. Fifty-nine percent used the traditional 4:1 (four parts fat : one part carbohydrate, one part protein) classical ketogenic diet and 41% used the medium chain triglyceride diet (60% MCT fat). The age of patients ranged from 1 to over 11 years. There were wide variations in its application, with 66% of hospitals initiating the diet in hospital and 33% at home. The dietary energy administered varied from 60 to 90 kcal/kg/day, and there was no consistent policy on vitamin and mineral supplementation. Twenty-five patients continued to follow the diet after 12 months. Therefore, the ketogenic diet is commonly used for the treatment of intractable epilepsy in the UK. Further research work is needed on its nutritional safety and application.

A cluster of cases of legionnaires' disease associated with exposure to a spa pool on display

Interviews with four apparently sporadic cases of legionnaires' disease identified by laboratory reporting in one health district revealed that three of the four cases had been exposed to a new design of spa pool on display at a retail outlet. The fourth case had been exposed to the same design of spa pool in a private home. None had bathed in the spa pool. Legionella pneumophila serogroup 1 mAB subgroup 'Philadelphia' was isolated from samples taken from both spa pools. The display pool had not been maintained as recommended for a public spa pool in use by bathers. Revised maintenance instructions were issued to all purchasers of these spa pools in the United Kingdom (UK) and overseas. Patients may not remember specific exposures; scrutiny of activity diaries helped to identify exposure to a common location. Even when not in use by bathers, spa pools on display can be a source of legionella infection and should be maintained according to current hygiene guidelines.

Beta 1-, beta 2- and atypical beta-adrenoceptor-mediated relaxation in rat isolated aorta

beta-adrenoceptor-mediated relaxation was investigated in ring preparations of rat isolated thoracic aorta. Rings were pre-constricted with a sub-maximal concentration of noradrenaline (1 microM) and relaxant responses to cumulative concentrations of beta-adrenoceptor agonists obtained. The concentration-response curve (CRC) to isoprenaline was shifted to the right by propranolol (0.3 microM) with a steepening of the slope. Estimation of the magnitude of the shift from EC(50) values gave a pA(2) of 7.6. Selective beta(1)- and beta(2)-adrenoceptor antagonists, CGP 20712A (0.1 microM) and ICI 118551 (0.1 microM), respectively, produced 4 and 14 fold shifts of the isoprenaline CRC. Atypical beta-adrenoceptor agonists also produced concentration-dependent relaxation of aortic rings. The order of potency of the beta-adrenoceptor agonists was (-log EC(50)): isoprenaline (6. 25)>cyanopindolol (5.59)>isoprenaline+propranolol (5.11)>CGP 12177A (4.40)>ZD 2079 (4.24)>ZM 215001 (4.07)>BRL 37344 (3.89). Relaxation to CGP 12177A and ZM 215001 was unaffected by propranolol (0.3 microM). SR 59230A ( Collapse

Key Words

• atypical β-adrenoceptors
• β₃-adrenoceptors
• β₄-adrenoceptors
• β₁-adrenoceptors
• β₂-adrenoceptors
• vascular smooth muscle
• rat aorta

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MESH Headings

• Acetylcholine/pharmacology
• Adrenergic alpha-Agonists/pharmacology
• Adrenergic beta-Agonists/pharmacology
• Adrenergic beta-Antagonists/pharmacology
• Animals
• Aorta, Thoracic/drug effects
• Aorta, Thoracic/physiology
• Bupranolol/pharmacology
• Dose-Response Relationship, Drug
• Imidazoles/pharmacology
• In Vitro Techniques
• Isoproterenol/pharmacology
• Male
• Muscle Relaxation/drug effects
• Muscle Relaxation/physiology
• Muscle, Smooth, Vascular/drug effects
• Muscle, Smooth, Vascular/physiology
• Norepinephrine/pharmacology
• Pindolol/analogs & derivatives
• Pindolol/pharmacology
• Propanolamines/pharmacology
• Propranolol/pharmacology
• Rats
• Rats, Wistar
• Receptors, Adrenergic, beta/classification
• Receptors, Adrenergic, beta/physiology
• Receptors, Adrenergic, beta-1/physiology
• Receptors, Adrenergic, beta-2/physiology
• Substrate Specificity
• Vasodilator Agents/pharmacology

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Poly(ADP-ribose) polymerase at active centromeres and neocentromeres at metaphase

A double-stranded 9 bp GTGAAAAAG pJ alpha sequence found in human centromeric alpha-satellite DNA and a 28 bp ATGTATATATGTGTATATAGACATAAAT tandemly repeated AT28 sequence found within a cloned neo- centromere DNA have each allowed the affinity purification of a nuclear protein that we have identified as poly(ADP-ribose) polymerase (PARP). Use of other related or unrelated oligonucleotide sequences as affinity substrates has indicated either significantly reduced or no detectable PARP purification, suggesting preferential but not absolute sequence-specific binding. Immunofluorescence analysis of human and sheep metaphase cells using a polyclonal anti-PARP antibody revealed centromeric localization of PARP, with diffuse signals also seen on the chromosome arms. Similar results were observed for mouse chromosomes except for a significantly enlarged PARP-binding region around the core centromere-active domain, suggesting possible 'spreading' of PARP into surrounding non-core centromeric domains. Enhanced PARP signals were also observed on alpha-satellite-negative human neo- centromeres and on the active but not the inactive alpha-satellite-containing centromere of a human dicentric chromosome. PARP signals were absent from the q12 heterochromatin of the Y chromosome, suggesting a correlation of PARP binding with centromere function that is independent of heterochromatic properties. Preliminary cell cycle analysis indicates detectable centromeric association of PARP during S/G(2)phase and that the total proportion of PARP that is centromeric is relatively low. Strong binding of PARP to different centromere sequence motifs may offer a versatile mechanism of mammalian centromere recognition that is independent of primary DNA sequences.

5-hydroxytryptamine- and U46619-mediated vasoconstriction in bovine pulmonary conventional and supernumerary arteries: effect of endogenous nitric oxide

We compared 5-hydroxytryptamine (5-HT)- and U46619-mediated contractions in bovine pulmonary conventional arteries (CA) and supernumerary arteries (SA). The effects of the NO synthase inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME) (100 microM) and the guanylate cyclase inhibitor 1H-[1,2,4]oxadiazolo[4, 3-a]quinoxalin-1-one (ODQ) (10 microM) on the responses of CA and SA to 5-HT and U46619 were also examined. In addition, the effects of the 5-HT(2B) receptor antagonist SB 200646 (1 nM-1 microM) on the responses to 5-HT in SA and CA were studied. Tissue cGMP levels were measured in the absence and presence of L-NAME, ODQ, 5-HT and U46619. 5-HT was approximately 30 times more potent in SA ¿-log[EC(50) (M)] (pEC(50)) 6.32+/-0.13¿ than in CA (5.05+/-0.14). U46619 displayed a similar potency in both CA (pEC(50) 7.80+/-0.07) and SA (7.75+/-0. 12). L-NAME did not significantly alter the resting tone of CA or SA. In contrast, ODQ produced a transient increase in the tone of both CA and SA. Neither L-NAME nor ODQ altered the responses to 5-HT or U46619 in CA. In addition, neither L-NAME nor ODQ altered the responses to U46619 in SA, but both L-NAME and ODQ increased the magnitude of the response to 5-HT in SA without changing the sensitivity. Inhibition of the 5-HT(2B) receptor with SB 200646 did not alter the response to 5-HT in SA or CA. Basal levels of cGMP (pmol/mg of protein) were similar in CA (1.16+/-0.33) and SA (0. 8+/-0.51), and were not significantly changed in the presence of 5-HT or U46619. L-NAME and ODQ reduced the basal levels of cGMP in both SA and CA. The results suggest that endogenous NO selectively attenuates the vasoconstrictor response to 5-HT in SA, but not in CA. These results also suggest that the NO/cGMP pathway may have a role in maintaining low vascular tone, but that other mechanisms are able to compensate for the absence of this pathway.

V-shaped cushion at the origin of bovine pulmonary supernumerary arteries: structure and putative function

This study investigates the anatomic structure at the origin of pulmonary supernumerary arteries and their parent conventional artery. Histological examination showed that at the origin of each supernumerary artery the wall of the parent conventional artery is organized into a distinct V-shaped structure, which begins on the hilum side of each supernumerary artery as a funnel-shaped channel running into the supernumerary artery. The base of the channel is particularly thin walled. The lateral walls of the channel are composed of musculoelastic cushions that become more pronounced toward the supernumerary artery and fuse on its distal side, forming a baffle that projects over the supernumerary artery lumen. These V-shaped structures/cushions were observed with video stereo dissecting microscopy in both an open and closed state in isolated arteries in vitro. Pulmonary vasoconstriction of isolated arteries with the thromboxane A(2) mimetic U-46619 increased the number of V-shaped structures in the closed state. These studies indicate the presence of a novel anatomic structure at the origin of pulmonary supernumerary arteries, which may be able to regulate blood flow into the supernumerary artery.

Identification of patients to include in trauma audit: a modification of the pre-chart

Trauma audit is commonly focused using a Pre-Chart to illustrate calculations made using the TRISS model. A line is drawn at Ps = 0.5 to divide expected survivors and nonsurvivors. The use of this cut-off in a severely injured population was examined. The 'M statistic' for a group of injured patients selectively triaged to a Trauma Centre was calculated. The ideal cut-off point between predicted outcomes when using the TRISS model to focus trauma audit in this population was determined using a Receiver Operating Characteristic (ROC) curve. For this population the TRISS 'M statistic' was 0.71 (indicating a significantly different case mix from the reference database) and the best cut-off point was at Ps = 0.76. Trauma audit in populations with a case mix of injury severity different from the reference database should use a different Ps line to define unexpected outcomes.

Psychological characteristics of people with perceived food intolerance in a community sample

In most adults who believe themselves to be food intolerant there is no objective supporting evidence. It has therefore been proposed that the misperception of intolerance to food is linked to psychiatric illness or personality disorder. This hypothesis was tested in a community-derived sample of individuals who attributed an adverse symptom to a type of food. A random mailing recruited 955 participants aged > or =18 years, of whom 232 perceived themselves to be food intolerant (PFI). All recruits were sent two questionnaires, the General Health Questionnaire-28 (GHQ-28) and the shortened version of the Eysenck Personality Questionnaire (EPQ-R). A total of 535 GHQ-28 and 518 EPQ-R forms were returned that were correctly completed, an overall response rate of 55%. For the subscales of the EPQ-R, neuroticism was greater in those with a PFI than those without. Women with a PFI were more extroverted than control women. For the GHQ-28 subscales, women with a PFI had significantly higher scores than control women on somatic symptoms, anxiety, insomnia, and severe depression. There was a greater percentage of psychiatric caseness among women with a PFI than among men with a PFI or control women. Nevertheless, this percentage was no greater than that reported among a reference sample derived from NHS and university staff. It is concluded that perceived food intolerance is associated with psychological distress in women with a PFI, and neurotic symptoms in both men and women with a PFI, but there is no greater prevalence of psychiatric disorder among women or men with a PFI than there is in some professional groups.

Effects of propranolol and L-NAME on beta-adrenoceptor-mediated relaxation in rat carotid artery

1. The properties of beta-adrenoceptors mediating vascular relaxation in rat isolated carotid artery were investigated. Ring segments of arteries were preconstricted with the thromboxane A2 receptor agonist U-46619 and relaxation to beta-adrenoceptor agonists determined. 2. Isoprenaline produced a concentration-dependent relaxation of U-44619-constricted arteries. The concentration-response curve (CRC) to isoprenaline was shifted to the right by propranolol (1 microM) although the shift was less (105 fold; pA2, 8.02) than would be expected for an effect of isoprenaline at classical beta-adrenoceptors (300-1000 fold; pA2, 8.5-9). L-NAME (100 microM) significantly reduced responses to isoprenaline, lowering the slope of the CRC and reducing the maximum response. 3. The selective beta3-adrenoceptor agonists, BRL 37344 and ZD2079, also produced concentration-dependent relaxation of the arteries. L-NAME (100 microM) shifted the BRL 37344 CRC to the right 15 fold with no reduction in the slope or maximum response. L-NAME (100 microM) had no significant effect on the ZD2079 CRC. 4. In conclusion, relaxation to isoprenaline in rat carotid artery is inhibited by propranolol in a manner suggesting a mixed population of classical (beta1-/beta2-) and atypical (beta3-) adrenoceptors. The presence of beta3-adrenoceptors was confirmed by the relaxant effects of the selective beta3-adrenoceptor agonists BRL 37344 and ZD2079. L-NAME attenuated responses to both isoprenaline and the beta3-adrenoceptor agonist BRL 37344, suggesting a role for endothelial release of nitric oxide in beta-adrenoceptor mediated relaxation. However, the relaxant effect of BRL 37344 was attenuated by L-NAME to a lesser extent than that of isoprenaline. In addition, L-NAME had no effect on relaxation induced by ZD2079. These results suggest that there may be a differential contribution of endothelium to classical beta-and beta3-adrenoceptor-mediated effects, with endothelium contributing less to beta3-adrenoceptor-mediated relaxation.

Characterisation of the atypical beta-adrenoceptor in rabbit isolated jejunum using BRL 37344, cyanopindolol and SR 59230A

The present study was carried out to further investigate the nature of the beta-adrenoceptor in rabbit jejunum using BRL 37344, a selective beta3-adrenoceptor agonist, cyanopindolol, a beta-adrenoceptor antagonist with blocking activity at beta3-adrenoceptors and SR 59230A, a new selective beta3-adrenoceptor antagonist. Isoprenaline produced a concentration-dependent inhibition of the spontaneous contractions of rabbit jejunum with a pD2 of 7.14. Propranolol (1 microM) shifted the isoprenaline concentration-response curve (CRC) to the right with a concentration-ratio of 5.85, considerably less than would be expected for an action at classical beta-adrenoceptors (estimated pA2 6.66). BRL 37344 also produced a concentration-dependent inhibition of spontaneous contractions with a pD2 of 7.41. The BRL 37344 CRC was unaffected by propranolol (1 microM). In the presence of propranolol (1 microM), cyanopindolol (1 microM) shifted the isoprenaline CRC to the right (concentration-ratio of 21). Cyanopindolol also shifted the BRL 37344 CRC to the right (concentration-ratio of 38). These shifts are consistent with the affinity of cyanopindolol for beta3-adrenoceptors (estimated pA2 values of 7.27 and 7.38 against isoprenaline and BRL 37344, respectively). In the presence of propranolol (1 microM), SR 59230A produced a concentration-dependent rightward shift of the isoprenaline CRC. The Schild plot gave a pA2 value of 7.16, although the slope of the regression line was significantly different from unity (0.65). SR 59230A also produced a concentration-dependent shift of the BRL 37344 CRC. The Schild plot gave a pA2 of 7.58 with the slope of the regression line not significantly different from unity (0.81). The presence of beta3-adrenoceptors mediating relaxation of spontaneous contractions in rabbit jejunum is supported by the relatively poor antagonism of isoprenaline by propranolol, the relaxant effect of BRL 37344 and the antagonism of isoprenaline and BRL 37344 by cyanopindolol and SR 59230A. The lack of simple competitive antagonism of isoprenaline, but not BRL 37344, by SR 59230A may suggest more than one population of atypical beta-adrenoceptor.

Iron supplemented formula milk related to reduction in psychomotor decline in infants from inner city areas: randomised study

OBJECTIVE

To compare the effect of unmodified cows' milk and iron supplemented formula milk on psychomotor development in infants from inner city areas when used as the main milk source.

DESIGN

Double blind, randomised intervention trial.

SETTING

Birmingham health centre.

SUBJECTS

100 infants, mean age 7.8 months (range 5.7 to 8.6 months), whose mothers had already elected to use unmodified cows' milk as their infant's milk source.

INTERVENTION

Changing to an iron supplemented formula milk from enrolment to 18 months of age, or continuing with unmodified cows' milk.

MAIN OUTCOME MEASURES

Developmental assessments using Griffiths scales at enrolment and at 18 and 24 months.

RESULTS

85 participants completed the trial. There were no significant differences in haemoglobin concentration between the two groups at enrolment, but by 18 months of age 33% of the unmodified cows' milk group, but only 2% of the iron supplemented group, were anaemic (P<0.001). The experimental groups had Griffiths general quotient scores that were not significantly different at enrolment, but the scores in both groups declined during the study. By 24 months the decrease in the mean scores in the unmodified cows' milk group was 14.7 whereas the decrease in the mean scores in the iron supplemented group was 9.3 (P<0.02, 95% confidence interval 0.4 to 10.4). Mean subquotient scores were considerably lower in the unmodified cows' milk group at 24 months; significantly so for personal and social scores (P<0.02, 1.2 to 16.8 [corrected]).

CONCLUSION

Replacing unmodified cows' milk with an iron supplemented formula milk up to 18 months of age in infants from inner city areas prevents iron deficiency anaemia and reduces the decline in psychomotor development seen in such infants from the second half of the first year.

Red cell membrane fatty acids, cytosolic phospholipase-A2 and schizophrenia

Forty subjects with schizophrenia and 40 age- and sex-matched controls were recruited, and blood samples were obtained for analysis of red cell membrane fatty acid composition by capillary gas chromatography. A blood sample was also taken from the same population to test for allelic association between schizophrenia and a polymorphism close to the promoter site of the cytosolic phospholipase-A2 gene which is mapped to chromosome 1q25. The schizophrenic population was heterogeneous with regards age, symptoms severity and treatment. A significantly higher percentage concentration of dihomogamma-linolenic acid (DGLA) was found in the red cell membranes of schizophrenics compared to matched controls. All other fatty acids examined showed no difference from the normal population. No correlation was found between any demographic factor, treatment variable, diet, drug use, alcohol or tobacco consumption which could explain the biochemical findings. A negative correlation was found between the concentration of DGLA in red blood cell (RBC) membranes and severity of symptoms of schizophrenia. In particular, there was a significant correlation (r = -0.41, p = 0.009) between DGLA percentage concentrations and 'disorganised' symptoms. No association was found between schizophrenia and alleles of the polymorphism near the phospholipase-A2 gene or between fatty acid concentrations and the presence of any particular alleles. This study therefore finds support for membrane phospholipid abnormalities in patients with schizophrenia and particular symptom clusters, but does not replicate a previous report of an allelic association between a polymorphism close to the site of the cytosolic phospholipase-A2 gene and schizophrenia.

Rhizopus microsporus in wooden tongue depressors: a major threat or minor inconvenience?

The investigation and management of an apparent outbreak of Rhizopus spp. in a London paediatric referral centre between September 1995 and April 1996 is described. The organism was identified in microbiological surveillance samples from 23 patients nursed in four hospital areas. Investigations revealed the presence of the organism in spatulae from all ward areas investigated and from closed boxed containers held in the central hospital stores obtained from a new supplier. In contrast, culture of spatulae from the initial supplier failed to yield any fungal isolates. The incident was reported to the Medical Device Agency (MDA), the Central Public Health Laboratory Service (CPHLS) and the Birmingham PHLS. A statement was prepared for the weekly Communicable Disease Report and a hazard warning issued by the MDA. The spatulae were withdrawn from use and the contract with the original supplier was re-established. This incident resulted in contamination of samples only and no patient involvement. It highlights the problems which may follow use of equipment for unintended purposes and the need for good manufacturing practice guidelines to be applied to non-sterile equipment used in direct patient care.

Reducing bacterial contamination of enteral feeds

OBJECTIVE

It has previously been shown that microbial contamination of enteral feeds given to children in hospital and at home is common. This study therefore examined the effects of improvements in the enteral feeding protocol, coupled with an intensive staff training programme, on bacterial contamination.

METHODS

The enteral feeding protocol was modified by: priming the feeding set on an alcohol treated metal tray, spraying the bottle opener and top with 70% alcohol, wearing non-sterile disposable gloves, and filling the feeding reservoir with feed for up to 24 hours' use rather than only four hours. Daily feeds samples were collected from 16 inpatients and home patients on enteral nutrition at the start and end of feeding. Seventy seven samples were cultured. Results were compared with previously published control data.

RESULTS

Enteral feed contamination rates were reduced significantly from 62% to 6% of feeds given at home (p < 0.001), and from 45% to 4% of feeds given in hospital (p < 0.001).

CONCLUSIONS

This study highlights the importance of using an appropriate enteral feeding protocol, and of regular staff training in reducing contamination rates of enteral feeds to an acceptable level.

Does a single plasma phenylalanine predict quality of control in phenylketonuria?

A 1993 MRC working group on phenylketonuria suggested standardising blood phenylalanine measurements by taking blood samples at the same time each day. Since it is not known how representative of a 24 hour period a single phenylalanine concentration is, the aim of this study was to investigate the 24 hour variability of plasma phenylalanine in well controlled children with phenylketonuria. Sixteen subjects, 12 girls and four boys aged 1 to 18 years, had hourly venous blood samples collected for 13 hours between 09.00 and 21.00 on one day. Serial skin puncture blood specimens were then collected at 24.00, 03.00, and 06.00 within the same 24 hour period. All food and drink was weighed. The median variation in plasma phenylalanine concentration was 155 mumol/l/day, with a minimum of 80 and a maximum of 280. The highest concentration occurred in the morning between 6.00 and 9.00 in 63% of subjects; the lowest occurred between midday and midnight in 94%. Concentrations < 100 mumol/l occurred in 46% of children below 11 years, three having concentrations < 30 mumol/l for two, six, and seven hours respectively. Three of five subjects had concentrations above the MRC guidelines for 24% of the period studied. Except in two subjects, the blood concentrations did not rise in response to phenylalanine consumption. However, the greater the quantity of protein substitute taken between waking and the 16.00 specimen, the larger the decrease in daytime phenylalanine concentration (r = -0.7030) (p < 0.005). There is therefore wide variability in phenylalanine concentrations in a 24 hour period in children with phenylketonuria which is not reflected in a single observation. Further study is needed to investigate the effects of timing of protein substitute on the stability of phenylalanine concentrations.

Gastric emptying in patients with constipation following childbirth and due to idiopathic slow transit

BACKGROUND

Idiopathic slow transit constipation (ISTC) is considered to be a heterogeneous condition in which patients have varying sites and degrees of delayed gastrointestinal transit. The majority of patients have pancolonic disease, and colectomy with ileocolorectal anastomosis has been the mainstay of surgical treatment. Severe constipation following traumatic childbirth is now being recognized and this subgroup of patients may have delayed transit confined to the rectosigmoid colon. In theory, proximal transit in these patients should be normal.

METHODS

Gastric emptying was studied in patients with constipation following childbirth or ISTC and in controls. After an overnight fast, both patients and controls received breakfast, which consisted of cornflakes, sugar and milk. The liquid marker 111In-labelled di-ethylene tri-amine penta-acetic acid (DTPA) was added to the milk. A solid marker, 99mTc-labelled colloid, was impregnated on to paper and sealed with cellulose. The t1/2 for gastric emptying was calculated.

RESULTS

Liquid phase emptying was normal in both constipation following childbirth and ISTC. Solid phase emptying was delayed significantly in ISTC compared with that in patients with constipation following childbirth and controls. In addition, half the patients with ISTC had delayed transit through the small bowel and proximal colon. Small bowel and colonic transit were normal in patients with constipation following childbirth.

CONCLUSION

Patients with constipation following childbirth represent a distinct subgroup with normal proximal gastrointestinal function. Gastric emptying studies may be helpful in selecting patients for surgical management of severe constipation.

Gastric emptying in patients with constipation following childbirth and due to idiopathic slow transit

BACKGROUND

Idiopathic slow transit constipation (ISTC) is considered to be a heterogeneous condition in which patients have varying sites and degrees of delayed gastrointestinal transit. The majority of patients have pancolonic disease, and colectomy with ileocolorectal anastomosis has been the mainstay of surgical treatment. Severe constipation following traumatic childbirth is now being recognized and this subgroup of patients may have delayed transit confined to the rectosigmoid colon. In theory, proximal transit in these patients should be normal.

METHODS

Gastric emptying was studied in patients with constipation following childbirth or ISTC and in controls. After an overnight fast, both patients and controls received breakfast, which consisted of cornflakes, sugar and milk. The liquid marker 111In-labelled di-ethylene tri-amine penta-acetic acid (DTPA) was added to the milk. A solid marker, 99mTc-labelled colloid, was impregnated on to paper and sealed with cellulose. The t1/2 for gastric emptying was calculated.

RESULTS

Liquid phase emptying was normal in both constipation following childbirth and ISTC. Solid phase emptying was delayed significantly in ISTC compared with that in patients with constipation following childbirth and controls. In addition, half the patients with ISTC had delayed transit through the small bowel and proximal colon. Small bowel and colonic transit were normal in patients with constipation following childbirth.

CONCLUSION

Patients with constipation following childbirth represent a distinct subgroup with normal proximal gastrointestinal function. Gastric emptying studies may be helpful in selecting patients for surgical management of severe constipation.

Enteral nutrition after bone marrow transplantation

Nutritional insult after bone marrow transplantation (BMT) is complex and its nutritional management challenging. Enteral nutrition is cheaper and easier to provide than parenteral nutrition, but its tolerance and effectiveness in reversing nutritional depletion after BMT is poorly defined. Nutritional status, wellbeing, and nutritional biochemistry were prospectively assessed in 21 children (mean age 7.5 years; 14 boys) who received nasogastric feeding after BMT (mean duration 17 days) and in eight children (mean age 8 years, four boys) who refused enteral nutrition and who received dietetic advice only. Enteral nutrition was stopped prematurely in eight patients. Greater changes in weight and mid upper arm circumference were observed in the enteral nutrition group, while positive correlations were found between the duration of feeds and increase in weight and in mid upper arm circumference. Vomiting and diarrhoea had a similar incidence in the two groups, while fever and positive blood cultures occurred more frequently in the dietetic advice group. Diarrhoea occurring during enteral nutrition was not associated with fat malabsorption, while carbohydrate malabsorption was associated with rotavirus infection only. Enteral feeding did not, however, affect bone marrow recovery, hospital stay, general wellbeing, or serum albumin concentrations. Hypomagnesaemia, hypophosphataemia, zinc and selenium deficiency were common in both groups. In conclusion, enteral nutrition, when tolerated, is effective in limiting nutritional insult after BMT. With existing regimens nutritional biochemistry should be closely monitored in order to provide supplements when required.

Acute mountain sickness is not altered by a high carbohydrate diet nor associated with elevated circulating cytokines

We investigated whether a diet of increased carbohydrate content reduces the symptoms of acute mountain sickness (AMS) and whether concentrations of circulating cytokines rise and correlate with hypoxia and AMS. There were 19 healthy volunteers who ingested in randomized order both a high carbohydrate (68% CHO) or normal carbohydrate (45% CHO) diet for 4 d. On the 4th d, subjects were exposed to 8 h of 10% normobaric oxygen. Each subject completed the Lake Louise Consensus Questionnaire (LLCQ: a questionnaire developed to quantify the common symptoms and consequences of AMS) at the beginning and end of each hypoxic session, at which times venous blood was obtained for the following cytokines: interleukins 1 beta, 6 and 8 (IL-1 beta, IL-6, IL-8) and tumor necrosis factor alpha (TNF-alpha). AMS symptoms did not differ significantly between the diets (LLCQ scores: 68% CHO = 10.1 +/- 3.8 vs. 45% CHO = 10.3 +/- 4.1). Cytokine concentrations did not change with hypoxia on either diet, nor did individual changes correlate with AMS symptoms. We conclude that a high carbohydrate diet for 4 d does not reduce the symptoms of AMS; and plasma cytokine concentrations do not change with hypoxia and the development of AMS and, thus, are not likely mediators of this syndrome.

Know how vitamins and minerals

Children are potentially at risk of vitamin and mineral deficiency. Young children have high nutrient requirements relative to their body size but frequently are faddy eaters and have small appetites. In contrast, school age children usually have good appetites, but have freedom of choice over what they eat and consume more meals outside the home. Their food choices are increasingly affected by peer pressure and advertising. This is a concern, as their knowledge of nutrition is limited.

Evaluation of full-term infants fed an evaporated milk formula

The objective of this prospective, cohort study was to compare the nutritional status of full-term infants who were fed human milk (BF, n = 29), formula (FF, n = 30) or evaporated milk formulae (EM, n = 30) for at least 3 months. Infants were seen at enrollment, 3 and 6 months, at which times a blood sample, diet record and anthropometric data were collected. Infants in the EM group received solids earlier (12 +/- 5 weeks) than did FF infants (15 +/- 4 weeks), and both were earlier than BF infants (19 +/- 4 weeks). Only 26% of the EM fed group received iron supplements as ferrous sulphate drops. Seven BF, 12 FF and 20 EM had abnormal ferritin values (< 10 ng ml-1) at 6 months. Copper intake was lower in the EM infants at 3 and 6 months. However, plasma copper and erythrocyte copper zinc superoxide dismutase (ZnCuSOD) levels did not differ between groups. Selenium intake was lower in the EM group (5 +/- 1 and 10 +/- 5 micrograms d-1; 3 and 6 months) than in the FF infants (13 +/- 4 and 19 +/- 7 micrograms d-1; 3 and 6 months). Erythrocyte SeGHSPx levels in EM infants were lower at 6 months (EM, 33.2 +/- 3.4; FF. 35.2 +/- 3.9: BF, 36.1 +/- 3.8 mU mg Hb-1). Thiamin intake (0.99 +/- 0.08 and 1.24 +/- 0.32; 3 and 6 months, mg 1000 kcal-1) was higher in the FF group than in EM infants (0.38 +/- 0.39 and 0.66 +/- 0.38; 3 and 6 months). There were more (13%) abnormal thiamin assays in the EM group at 6 months than in the BF and FF infants (0%). In conclusion, infants fed evaporated milk formula receive adequate copper but may not receive enough thiamin or selenium. Unless supplemented from birth with medicinal iron, intakes of iron will be inadequate.

Psychological preparation for nasogastric feeding in children

Psychological preparation of children undergoing enteral nutrition by nasogastric tube was evaluated in a prospective study of 48 children nursed at home. They were randomly allocated to receive either standard informal preparation or detailed psychological preparation and support. The children were divided into two groups according to age: group A comprised toddlers and younger children aged 2-6 years and group B comprised older children and adolescents aged 7-16 years. Detailed questionnaires were administered to all parents and older children by dietetic colleagues who were blinded to the type of preparation received by the children. The results emphasize that detailed psychological preparation of families takes time. Passage of a nasogastric tube was seen as very distressing to both parents and children. Having a nasogastric tube was perceived as a major problem by group A. There was no statistical difference in the effects of enteral nutrition between younger children who received routine preparation and those who received detailed preparation; however, parental assessment of their child's behaviour was the sole means of determining how the younger child felt and reacted. In group B, there were marked differences: scores suggested that those who received detailed preparation had been better prepared for enteral feeding in hospital and at home and that the passage of the nasogastric tube, although unpleasant, was less distressing to them (P < 0.05). Talking to a nurse and play therapist was seen by parents as essential (P < 0.05). The authors conclude that children should be prepared for painful procedures and followed up sensitively, according to their needs.