Development of an integrated care pathway for the management of hemiplegic shoulder pain

PURPOSE

To improve clinical management of patients with hemiplegic shoulder pain through development of an evidence-based multidisciplinary integrated care pathway (ICP), and to use this to audit quality of care against predefined standards.

METHODS

The ICP was developed by a team of medical, paramedical and nursing staff. The evidence base was established through a systematic literature review supplemented by clinical consensus to ensure best practice where scientific evidence was lacking. Following development, performance was assessed against standards in a cohort of stroke patients with hemiplegia (n = 32) consecutively admitted to a regional unit providing in-patient rehabilitation for young patients with complex disabilities.

RESULTS

Performance showed improvements in assessment and documentation of pain and in initial care, including analgesia and application of positioning/handling protocols. However, review and response to continuing or changing symptoms were poorly documented. Changes to the ICP were introduced to improve this.

CONCLUSIONS

Principal benefits have been to raise awareness of shoulder pain, to educate staff and prompt management in line with recommended best practice, but strong leadership is essential to ensure continuity in clinical practice. Future research is needed to establish whether improved quality of care offsets the substantial investment of staff time in ICP development.

Who would want to be a nurse? Violence in the workplace--a factor in recruitment and retention

In a climate of a declining nursing workforce where violence and hostility is a part of the day-to-day lives of most nurses, it is timely to name violence as a major factor in the recruitment and retention of registered nurses in the health system. Workplace violence takes many forms such as aggression, harassment, bullying, intimidation and assault. Violent acts are perpetrated against nurses from various quarters including patients, relatives, other nurses and other professional groups. Research suggests that nurse managers are implicated in workplace violence and bullying. Furthermore, there may be a direct link between episodes of violence and aggression towards nurses and sick leave, burnout and poor recruitment and retention rates. This paper explores what is known about workplace violence as it affects nurses, and calls for managerial support and policy to act to improve work environments for all nurses.

Quantifying 137Cs aggregated transfer coefficients in a semi-natural woodland ecosystem adjacent to a nuclear reprocessing facility

Radiocaesium (137Cs) activity concentrations and aggregated transfer factors (Tag values) were calculated for vascular plants, fungal fruiting bodies and invertebrates in a semi-natural Picea sitchensis woodland (Lady Wood) adjacent to the British Nuclear Fuels plc. reprocessing facility at Sellafield, Cumbria, UK. The Tag values for vascular plants ranged from 7.1 x 10(-4) - 1.9 x 10(-2) m2 kg(-1), the maximum value being for Pteridium aquilinum. Fungal fruiting bodies had higher Tag values (1.9 x 10(-3) - 1.8 x 10(-1) m2 kg(-1)) than vascular plants, with a maximum value for Mycena galericulata. None of the activity concentrations for edible foodstuffs collected within this study (fungi and berries) exceeded the EC recommended limits of 137Cs in foodstuffs grown within the UK. The invertebrate community sampled during the study had Tag values ranging from 3.4 x 10(-4) to 1.3 x 10(-2) m2 kg(-1). There were no systematic differences in 137Cs activity concentration between invertebrate guilds, or between seasonal cohorts within guilds. The invertebrates in Lady Wood were exposed to a dose from 137Cs (internal gamma + beta and external gamma) ranging between 4.37 x 10(-4) and 6.40 x 10(-4) mGy day(-1). Including dose from radionuclides other than 137Cs and accounting for uncertainties due to the relative biological effectiveness of differing radionuclides could increase total dose by approximately an order of magnitude. These dose rates are at least three orders of magnitude lower than the 1 mGy d(-1) level at which harm may be caused to terrestrial biota, hence the risk to the invertebrate community from the effects of ionising radiation in Lady Wood is low.

Retaining a viable workforce: a critical challenge for nursing

Nursing is facing a crisis nationally and internationall, with Australia, the United States, New Zealand, Canada, the United Kingdom and Western Europe experiencing critical shortages of nurses. Problems with recruitment, retention and an ageing workforce means that attempts to ensure a viable nursing workforce must be placed at the top of the professional agenda. Strategies currently used to manage the crisis, such as overseas recruitment, are not sustainable and are ethically dubious. The demographic timebomb is ticking and up to half the current nursing workforce will reach retirement age by 2020. It is vital that there are adequate numbers of skilled and qualified nurses to take their places. Nursing and nurses are facing unprecedented challenges and pressures in the workplace. Job satisfaction is threatened as nurses are pressured to do more with less, Nursing productivity has increased phenomenally over the past ten years in response to increased demands and decreasing numbers of staff. The nursing workplace has disturbingly high levels of occupational violence, and many nurses operate within a culture of blame and scapegoating. There is evidence that organizational change is imposed upon nurses with little or no consultation and the literature reveals that this has a direct and negative effect on job satisfaction and on retention of nurses. This paper explores some of the critical issues that nursing must confront to be successful in establishing and maintaining a vigorous, dynamic and viable workforce.

Topography and volume measurements of the optic nerve usingen-face optical coherence tomography

A special imaging instrument was developed which can acquire optical coherence tomography (OCT) en-face images from the eye fundus, and simultaneously a confocal image. Using this instrument we illustrate for the first time the application of en-face OCT imaging to produce topography and perform area and volume measurements of the optic nerve. The procedure is compared with the topography, area and volume measurements using a confocal scanning laser ophthalmoscope.

Technological advances in antigen delivery and synthetic peptide vaccine developmental strategies

Significant advances have been made in the field of peptide chemistry, especially in the design of synthetic peptide immunogens which has led to new concepts and strategies for human vaccine development. This article reviews some of these technological advances and approaches to vaccine design including the multiple antigenic peptide system, the lipid polylysine core peptide system, the polymerization of peptides into multivalent immunogens and self adjuvanting synthetic peptide-based immunogens.

Energy intake by multiple pass 24 h recall and total energy expenditure: a comparison in a representative sample of 3-4-year-olds

The accuracy of the multiple pass 24 h recall for assessment of habitual energy intake in pre-school children is unclear. The primary aim of this study was to assess its accuracy by comparison with measurement of total energy expenditure by doubly-labelled water in a representative sample of forty-one 3-4-year-olds. The recall method was well tolerated by subjects and was administered quickly and easily. However, it produced estimates of energy intake which significantly exceeded measures of total energy expenditure from doubly-labelled water, mean paired difference 660 kJ/d (P<0.01). Agreement between the two methods was poor at the individual level: limits of agreement 660+/-3018 kJ/d. Error and imprecision in both methods contribute to individual differences, but the present study suggests that the multiple pass 24 h recall does not provide accurate estimates of dietary energy intake in individual children.

Comparative genomics of Listeria species

Listeria monocytogenes is a food-borne pathogen with a high mortality rate that has also emerged as a paradigm for intracellular parasitism. We present and compare the genome sequences of L. monocytogenes (2,944,528 base pairs) and a nonpathogenic species, L. innocua (3,011,209 base pairs). We found a large number of predicted genes encoding surface and secreted proteins, transporters, and transcriptional regulators, consistent with the ability of both species to adapt to diverse environments. The presence of 270 L. monocytogenes and 149 L. innocua strain-specific genes (clustered in 100 and 63 islets, respectively) suggests that virulence in Listeria results from multiple gene acquisition and deletion events.

Accuracy of prediction of walking for young stroke patients by use of the FIM

BACKGROUND AND PURPOSE

Clinical prediction of walking outcome after a stroke is essential for effective discharge planning. However, its accuracy has hardly been explored. This study took place in a regional unit admitting patients with complex neurological disabilities for specialist inpatient rehabilitation. The aim was to compare predicted outcome (goal score) with achieved outcome (discharge score) on the seven-point locomotion subscale of the Functional Independence Measure (FIM), to evaluate its precision and identify factors influencing accuracy.

METHOD

Admission, goal and discharge scores were analysed retrospectively for 141 subjects (90 M; 51 F) admitted consecutively to the Unit with median age 54 years (range 15-68 years) with median length of stay 13.6 weeks (range 3-35 weeks).

RESULTS

Ninety subjects (64%) gained from two to six points; 50 subjects (35%) gained one point or showed no change. One patient deteriorated by two points. Excluding patients admitted with the highest score (FIM level 7), the overall level of agreement between predicted and discharge scores was moderate (weighted kappa 0.47). Prediction was accurate to +/- 1 point in 113 subjects (80%). Overprediction by > or = 2 points occurred in 16 subjects (11%) and underprediction by > or = 2 points in 12 subjects (9%). Analysis of the most-disabled cohort, admitted with FIM levels 1 or 2 scores, revealed a higher sensitivity for predicting 'independence' (FIM levels 5-7) (78%) than 'dependence' (FIM levels 1-4) (65%). Accuracy was not affected by age, gender or side of stroke. Inaccurate predictions were associated with lower admission FIM level scores (p = -0.26; p = 0.002) and a greater length of stay (p = 0.36; p < 0.001). Subjects with quadriplegia were more likely to have inaccurate outcome predictions made than those with hemiplegia (p = 0.025) and those with neglect were more likely to have inaccurate outcome predictions made than those without neglect (p = 0.017).

CONCLUSION

Further investigation into clinical prediction and the variables which confound accuracy is needed for effective planning.

The fasciated ear2 gene encodes a leucine-rich repeat receptor-like protein that regulates shoot meristem proliferation in maize

The ability to initiate organs throughout the lifecycle is a unique feature of plant development that is executed by groups of stem cells called meristems. The balance between stem cell proliferation and organ initiation is carefully regulated and ensures that organs can be initiated in regular geometric patterns. To understand how this regulation is achieved, we isolated a novel mutant of maize, fasciated ear2 (fea2), which causes a massive overproliferation of the ear inflorescence meristem and a more modest effect on floral meristem size and organ number. We cloned the fea2 gene using transposon tagging, and it encodes a membrane localized leucine-rich repeat receptor-like protein that is most closely related to CLAVATA2 from Arabidopsis. These findings provide evidence that the CLAVATA pathway for regulation of meristem size is functionally conserved throughout the angiosperms. A possible connection of fea2 to the control of crop yields is discussed.

Can brain-injured patients participate in an aerobic exercise programme during early inpatient rehabilitation?

OBJECTIVE

We investigated the capacity of brain-injured patients to participate in an aerobic exercise programme early after injury.

DESIGN

Retrospective analysis of exercise achievements in patients participating in a randomized controlled trial.

SETTING AND SUBJECTS

Ninety patients participated in an exercise training programme on a cycle ergometer at four inpatient neurological rehabilitation units for younger patients. At intake, impairments and function were rated on: Motricity Index, Ashworth Scale, Berg Balance Scale, Barthel Index and Functional Independence Measure.

INTERVENTIONS

Patients cycled for up to 30 minutes three times weekly for 24-36 sessions over 12 weeks.

MAIN OUTCOME MEASURES

Exercise performance was measured by: (a) number of sessions to achieve a cycling time of 30 minutes, (b) overall mean cycling time per session over 24 sessions and (c) mean time per session cycling at >60% of age predicted maximum heart rate (HR max) over 24 sessions.

RESULTS

Fifty-five patients completed 24 sessions. Thirty-five withdrew, largely for logistic reasons, before completing training; they were significantly less disabled than the 55 who remained. Forty-four of the 55 patients trained for an average of at least 20 minutes per session, 18 training at >60% HR max for this time. There were no differences in performance on the three exercise parameters between two groups of patients with baseline Barthel scores of < or = 12 and > or = 13.

CONCLUSIONS

Brain-injured patients with a range of disabilities have the capacity to participate in an exercise programme during early inpatient rehabilitation, though some may take longer to achieve adequate intensity of aerobic exercise.

The relationship between metformin therapy and the fasting plasma lactate in type 2 diabetes: The Fremantle Diabetes Study

AIMS

To determine (i) which factors, including metformin, are associated with the fasting plasma lactate concentration in type 2 diabetes, and (ii) whether plasma lactate is associated with haemodynamic and metabolic effects.

METHODS

We measured fasting plasma lactate in 272 well-characterized diabetic patients from a community-based sample, 181 (67%) of whom were taking metformin with or without other therapies. Linear regression analysis was used to identify predictors, including metformin therapy, of the plasma lactate, and to investigate associations between plasma lactate and resting pulse rate and serum bicarbonate. Factor analysis assessed independent relationships between groups of cosegregating variables.

RESULTS

Metformin-treated patients had higher plasma lactate concentrations than nonmetformin-treated subjects (geometric mean [s.d. range] 1.86 [1.34-2.59] vs 1.58 [1.09-2.30] mmol x l(-1), respectively; P < 0.001). In a linear regression model, plasma glucose, BMI and metformin use (but not dose) were independently associated with plasma lactate (P < or = 0.028); after adjustment for the former two variables, metformin-treated patients had a mean plasma lactate 0.16 mmol l-1 greater than in subjects not taking the drug. Factor analysis revealed that plasma lactate, plasma glucose, BMI and pulse rate cosegregated but serum bicarbonate was not in this grouping.

CONCLUSIONS

The present results show that metformin therapy increases the fasting plasma lactate in ambulant patients with type 2 diabetes from a community-based cohort. From associations in the data we hypothesize that this increase reflects (i) increased sympathetic activity in patients with the metabolic syndrome (ii) increased substrate (glucose) availability and (iii) a direct metformin effect.

Human RAD52 protein has extreme thermal stability

The human RAD52 protein plays an important role in the earliest stages of chromosomal double-strand break repair via the homologous recombination pathway. Individual subunits of RAD52 associate into seven-membered rings. These rings can form higher order complexes. RAD52 binds to DNA breaks, and recent studies suggest that the higher order self-association of the rings promotes DNA end joining. Monomers of the RAD52(1--192) deletion mutant also associate into ring structures but do not form higher order complexes. The thermal stability of wild-type and mutant RAD52 was studied by differential scanning calorimetry. Three thermal transitions (labeled A, B, and C) were observed with melting temperatures of 38.8, 73.1, and 115.2 degrees C. The RAD52(1--192) mutant had only two thermal transitions at 47.6 and 100.9 degrees C (labeled B and C). Transitions were labeled such that transition C corresponds to complete unfolding of the protein. The effect of temperature and protein concentration on RAD52 self-association was analyzed by dynamic light scattering. From these data a four-state hypothetical model was developed to explain the thermal denaturation profile of wild-type RAD52. The three thermal transitions in this model were assigned as follows. Transition A was attributed to the disruption of higher order assemblies of RAD52 rings, transition B to the disruption of rings to individual subunits, and transition C to complete unfolding. The ring-shaped quaternary structure of RAD52 and the formation of higher ordered complexes of rings appear to contribute to the extreme stability of RAD52. Higher ordered complexes of rings are stable at physiological temperatures in vitro.

Involvement of pallidothalamic circuitry in working memory

This study evaluated the capacity of mu-opioid and glutamate receptor agonists to differentially regulate the involvement of the GABAergic projection from the ventral pallidum to the mediodorsal thalamus in working memory and locomotor activity. Microinjection of either the ionotropic glutamate receptor agonist alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) or the mu agonist [D-Ala(2),N-Me-Phe(4),Gly-ol(5)]enkephalin into the ventral pallidum of male Sprague-Dawley rats produced a dose-dependent impairment in working memory, estimated using a forced delayed alternation task in a T-maze. Performance in a spatial discrimination task without delay was also impaired by glutamate, but not by mu receptor, stimulation. Involvement of the GABAergic projection from the ventral pallidum to the mediodorsal thalamus in mu-opioid-induced impairment of working memory was verified by showing that inhibiting GABA(B) receptors in the mediodorsal thalamus blocked the effect of [D-Ala(2),N-Me-Phe(4),Gly-ol(5)]enkephalin in the ventral pallidum. Similarly, either glutamate or mu-opioid receptor stimulation in the ventral pallidum elicited motor activity, and the motor stimulant effect of the mu agonist was blocked, while that of AMPA is not affected by GABA(B) receptor blockade in the mediodorsal thalamus. Distinction between mu and glutamate receptor stimulation was further revealed by the fact that stimulating mu receptors in the ventral pallidum caused a dose-dependent reduction in extracellular GABA levels, while AMPA was without effect on GABA in the ventral pallidum. These data indicate that stimulating mu-opioid receptors reduces GABAergic tone in the ventral pallidum, which increases activity in the GABAergic projection to the mediodorsal thalamus, thereby impairing working memory. Moreover, it is hypothesized that mu receptors in the ventral pallidum gate the recruitment of working memory into ongoing behavioral activity.

Total energy expenditure in children with obstructive sleep apnoea syndrome

Childhood obstructive sleep apnoea syndrome (OSAS) acts as a check on growth and nutritional status. An increase in sleeping energy expenditure has been proposed as a possible mechanism, but to date, no studies have determined whether energy requirements (total energy expenditure; TEE) are raised in OSAS. The aim of this study was to test the hypothesis that OSAS is associated with increased TEE. Eleven children (mean+/-SD 5.8+/-2.2 yrs of age) with OSAS confirmed by nocturnal polysomnography were each matched with a pair of healthy controls (n=22) of the same age and sex. TEE was measured using the doubly-labelled water method in all subjects. In 10/11 patients TEE was also measured after adenotonsillectomy and changes in TEE assessed. There was no significant difference in TEE between patients (mean+/-SD 325+/-44 kJ x kg(-1) x day(-1)) and controls (339+/-48 kJ x kg(-1) x day(-1)), nor between patients and age- and sex-specific literature data on TEE, using the doubly-labelled water method. Differences in TEE within patients, before versus after surgery, were minor and not statistically significant. This study does not support the hypothesis that obstructive sleep apnoea syndrome in childhood is associated with increased energy requirements, and suggests that alternative explanations for the effect of this syndrome on growth and energy balance should be sought.

Human RAD52 exhibits two modes of self-association

The human RAD52 protein plays an important role in the earliest stages of chromosomal double-strand break repair via the homologous recombination pathway. Individual subunits of RAD52 self-associate into rings that can then form higher order complexes. RAD52 binds to double-strand DNA ends, and recent studies suggest that the higher order self-association of the rings promotes DNA end-joining. Earlier studies defined the self-association domain of RAD52 to a unique region in the N-terminal half of the protein. Here we show that there are in fact two experimentally separable self-association domains in RAD52. The N-terminal self-association domain mediates the assembly of monomers into rings, and the previously unidentified domain in the C-terminal half of the protein mediates higher order self-association of the rings.

Clinical nurses as teachers: insights from students of nursing in their first semester of study

This paper reports the findings of a study which sought to gain insights about the role of clinical nursing staff in the planned clinical experience of undergraduate nursing students. This study differs from others in that the perspectives of students of nursing in their first year of the undergraduate programme are sought, and the role of clinical nurses rather than clinical teachers is of particular interest. Using a story-telling approach, an exploration of students' perspectives on the role of clinical nursing staff in their clinical learning was undertaken. Analysis allowed findings to be grouped into helpful and unhelpful behaviours, Helpful behaviours included understanding and being friendly, showing interest and explaining. Behaviours that students found unhelpful to their learning were often passive rather than active, but they made students feel acutely aware of being unwelcome in the clinical area. Several students described feeling intrusive, uncomfortable and even unwelcome in clinical areas because o the attitudes and behaviour of clinicians. Findings of this study highlight the importance of clinicians and academic nurses working together to ensure that students of nursing, who represent the future of the profession, are provided with the best possible opportunities for clinical learning.

Toxicologic lesions associated with two related inhibitors of oxidosqualene cyclase in the dog and mouse

Two novel hypolipidaemic agents, both members of the aminopyrimidine series, with a mode of action of inhibition of oxidosqualene cyclase (OSC), were administered orally to dogs and mice for 14 and 28 days. Both compounds produced a similar spectrum of pathologic changes. In dogs, the agents produced equatorial single cell necrosis and cataract in the lens (also observed clinically); atrophy, ulceration, and inflammation of the cornea; hyperkeratosis, acanthosis, hair papillary atrophy, and inflammation of the skin; and epithelial degeneration and sperm granuloma in the epididymides. One female dog showed signs of liver toxicity. In mice, severe cataract formation was seen with both compounds, and liver toxicity was produced by one of the compounds. The severity and speed of onset of the cataract formation were very marked. The changes seen were dissimilar to those reported with the most commonly used class of hypolipidaemic agents in the clinic, the hydroxymethyl glutaryl coenzyme A (HMGCoA) reductase inhibitors but were reminiscent of those reported for the hypolipidaemic agent Triparanol. which was predictive of toxicity seen in man.

Fibroblast growth factor signalling and cyclin D1 function are necessary for normal mammary gland development during pregnancy. A transgenic mouse approach

A number of growth factors, growth factor receptors and cell cycle regulatory proteins have been implicated in the genesis of mammary carcinomas both in animal models as well as in human breast tumour samples. Studies on the development of the mammary gland has revealed that several of the proto-oncogenes, or their closely related gene-family members, have a function in the normal growth and differentiation of the gland. In this review the role of fibroblast growth factor signalling and the critical requirement for the cell cycle regulator, cyclin D1 is discussed with respect to their normal function in mammary gland development and abnormal role in mammary carcinogenesis.

A dynamic compartmental food chain model of radiocaesium transfer to Apodemus sylvaticus in woodland ecosystems

A study was undertaken to quantify the activity concentrations of 137Cs in Apodemus sylvaticus (the woodmouse) in two woodland sites, Lady Wood and Longrigg Wood, adjacent to British Nuclear Fuels Ltd. (BNFL) Sellafield, Cumbria, UK. A deterministic dynamic compartmental food chain model was also constructed to predict 137Cs activity concentration [Bq kg(-1) dry weight (dw)] in A. sylvaticus on a seasonal basis given the activity concentrations in its diet. Within the coniferous woodland site (Lady Wood), significant differences were found between seasons (P < 0.05, summer vs. autumn cohort; P < 0.001, spring vs. autumn cohort), with an autumn peak in activity concentration (geometric mean = 140 x/divided by 2.3 Bq kg(-1) dw) being attributed to mycophagy. Fungal concentrations ranged from 2-3213 Bq kg(-1) dw. The modelled activity concentrations fell between the confidence intervals of the observed data in four of the six seasonal cohorts sampled. Disparities between predicted and observed activity concentrations are attributed to uncertainties surrounding the fundamental feeding ecology of small mammals.

Interprofessional working and learning in a UK operating department

This study explores the issues of working and training together for nurses and operating department assistants and practitioners (ODAs/ODPs), based on experiences in an operating department. Interviews and focus groups with nurses, ODAs/ODPs and medical staff were the means of collecting data.

Alpha-emitting 'hot particles' in the vicinity of BNFL Sellafield, Cumbria

In a survey of environmental samples in the vicinity of BNFL Sellafield, two alpha-emitting radioactive particles were found in samples of grass. One particle appears to be of mineral origin, the other was not definitively identified, but may be a fragment of fuel cladding. Conservative estimates of the activities of these particles are very low. The abundance of radioactive particles in the terrestrial food chain appears to be low, with no evidence for any alpha-emitting hot particles in foodstuffs for consumption by humans. Results suggest that there is no significant dose to man through inhalation or ingestion pathways.

Women recovering from first-time myocardial infarction (MI): a feminist qualitative study

Although myocardial infarction (MI) is a leading cause of death and disablement for women internationally, little is known about women's recovery. This paper describes an exploratory descriptive study that was informed by feminist principles, and which aimed to explore the recovery experiences of a group of women survivors of first-time MI in the initial period following discharge from hospital. A total of 10 female survivors were interviewed using an open-ended semi-structured interview schedule administered at 7, 14 and 21 days post-hospital discharge. Findings revealed that recovery was experienced as a complex process, initially characterized by fear and uncertainty. Over the duration of the study these feelings were replaced with a more positive outlook, a return of energy, and a sense of confidence in the future. Participants identified an unmet need for reliable information which persisted over the duration of the study. The findings of this study have implications for nursing practice and research. Chief among these is the issue of effective provision of information to women following an acute MI. The importance of providing relevant information to be understood and retained by people experiencing crisis cannot be overstated. Equally important are the provision of opportunities for patients to have regular contact with health professionals to question and seek clarifying information. These findings should now be tested on larger populations.

The emergence of Streptococcus pneumoniae resistant to macrolide antimicrobial agents: a 6-year population-based assessment

From 1994 through 1999, the available isolates (4148 isolates) from active population-based surveillance of invasive pneumococcal disease in metropolitan Atlanta were serotyped and were tested for antimicrobial susceptibility. Macrolide-resistant isolates were studied for the presence of ermAM (a ribosomal methylase gene), mefE (a macrolide efflux gene), and tetM (the class M tetracycline resistance gene). Macrolide resistance increased from 16% of all invasive isolates in 1994 to 32% in 1999. Of the macrolide-resistant pneumococcal isolates studied, 99% contained genomic copies of mefE or ermAM. Isolates with ermAM were mainly serotypes 6B, 23F, 14, or 19F and contained tetM; mefE-associated isolates were predominantly serotypes 14, 6A, or 19F, and most did not contain tetM. The frequency of the ermAM-mediated phenotype in invasive Streptococcus pneumoniae remained stable over the 6-year surveillance. However, the mefE-mediated phenotype increased from 9% in 1994 to 26% of all isolates in 1999 and was noted in new serotypes. By 1999, 93% of the mefE-containing strains had minimum inhibitory concentrations >/=8 microgram/mL. Dissemination of the mefE determinant accounted for the rapid increase in the rate of macrolide resistance in our S. pneumoniae population.

The E1E4 protein of human papillomavirus type 16 associates with a putative RNA helicase through sequences in its C terminus

Human papillomavirus type 16 (HPV16) infects cervical epithelium and is associated with the majority of cervical cancers. The E1E4 protein of HPV16 but not those of HPV1 or HPV6 was found to associate with a novel member of the DEAD box protein family of RNA helicases through sequences in its C terminus. This protein, termed E4-DBP (E4-DEAD box protein), has a molecular weight of 66,000 (66K) and can shuttle between the nucleus and the cytoplasm. It binds to RNA in vitro, including the major HPV16 late transcript (E1E4. L1), and has an RNA-independent ATPase activity which can be partially inhibited by E1E4. E4-DBP was detectable in the cytoplasm of cells expressing HPV16 E1E4 (in vivo and in vitro) and could be immunoprecipitated as an E1E4 complex from cervical epithelial cell lines. In cell lines lacking cytoplasmic intermediate filaments, loss of the leucine cluster-cytoplasmic anchor region of HPV16 E1wedgeE4 resulted in both proteins colocalizing exclusively to the nucleoli. Two additional HPV16 E1E4-binding proteins, of 80K and 50K, were identified in pull-down experiments but were not recognized by antibodies to E4-DBP or the conserved DEAD box motif. Sequence analysis of E4-DBP revealed homology in its E4-binding region with three Escherichia coli DEAD box proteins involved in the regulation of mRNA stability and degradation (RhlB, SrmB, and DeaD) and with the Rrp3 protein of Saccharomyces cerevisiae, which is involved in ribosome biogenesis. The synthesis of HPV16 coat proteins occurs after E1E4 expression and genome amplification and is regulated at the level of mRNA stability and translation. Identification of E4-DBP as an HPV16 E1E4-associated protein indicates a possible role for E1E4 in virus synthesis.

Three dimensional OCT images from retina and skin

We demonstrate the functionality of an en-face optical coherence tomography (OCT) system with images from the retina and skin. En-face images collected at different depths are subsequently used to reconstruct a 3D volume of the tissue. The reconstruction allows software inferred OCT longitudinal images at any transversal position in the stack. The position in depth in the stack before creating longitudinal OCT images is also adjustable, offering a valuable guidance tool for exploring the 3D volume of the tissue. This is illustrated by Quick time movies showing either depth or lateral exploration along one of two possible different directions in the stack of transversal OCT images. Sufficient accuracy of the volume rendered is obtained in 20 seconds when the system operates at 2 frames a second. The system, equipped with the 3D rendering feature acts as a valuable diagnostic tool allowing "peeling off" of transversal and longitudinal biologic material to investigate different internal features.

The diagonal ear lobe crease (Frank's sign) is not associated with coronary artery disease or retinopathy in type 2 diabetes: the Fremantle Diabetes Study

BACKGROUND

The diagonal ear lobe crease (ELC) has been suggested as a simple marker of vascular disease in the general population but there are few data from diabetic patients despite their increased risk of angiopathy.

AIM

To determine whether the ELC is a clinically useful sign of coronary artery disease (CAD) or retinopathy in type 2 diabetes.

METHODS

One thousand and twenty-two patients from the multi-ethnic urban catchment area of Fremantle Hospital in Western Australia were studied. This sample represents 79% of the type 2 diabetic subjects recruited to the ongoing Fremantle Diabetes Study and 49% of all 2072 patients with type 2 diabetes identified through active case detection in a postcode-defined region of 120,097 people. In addition to other comprehensive data relating to diabetes and its management, the presence of an ELC and evidence of both CAD and retinopathy were ascertained for each patient.

RESULTS

The prevalence of ELC was 55%. Patients with an ELC were more likely to have CAD than those without an ELC (p=0.019), but the proportions with retinopathy were not significantly different (p=0.085). The sensitivity and specificity of ELC for detecting CAD were 60% and 48%, and for retinopathy 61% and 47% respectively. The patients with an ELC were significantly older, more likely to be male and had a higher systolic blood pressure than those without (p<0.02). After adjusting for known vascular risk factors, socioeconomic variables and ethnicity in a logistic regression model, an ELC was neither a significant independent predictor of CAD (p=0.45) nor of retinopathy (p=0.14).

CONCLUSIONS

The ELC is of little value as a sign of the presence of diabetic vascular complications.

Opening up the communication channels: recent insights into plasmodesmal function

The past year has seen significant advances in our understanding of the function and regulation of plasmodesmata. Notably, we have learned that plasmodesmata undergo dynamic changes during development and may participate in long-range communication through the transmission of RNA signals. Biochemical studies have enriched our understanding of a putative plasmodesmal receptor and of plant factors involved in viral cell-to-cell movement.

Can young severely disabled stroke patients regain the ability to walk independently more than three months post stroke?

OBJECTIVE

To investigate the acquisition of ability to walk independently in young severely disabled stroke patients unable to walk three months after onset.

SETTING

A regional rehabilitation unit providing post-acute neurorehabilitation mainly for patients aged 16-65 years.

SUBJECTS AND METHODS

A retrospective analysis of records was undertaken for 152 stroke patients admitted consecutively over a three-year period. All had a combination of physical, cognitive and language impairments; male/female 98/54; median age 54 (IQR 47-60) years.

MAIN OUTCOME MEASURES

Time taken from stroke onset to regain the ability to walk safely and independently at least 5 metres around the hospital bay.

RESULTS

Seventy-five (49%) regained the ability to walk independently between 3 and 11 months post onset. Patients with cognitive impairments and neglect took longer to walk. Time from stroke onset to admission was longer in patients who did not walk (median 16.3 weeks), than in those who regained walking (median 12.7 weeks; p = 0.009). Independent positive associations were found between the time taken to walk and time from onset to referral for rehabilitation (p = 0.55; p < 0.001), and time from acceptance to admission (p = 0.30; p = 0.008).

CONCLUSION

With intensive specialist input, significant numbers of severely disabled young stroke patients can regain independent walking many months after onset, though late walkers may follow a slower recovery course. These results argue for investment in appropriate rehabilitation for these patients. Waiting list delays may prolong rehabilitation and potentially compromise cost effectiveness.

Effects of prenatal cocaine exposure on dopamine system development: a meta-analysis

Several studies have investigated the effects of prenatal cocaine (PCOC) exposure on the nigrostriatal dopaminergic system in animal models of maternal drug abuse, yet independent examinations of striatal dopamine (DA) receptors and tissue DA levels have produced equivocal results. The current meta-analysis provides a quantitative review of the literature on these topics, and analyzes potential moderators of the effects of PCOC exposure on these variables. The results indicate that the effects of PCOC exposure on striatal DA levels, D1 and D2 receptor-binding densities, and D2 receptor-binding affinity are negligible when collapsed over age, sex, species, and several other methodological variables. However, effects of PCOC exposure on some dopaminergic measures were significantly influenced by factors such as age and sex. As expected, and as suggested by the selectivity and specificity of PCOC-induced changes reported in the published literature, the direction and magnitude of differences between genders or age groups in this study were not systematic across all dependent measures. Generally, PCOC exposure was more often linked to decreases, rather than increases, in the selected dependent measures. These findings indicate that PCOC exposure produces selective alterations in striatal dopaminergic system function which do not appear under all experimental circumstances, but which may be important factors in behavioral alterations seen in selected groups after PCOC exposure.

Magnetic resonance contrast enhancement of neovasculature with alpha(v)beta(3)-targeted nanoparticles

Site-directed contrast enhancement of angiogenic vessels in vivo was demonstrated using antibody targeting of an MRI contrast agent to the alpha(v)beta(3) integrin, a molecular marker characteristic of angiogenic endothelium. The agent was tested in a rabbit corneal micropocket model, in which neovasculature is induced in the cornea using basic fibroblast growth factor. The targeted contrast agent consists of Gd-perfluorocarbon nanoparticles linked to alpha(v)beta(3) integrin antibody DM101. The animal group receiving the targeted contrast agent displayed a 25% increase in the average MR signal intensity after 90 min. Control groups in which the nanoparticles are either used alone, linked to an isotype-matched antibody, or linked to DM101 and administered following receptor blocking did not display MR contrast enhancement at similar dose levels. These findings indicate that the antibody-targeted agent enhances MR signal intensity in the capillary bed in a corneal micropocket model of angiogenesis, and is selectively retained within the angiogenic region via specific interaction with the alpha(v)beta(3) epitope.

Radiation doses to members of the public near to Sellafield, Cumbria, from liquid discharges 1952-98

Liquid wastes containing low levels of radioactivity have been discharged to the Irish Sea from the nuclear fuel reprocessing site at Sellafield since operations began in the early 1950s, and monitoring of radioactivity in foodstuffs has been undertaken over many years. Based on the best available monitoring data, supplemented by modelled values where necessary, doses to local critical groups have been reassessed using the most recent dosimetry. Contemporary habits data have been used where available, again supplemented by assumed habits where necessary. During the 1950s and 1960s the highest doses were received by individuals consuming Cumbrian Porphyra as laverbread, and peak doses around 0.8 to 1.0 mSv year(-1) have been estimated. During the 1970s and 1980s the critical exposure group switched to consumers of local fish and shellfish, with peak doses possibly reaching 2.5 to 3.0 mSv year(-1). Latterly, doses to all marine-related groups have declined to less than 150 to 200 microSv year(-1). At all times, doses have been within the appropriate limits set for members of the public.

Epidemic nephritis in Nova Serrana, Brazil

BACKGROUND

Outbreaks of nephritis have been rare since the 1970s. From December, 1997, to July, 1998, 253 cases of acute nephritis were identified in Nova Serrana, Brazil. Seven patients required dialysis, and three patients died. We did a case-control study to investigate the cause of the outbreak.

METHODS

Using a matched cluster design, we examined seven recent patients, their family members (n=23), and members of neighbourhood-matched control households (n=22). We subsequently interviewed 50 patients and 50 matched controls about exposure to various dairy products. We also cultured dairy foods and took udder-swab and milk samples from cows.

FINDINGS

Throat cultures indicated that nephritis was associated with group C Streptococcus equi subspecies zooepidemicus, a cause of bovine mastitis. S. zooepidemicus was detected in four of seven case households (six of 30 people) and no control households (p=0.09). Patients were more likely than matched controls to have consumed a locally produced cheese called queijo fresco (matched odds ratio 2.1, p=0.05). The nephritis attack rate was 4.5 per 1000 in Nova Serrana but 18 per 1000 in the village Quilombo do Gaia (p=0.003). The largest supplier of unpasteurized queijo fresco was a farm in Quilombo do Gaia. S. zooepidemicus was not detected in food samples or in swabs collected from cows in August, 1998, although mastitis was evident among cows on the suspected farm. Throat cultures of the two women who prepared cheese on this farm yielded the outbreak strain of S. zooepidemicus. After the cheese was removed from the distribution system, no further cases were reported.

INTERPRETATION

A large outbreak of glomerulonephritis was attributed to S. zooepidemicus in unpasteurised cheese. This outbreak highlights the dangers of consuming unpasteurized dairy products and need for global efforts to promote food safety.

Prenatal cocaine exposure increases serotonergic inhibition of electrically evoked acetylcholine release from rat striatal slices at adulthood

This study tests the hypothesis that prenatal cocaine (pCOC) exposure (20 mg/kg, bidaily from embryonic days 15-21) modifies 5-HT(3) receptor regulation of electrically-evoked [(3)H]acetylcholine (ACh) overflow from adult male and female (proestrus, diestrus) rat striatal slices. Also, the influence of endogenous dopamine (DA) on serotonin (5-HT) regulation of ACh overflow was determined by assessing the effects alpha-methyl-para-tyrosine (AMPT) pretreatment or sulpiride. Phenylbiguanide (PBG, 5-HT(3) agonist) superfusion dose-dependently inhibited ACh overflow in all groups except the diestrus pCOC group in which there was an enhanced sensitivity to PBG. PBG (10, 30, and 60 microM) produced greater effects in the pCOC male than in the prenatal saline (pSAL) group. The pCOC male group also exhibited greater sensitivity to PBG (30 and 60 microM) than the pCOC proestrus group. PBG inhibition of ACh overflow was comparable in the pSAL male and female (proestrus) groups. PBG inhibition of ACh overflow was greater in the pCOC diestrus group than in the pCOC proestrus (10, 30, and 60 microM), the pSAL diestrus (10 and 30 microM), and the pCOC male (10 microM) conditions. In slices from untreated rats superfused with 30 microM PBG, AMPT pretreatment (68% DA loss) reduced inhibition of ACh overflow, and 1 microM sulpiride increased ACh overflow. ICS205-930 (5-HT(3) antagonist) reduced effectiveness of PBG indicating 5-HT(3) receptor specificity for PBG. In summary, pCOC exposure enhances modulatory effects of 5-HT (via 5-HT(3) receptors) on striatal ACh release in male and females rats and the inhibitory actions of 5-HT(3) receptors are mediated by DA.

Environmental effects of radionuclides--observations on natural ecosystems

To better quantify risk to non-human species from exposure to environmental radioactivity, understanding of the behaviour of radionuclides in the biosphere needs to be increased. This study outlines current thinking on ecological risk assessment (ERA) methodology and applies the indicator species or critical groups approach to biota inhabiting a semi-natural coniferous woodland contaminated with the radionuclides 137Cs, 238Pu, 239+240Pu and 241Am. The majority of these radionuclides originate from routine aerial emissions from the nuclear fuel reprocessing plant at BNFL, Sellafield, Cumbria, UK. Radionuclide activity concentrations have been determined in biota from the woodland and estimates of absorbed dose rates (mGy d(-1)) have been calculated using the dosimetric models outlined. Dose rates to the key indicator species, Oniscus asellus, Carabus violaceous and Apodemus sylvaticus (detritivorous invertebrate, predatory invertebrate and the granivorous wood mouse) have been determined at 3.0 x 10(-3) mGy d(-1), 2.2 x 10(-3) mGy d(-1) and 1.0 x 10(-3) mGy d(-1) respectively. The values are at least three orders of magnitude lower than the 1 mGy d(-1) level below which no observable effects on populations in a terrestrial ecosystem are thought to occur. Limitations of this approach are discussed.

Prenatal cocaine exposure alters behavioral and neurochemical sensitization to amphetamine in adult rats

This study examined the neurochemical correlates of amphetamine (AMPH)-induced behavioral effects in prenatally saline (PSAL)-exposed or cocaine (PCOC)-exposed male rats. Pregnant Long-Evans rats received saline or saline containing cocaine hydrochloride (20 mg/kg s.c., b.i.d.) from gestational days 15-21. Animals were left with their biological mothers. Adult offspring were exposed to daily saline or AMPH (0.5, 1.5, or 5 mg/kg, i.p.) injections for 7 days. Behaviors were recorded in an open field during the first hour post-injection. PCOC rats did not exhibit behavioral anomalies during habituation to injection-stress or placement in the open field. PCOC rats displayed significant alterations in stereotyped responses to acute or intermittent exposure to various doses of AMPH. Within 48 h of the final testing day, striatal tissue was obtained from these animals and electrically-evoked [3H]acetylcholine (ACh) release was measured from striatal slices. Superfusion of tissue slices with various concentrations of AMPH (1-1000 nM) produced dose-dependent inhibition of ACh release in both PSAL and PCOC rats repeatedly injected with saline as adults. However, AMPH-induced inhibition of ACh release was decreased in PCOC rats repeatedly injected with AMPH as adults. At 5 mg/kg AMPH, PCOC rats exhibited increased mortality compared to PSAL rats. These data suggest that PCOC exposure produces long-lasting alterations in nigrostriatal transmission and behaviors mediated by this system.

Health care support workers in the critical care setting

The 1999/2000 winter demands on the NHS have once again highlighted deficits in UK critical care provision (Daily Telegraph, 2000; London Evening Standard, 2000) Recent years have seen the development of the role of health care support workers in the NHS; some critical care units now employ health care support workers This research examined the views of critical care unit staff on the introduction of health care support workers into the critical care unit It is concluded that the role is viable within the setting of this study A framework is outlined that could form the basis for a critical care health care support worker training programme

Health status, perceptions of coping, and social support immediately after discharge of survivors of acute myocardial infarction

BACKGROUND: The period immediately after discharge from the hospital after an acute myocardial infarction is a stressful and vulnerable time about which little is known. OBJECTIVE: To explore health status, perceptions of coping, and social support among survivors of a recent myocardial infarction in the first 3 weeks after discharge from hospitals in southwestern Sydney, Australia. METHODS: A descriptive, exploratory approach with a triangulated methodology was used to assess the experiences of 38 survivors, detect patterns in these experiences, explore the health-support needs of survivors, and determine changes in health status in the first 3 weeks after discharge. Quantitative data were collected with the Medical Outcomes Study SF-36, New York Heart Association classification, Canadian Cardiovascular Society Angina Scale, and the Jalowiec Coping Scale. A semistructured interview schedule provided additional qualitative data about the experiences of the survivors. RESULTS: The health status of participants was relatively stable during the 3-week period; most had no activity limitation due to dyspnea or angina. However, the subjects' health status was considerably lower than that of their age-matched population. The most common and most effective coping strategies adopted during this period were confrontation, optimism, and self-reliance. In addition, the subjects experienced anxiety, depression, ambiguity and uncertainty, fear of recurrence of the infarction and of deterioration in health, of boredom and of inertia. CONCLUSION: These findings can help nurses in hospital and community settings assist survivors of acute myocardial infarction to prepare for and deal effectively with experiences during convalescence.

Health status, perceptions of coping, and social support immediately after discharge of survivors of acute myocardial infarction

BACKGROUND

The period immediately after discharge from the hospital after an acute myocardial infarction is a stressful and vulnerable time about which little is known.

OBJECTIVE

To explore health status, perceptions of coping, and social support among survivors of a recent myocardial infarction in the first 3 weeks after discharge from hospitals in southwestern Sydney, Australia.

METHODS

A descriptive, exploratory approach with a triangulated methodology was used to assess the experiences of 38 survivors, detect patterns in these experiences, explore the health-support needs of survivors, and determine changes in health status in the first 3 weeks after discharge. Quantitative data were collected with the Medical Outcomes Study SF-36, New York Heart Association classification, Canadian Cardiovascular Society Angina Scale, and the Jalowiec Coping Scale. A semistructured interview schedule provided additional qualitative data about the experiences of the survivors.

RESULTS

The health status of participants was relatively stable during the 3-week period; most had no activity limitation due to dyspnea or angina. However, the subjects' health status was considerably lower than that of their age-matched population. The most common and most effective coping strategies adopted during this period were confrontation, optimism, and self-reliance. In addition, the subjects experienced anxiety, depression, ambiguity and uncertainty, fear of recurrence of the infarction and of deterioration in health, of boredom and of inertia.

CONCLUSION

These findings can help nurses in hospital and community settings assist survivors of acute myocardial infarction to prepare for and deal effectively with experiences during convalescence.

Radionuclide behaviour and transport in a coniferous woodland ecosystem: vegetation, invertebrates and wood mice, Apodemus sylvaticus

Activity concentrations of radionuclides (134Cs, 137Cs, 238Pu, 239 + 240Pu and 241Am) were measured in vegetation, invertebrates and wood mice, Apodemus sylvaticus, collected in Lady Wood, a coniferous woodland in the vicinity of the British Nuclear Fuels reprocessing plant at Sellafield, Cumbria, UK. Vegetation was of low diversity and biomass with activity concentrations ranging from 1 to 5 Bq kg-1 (134Cs), 0.3-0.5 Bq kg-1 (238Pu), 0.8-8 Bq kg-1 (239 + 240Pu), and 0.6-16 Bq kg-1 (241Am), dry wt. Caesium-137 activity concentrations were high compared to the reference site in Cheshire, varying between 65 and 280 Bq kg-1. Marked inter-specific and temporal differences in radionuclide activity concentrations were recorded for invertebrate populations. Caesium-137, 238Pu, 239 + 240Pu and 241Am activity concentrations in detritivorous invertebrates were consistently higher than in all other invertebrate groups reflecting contamination of the leaf litter. The activity concentrations in detritivores increased during the autumn and winter, reflecting changes in diet as food sources varied throughout the year. Activity concentrations in invertebrates caught in Lady Wood were generally an order of magnitude higher than for the reference site. Activity concentrations in wood mice varied between 7 and 150 Bq kg-1 (137Cs), 0.1-0.3 Bq kg-1 (238Pu), 0.1-0.6 Bq kg-1 (239 + 240Pu) and 0.2-0.4 Bq kg-1 (241Am). There were clear differences in the activity concentration of 137Cs (P < 0.01), 239 + 240Pu (P < 0.05) and 241Am (P < 0.05) in animals caught in Lady Wood compared to the reference site. However, the activity concentrations for 238Pu were similar at both sites, reflecting a low gastrointestinal transfer. Seasonal variation in activity concentrations was observed for 137Cs, 238Pu and 241Am. This variation is attributed to changes in the age structure of the population and diet throughout the year.