Thrombophlebitis diagnosed on indium-111 labelled white cell scan

A 64-year-old lady with type 2 diabetes and a non-resolving right foot ulcer, had an indium-111 labelled white cell scan (indium-111 WCS) to investigate the possibility of underlying osteitis. The scan suggested the possibility of infective thrombophlebitis. Unknown to the clinical team who requested the scan and the radiologist who performed it, the lady was admitted to hospital 2 days following the procedure with cellulitis and septic thrombophlebitis in the right leg. There is only one previous report in the literature of septic thrombophlebitis being diagnosed in this way. Perhaps indium-111 WCS has something to offer in the diagnosis of this condition and in determining those who require antibiotic treatment.

Evidence for affluence-related hypertension in urban Brazil

Cardiovascular diseases are a leading cause of mortality, and systemic hypertension is a major risk factor. There is an increasing prevalence of hypertension in urban areas of developing countries, due to lifestyle changes associated with economic transition and urbanisation. This study aimed to describe the prevalence and identify risk factors for hypertension in an urban area of South America (Coroa do Meio district in Aracaju, Sergipe State, north-east Brazil) and to examine intraurban hypertension prevalence differences. A cross-sectional survey of 400 adults aged 25 years and over was carried out. Information about health and lifestyle was obtained from a structured interview, followed by assessment of blood pressure (BP) and anthropometry. There were 31.8% (95% confidence interval 27.3-36.6%) participants with hypertension (defined as a systolic BP >140, diastolic BP >90 mmHg, or on antihypertensive medication). Hypertension was independently associated with older age, central obesity (greater waist-to-hip ratio), shorter height and residing in a high socio-economic residential area. Of the four neighbouring areas, hypertension prevalence was 52% in the area of highest income and education, compared with 19, 24 and 34% in the other three areas. The high prevalence of hypertension in this population, and the strong independent association with relative affluence, demonstrates the need for effective primary prevention of hypertension, targeted at modifiable risk factors.

Influence of chlorsulfuron on rhizobial growth, nodule formation, and nitrogen fixation with chickpea

Sulfonylurea residues have been found to inhibit the growth of some legume crops and pastures in seasons following application. Negative effects of these herbicides on symbiotic nitrogen fixation by legume crops and pastures have been demonstrated. Reductions in nitrogen fixation may result from a direct effect of the herbicide on rhizobial growth and/or an indirect effect on plant growth. In this study the influence of chlorsulfuron on the growth of chickpea rhizobia [Mesorhizobium ciceri (CC1192)], the growth of chickpea plants, and the extent of nodulation and nitrogen fixation by the chickpea/rhizobia symbiosis were examined. In vitro studies (in yeast mannitol broth and a defined medium) showed that chlorsulfuron applied at double the recommended field application rate did not influence the growth of chickpea rhizobia. An experiment using 14C-labelled chlorsulfuron was conducted to determine if rhizobial cells exposed to chlorsulfuron could deliver the herbicide to the point of root infection and nodule formation. Approximately 1% of the herbicide present in the rhizobial growth medium remained with the cell/inoculum material after rinsing with 1/4 strength Ringer’s solution. This was considered unlikely to affect chickpea growth, nodulation, or nitrogen fixation. A pot experiment was used to define the influence of chlorsulfuron on the growth, nodulation, and nitrogen fixation of chickpeas. The presence of chlorsulfuron in the soil reduced the nodulation and nitrogen fixation of the chickpea plants. Pre-exposing rhizobia to chlorsulfuron before inoculating them into pots with germinating chickpea seeds, reduced the number of nodules formed by 51%. Exposure of chickpeas and chickpea rhizobia to chlorsulfuron can adversely affect the formation and activity of symbiotic nitrogen-fixing nodules, even when only the rhizobial inoculant is exposed briefly to the herbicide.

Patients' perspectives on diabetes health care education

Living with Type 2 diabetes requires that patients develop a range of competencies that allow them to take greater control over the treatment of their disease. This requires education that promotes health whilst respecting individuals' self-perceived needs and voluntary choices. Whilst such a concept is not new in the field of diabetes, health professionals are still struggling with how to administer it successfully. This paper presents the findings of a research trial of a theoretically constructed educational intervention. It focuses on the patients' perspectives of what they valued about the intervention which was found to be clinically effective over a short-term period only. Limitations to maintaining effects were associated with a number of factors. The study found that whilst patients can be educated toward greater autonomy, not all health professionals are ready to work in partnership with them. It highlighted the importance of clinical staff not only gaining a better understanding of diabetes management, but also of the theoretical principles underlying patient empowerment. This paper outlines these principles and shows how they were synthesized to produce a framework for informing practice. Patients' views are utilized to provide guidelines for improving the outcomes of patient education.

Adverse pulmonary vascular effects of high dose tricyclic antidepressants: acute and chronic animal studies

Overdose of tricyclic antidepressants, which inhibit cellular serotonin (5-HT) uptake, sometimes causes acute respiratory syndrome-like symptoms. Their acute and chronic cardiopulmonary actions, which might be implicated, utilising both in vivo and ex vivo animal studies, were investigated in this study. Acute amitriptyline (AMI), iprindole and imipramine caused dose-dependent prolonged rises in pulmonary artery pressure and oedema in anaesthetised cats in vivo. Acute AMI, in isolated ex vivo blood-perfused rat lungs, also caused dose-dependent sustained vasoconstriction, which could be attenuated with either calcium channel inhibition or a nitric oxide donor. It was demonstrated that the pressor effects of AMI were not due to release of histamine, serotonin, noradrenaline, or the activities of cycloxygenase or lipoxygenase. After AMI, hypoxic pulmonary vasoconstriction and the pressor actions of 5-HT and noradrenaline were diminished, possibly due to uptake inhibition. Activities of the endothelial-based enzymes, nitric oxide synthase and endothelin-converting enzyme, were undiminished. Large acute doses of AMI caused oedema with rupture of capillaries and alveolar epithelium. Chronic iprindole raised pulmonary artery pressure and right ventricle (RV)/left ventricle (LV) + septal (S) weight. Chronic AMI led to attenuation of the pressor action of 5-HT, especially when associated with chronic hypoxic-induced pulmonary hypertension. RV/LV+S weight increased, attributable to LV decline. The acute and chronic effects observed might have relevance to clinical overdose, while the attenuation of acute effects offers possible therapeutic options.

Insulin-treated diabetes and driving in the UK

Diabetes, and particularly insulin-treated diabetes, has important implications for motor vehicle driving, largely because of its association with potential hypoglycaemia. For this reason, most countries operate some driving restrictions on insulin-treated diabetic patients, as well as systems of intermittent reassessment of hypoglycaemic risk. In the UK, regulations are operated by the Driver and Vehicle Licensing Agency (DVLA), which is an agency of the Department of the Environment, Transport and the Regions (DETR). They are supported by an Expert Panel which advises the Secretary of State on diabetes-related issues relating to fitness to drive. The patient organization Diabetes UK is also concerned with diabetes and driving issues, largely from a position of lobbying policy-influencers and supporting individual cases. All parties involved with diabetes and driving issues recognize the need for more research on the subject, as the current literature is flawed in design, though no convincing excess of accidents amongst diabetic drivers has been conclusively demonstrated. Currently in the UK, Class 2 vehicles (large trucks and passenger vehicles) are barred to diabetic drivers on insulin. European law has recently extended this to so-called C1 (large vans and small lorries) and D1 (minibuses) vehicles, though the law has recently been revised to allow individual consideration for potential diabetic C1 drivers on insulin treatment. Diabetes and insulin-treated diabetes is an emotive and difficult issue, for which a stronger evidence base is urgently needed.

Regulation of the initiation of eukaryotic transcription

DNA sequences that determine transcriptional regulation of a typical eukaryotic gene consist of a core promoter, which serves as a binding site for the GTF TFIID, and regulatory promoter or enhancer sequences, which bind transcriptional activators. The RNA polymerase II transcription machinery consists of over 50 proteins which are thought to bind to the core promoter in as few as two steps: binding of TFIIA-TFIID, followed by binding of a large pre-assembled holoenzyme complex consisting of the remaining GTFs, RNA polymerase II and associated regulatory proteins. Activators function to increase binding of the transcription machinery to the promoter in at least two ways: (i) simple protein-protein interactions with activators increases the affinity of the transcription machinery for the promoter, and (ii) some activators stabilize a conformation of the TFIIA-TFIID-DNA complex that enhances binding of the holoenzyme. Recent studies have identified many co-activators that function with activators to increase transcription by the RNA polymerase II transcription machinery. Although some co-activators may serve as bridges to connect activators with the transcription machinery, the mechanism of action of many co-activators has not yet been determined.

Plexiform neurofibroma of the submandibular salivary gland in a child

Plexiform neurofibromas in major salivary glands are rarely described. In the literature, most reported tumours have been present in the parotid gland region. A three-year-old boy with a family history of neurofibromatosis presented with a rapidly growing left submandibular mass. The clinical diagnosis was that of a neurofibroma rather than a primary salivary gland tumour. Resection of the lesion revealed a plexiform neurofibroma involving the submandibular gland. Although these tumours have a neurogenic rather than a salivary gland origin, they must be considered in the differential diagnosis of a salivary gland lesion in a patient with a history of neurofibromatosis.

Pulmonary oxygen consumption: a hypothesis to explain the increase in oxygen consumption of low birth weight infants with lung disease

OBJECTIVE

We determined pulmonary oxygen consumption (VO2lung) in low-birthweight infants with acute lung disease to help explain the greater whole-body oxygen consumption (VO2wb) in these infants with than in those without lung disease.

METHODS AND MATERIALS

Eleven infants (birth weight 1,076+/-364 g; gestational age 28+/-3 weeks) undergoing mechanical ventilation for respiratory distress syndrome were studied in their first week of life. We measured VO2wb by indirect calorimetry and simultaneously determined systemic oxygen uptake (VO2Fick) as the product of cardiac output (echocardiography) and the arterial-mixed venous oxygen content difference (cooximetry) assuming that VO2wb-VO2Fick accounts for VO2lung. Right atrial blood samples were used to determine mixed venous oxygenation, and infants were excluded if samples returned saturations greater than 89%.

RESULTS

VO2lung was 1.92+/-1.74 ml x kg(-1) x min(-1), representing 25% of their VO2wb (7.58+/-1.48 ml x kg(-1) x min(-1)). VO2lung was not correlated with clinical measures of acute disease severity. However, infants with the most severe changes on follow-up radiography (Edwards score 5 as assessed by radiologist blinded for VO2 data) all had a VO2lung level greater than 2.0 ml x kg(-1) x min(-1).

CONCLUSION

VO2lung can account for the elevated metabolic rate in low-birthweight infants with lung injury. We speculate that this reflects in part inflammatory pulmonary processes and may herald chronic lung disease.

Death signals changes in TFIID

In this issue of Molecular Cell, Bell et al. identify an isoform of hTAF(II)80 that is induced in response to several proapoptotic stimuli. The finding that extracellular signals can lead to changes in the subunit composition of TFIID provides an example of how regulated activity of the general transcription factors may contribute to inducible programs of gene expression.

Regulation of cytokine-independent survival kinase (CISK) by the Phox homology domain and phosphoinositides

PKB/Akt and serum and glucocorticoid-regulated kinase (SGK) family kinases are important downstream targets of phosphatidylinositol 3 (PI-3) kinase and have been shown to mediate a variety of cellular processes, including cell growth and survival. Although regulation of Akt can be achieved through several mechanisms, including its phosphoinositide-binding Pleckstrin homology (PH) domain, how SGK kinases are targeted and regulated remains to be elucidated. Unlike Akt, cytokine-independent survival kinase (CISK)/SGK3 contains a Phox homology (PX) domain. PX domains have been implicated in several cellular events involving membrane trafficking. However, their precise function remains unknown. We demonstrate here that the PX domain of CISK interacts with phosphatidylinositol (PtdIns)(3,5)P2, PtdIns(3,4,5)P3, and to a lesser extent PtdIns(4,5)P2. The CISK PX domain is required for targeting CISK to the endosomal compartment. Mutation in the PX domain that abolished its phospholipid binding ability not only disrupted CISK localization, but also resulted in a decrease in CISK activity in vivo. These results suggest that the PX domain regulates CISK localization and function through its direct interaction with phosphoinositides. Therefore, CISK and Akt have evolved to utilize different lipid binding domains to accomplish a similar mechanism of activation in response to PI-3 kinase signaling.

Chronic disease patient education: lessons from meta-analyses

Twelve meta-analyses were identified concerning education for people with chronic diseases where behaviour modification is a part of the treatment regime. By combining the results of these meta-analyses a second stage descriptive meta-analysis was conducted. The aim of the exercise was to explore the effects of patient education and implications for educational treatment. The results provided evidence of the gaps that exist in current research practice. These gaps include the need to utilise rigorous research designs to explore the quantitative effects of patient education, and the need to qualitatively explore the processes by which these effects have transpired. Where randomised controlled trials had been conducted the effects of patient education were usually small and were only known for 6 months of follow-up. In addition, the educational interventions tested were generally poorly described, and failed to adhere to theoretical models. The results of this review have highlighted the need for practitioners to use theoretically based teaching strategies which include behaviour change tactics that affect feelings and attitudes. In alignment with these conclusions, the review has provided guidelines for future research practice.

Use of heparin in the investigation of obscure gastrointestinal bleeding

OBJECTIVE

To determine if the administration of heparin improves the predictive value of angiography in the investigation of obscure gastrointestinal (GI) bleeding.

METHODS

18 patients with a history of chronic GI bleeding were investigated with angiography. For 6 patients, the cause of GI bleeding was established with angiography; the 12 patients who had negative results were given heparin for 24 h and were reassessed with angiography.

RESULTS

After heparin administration, the source of GI bleeding was determined with angiography for 6 of the remaining 12 patients. Thus, heparinization increased diagnostic yield from 33% (6 of 18) to 67% (12 of 18). No significant complications, such as uncontrolled GI bleeding, occurred.

CONCLUSION

Heparinization improves the diagnostic yield of angiography when obscure GI bleeding is being investigated.

Fear and frustration--the Liverpool cholera riots of 1832

Public mistrust in the medical profession is not new. We describe a series of street riots that took place in the city of Liverpool in north-west England in 1832 during a cholera epidemic. The disturbances were directed primarily against the local medical fraternity. The episode is of interest, since the same city recently experienced a similar crisis of confidence between doctors and public. On this occasion the cause was not cholera, but rather the reports from Alder Hey Children's Hospital that organ parts from deceased infants undergoing necropsy had been kept for several years without parental consent.

Trends in the smoking habits of young adults with diabetes

OBJECTIVES

To examine changes in the prevalence of smoking in young adult diabetic patients between 1990 and 1999.

SETTING

Walton Diabetes Centre, University Hospital Aintree, Liverpool, UK.

DESIGN

Direct questioning as well as the urinary cotinine:creatinine ratio were used to assess the smoking habits of 99 young type 1 diabetic patients in 1991 (mean age 21.5 years, duration of diabetes 7.3 years), and in 112 similar patients in 1999 (mean age 23.4 years, duration of diabetes 9.6 years).

RESULTS

The admitted smoking rate was 31/99 (31%) in 1990 compared with 31/112 (28%) in 1999 (not significant). However, in 1990 there were an additional 17 "covert" smokers (patients who denied smoking, but had an unequivocally raised urinary cotinine:creatinine ratio), but only three in 1999 (p<0.05). This gave a corrected validated smoking rate of 48/99 (48%) in 1990 and 34/112 (30%) in 1999, representing a significant fall (p<0.02).

CONCLUSION

Smoking rates in young type 1 diabetic patients appear to have fallen during the last decade, and reporting of smoking behaviour is now more honest.

Going Dutch? How to make clinical guidelines work: an innovative report from Holland

This article describes the findings of a recent Dutch enquiry on the translation of modern medical evidence and research into good clinical practice. There is a huge current increase in 'clinical guidelines' for many diseases, but even when reasonably evidence-based, there is little evidence that they positively affect clinical practice and patient care to any great extent. Educational and management issues are as important as the quality of the clinical advice. Patient acceptance factors also need to be considered.

Conserved regions of the Drosophila erect wing protein contribute both positively and negatively to transcriptional activity

Genetic studies of the Drosophila erect wing (ewg) gene have revealed that ewg has an essential function in the embryonic nervous system and is required for the specification of certain muscle cells. We have found that EWG is a site-specific transcriptional activator, and we report here that evolutionarily conserved regions of EWG contribute both positively and negatively to transcriptional activity. Using gel mobility shift assays, we have shown that an EWG dimer binds specifically to DNA. In transfection assays, EWG activated expression of a reporter gene bearing specific binding sites. Analysis of deletion mutants and fusions of EWG to the Gal4 DNA binding domain has identified a transcriptional activation domain in the C terminus of EWG. Deletion analysis also revealed a novel inhibitory region in the N terminus of EWG. Strikingly, both the activation domain and the inhibitory region are conserved in EWG homologs including human nuclear respiratory factor 1 (NRF-1) and the sea urchin P3A2 protein. The strong conservation of elements that determine transcriptional activity suggests that the EWG, NRF-1, and P3A2 family of proteins shares common mechanisms of action and has maintained common functions across evolution.

Normal medical practice of referring patients for complementary therapies among Australian general practitioners

OBJECTIVES

Assessing the extent to which general practitioners (GPs) accept complementary therapies as normal medical practice.

DESIGN

An examination of two Australian surveys of GPs undertaken in Tasmania and Victoria in 1997.

OUTCOME MEASURES

Type of referral (to doctors or non-medical therapists) and therapy. Levels of acceptance. Basis for judgement of acceptability.

RESULTS

In Tasmania 66% of GPs referred patients to doctors - primarily for acupuncture and hypnotherapy. Fifty-five per cent referred patients to non-medical practitioners - primarily for chiropractic, massage and osteopathy. In Victoria the rate of referral was 93%. Most GPs accepted acupuncture as a normal, but not orthodox, therapy. There are varying levels of acceptance of other complementary therapies and GPs judge by assessing safety and therapeutic value.

CONCLUSION

Some complementary therapies are clearly part of normal, if not orthodox, practice in Australia. Discussion of complementary therapies in medicine must consider the differential levels of acceptance of different therapies.

Daily physical activity program increases bone mineralization and growth in preterm very low birth weight infants

OBJECTIVE

A study of daily physical activity was performed with 32 preterm infants to evaluate changes in body weight and bone mineralization.

STUDY DESIGN

Subjects were matched by birth weight and gestational age and randomly assigned to the physical activity (PA; n = 16) or to the control (C; n = 16) program. PA consisted of range of motion against passive resistance to all extremities for 5 to 10 minutes daily. Peripheral dual-energy x-ray of the right forearm (ulna and radius); biomarkers of bone formation (serum type I collagen C-terminal propeptide [PICP]) and resorption (urine pyridinoline cross-links of collagen [Pyd]); serum calcium, phosphate, alkaline phosphatase, parathyroid hormone (PTH), and 1, 25-(OH)(2) vitamin D; and urine levels of calcium, phosphate, and creatinine were obtained. All measurements were made at study entry and at 2.0 kg of body weight.

RESULTS

Despite a similar nutrient intake at advised levels for preterm infants, gains in body weight (g) and forearm bone length (cm), bone area (BA; cm(2)), bone mineral content (BMC; mg), and fat-free mass (g) were greater in PA infants. Forearm bone mineral density and fat mass gains did not differ between groups. Serum PICP levels remained constant in PA infants but decreased in C infants suggesting a slower rate of bone formation. Urine Pyd or bone resorption activity was similar between groups. A higher level of serum PTH was observed in PA infants at 2. 0 kg of body weight; however, the change from study entry to completion did not differ between groups. All other serum and urine values were similar and within normal limits.

CONCLUSION

A daily PA program promotes greater gains in body weight, forearm length, BA, BMC, and fat-free mass in premature infants.

General practitioners' attitudes toward complementary therapies

Attitudes toward complementary therapies were elicited from a postal survey of all identified general practitioners in the state of Tasmania, Australia. Regression analysis of the data indicated that demographic features associated with favourable attitudes were younger age and location in small or single practices. Personal experiences of such therapies or patient endorsement of them were also associated with favourable attitudes. Those who saw the holistic orientation of complementary medicine as an advantage were likely to hold favourable attitudes. Those who saw the cure rate of complementary therapies as problematic and/or had personal knowledge of the harmful effects of such therapies were less likely to have favourable attitudes.