Exploring the use of an alginate dressing for diabetic foot ulcers

Few studies have investigated the use of dressings on patients with diabetic foot ulceration. This paper reports the results of a non-comparative, two-centre study investigating the performance characteristics of SeaSorb dressing in patients with this condition. This was an exploratory study to determine the potential use of this dressing, and not a large randomised control trial. All patients had diabetic foot ulceration of 1 cm or more in diameter, classified as Wagner grade I or II, with an ankle brachial pressure index of > 0.4. The investigators carried out objective assessments including photography and ulcer tracing as well as subjective assessments of exudate levels, wound bed condition, peri-ulcer skin condition, ease of application and removal of the dressing, dressing conformability, discomfort during dressing application and removal, and clinical signs of infection. Investigators recruited 41 patients in two sites (31 in site one and 10 in site two). Of these, the findings relating to 39 patients could be evaluated. The patients were treated for a maximum of six weeks or until the ulcer healed. The study found that 28.2% (11/39) of the ulcers healed within the six-week period. Overall, there was a significant reduction in mean ulcer area from 2.8 cm 2 to 1.02 cm 2 from week 0 to week six. The relative ulcer area showed a significant decrease from 100% to 33%. For patients who experienced ulcer pain (11 patients), its intensity decreased over the six weeks. Severe maceration was not reported for any patient throughout the study. Six patients required treatment for infection. A total of 12 adverse events were reported: seven mild to moderate and five severe. None were directly attributed to the study dressing.

The role of the insulin-like growth factor system in the developing brain

Insulin-like growth factors (IGFs) play a central role in brain growth and development, with IGF-1, its receptors and binding proteins (IGFBPs) being highly expressed, particularly in the olfactory bulb (OB), representing a local paracrine system. A potential role of IGFBPs in transporting and targeting IGFs to their receptors is supported by the finding that abundant IGFBP-2 is associated with cell surface proteoglycans. An OB organ culture system expressing IGF-1 and IGFBPs represents an in vitro injury model. Although IGF-1 is potently antiapoptotic for neurons and oligodendrocytes, marked gliosis and IGFBP-3 expression are seen, similar to in vivo injury responses, where intraventricular injection of IGF-1 postinjury enhances neuronal survival by blocking apoptosis. In contrast, des (1-3) IGF-1, which has low affinity for IGFBPs, is ineffective, supporting a transport or receptor targeting role for local IGFBPs. We conclude that the IGF system plays a crucial cell survival and growth role in the developing and injured brain and that IGFs have significant therapeutic potential.

Council tax valuation band as marker of deprivation and of general practice workload

This study tests the hypothesis that Council Tax Valuation Banding (CTVB) is a measure both of UK socioeconomic status and of general practice workload. It is a retrospective cohort study based in a UK semi-rural general practice, North Wiltshire. The study group is a randomised selection of UK general practice patients. The outcome measures are socio-demographic and primary care workload parameters versus CTVBs by logistic regression analyses in a sample of 378 patients (90% participation rate). People who pay little or no council tax are significantly less likely to live in owner-occupied homes or to have access to a car than their counterparts. There is also a significant inverse association between CTVB and demand for general practitioner services. CTVB could be an accessible, universal, non-census marker of UK socioeconomic status and of general practice workload that would have validity in the context of primary care resource allocation and is a concept worthy of further investigation.

A look to the past, directions for the future

This article represents the history of primary care and behavioral health integration at Group Health Cooperative (GHC) over the last decade, and foreshadows probable futures for this work into the next decade. To build from a logical progression, the article responds to a series of questions: 1. Why integrate primary care and behavioral health? 2. What has been done so far and how well has it worked? 3. Keeping the end in mind, what's the idealized picture of integration for the future? 4. How to get from here to there? What will help or hinder the effort? and 5. Again, why make these efforts to integrate?

Fasting hyperinsulinemia and increased waist-to-hip ratios in non-wasting individuals with AIDS

OBJECTIVE

To identify metabolic and body composition changes associated with HIV-1 infection in a cross-sectional study of individuals stratified by immunologic status and body mass.

DESIGN

Metabolic abnormalities including glucose intolerance and changes in body morphology have recently been described in HIV-1-infected individuals following therapy with protease inhibitor-containing highly active anti-retroviral therapy. Although this is suggestive of a direct drug effect, the possibility that HIV infection may induce a tendency towards such underlying derangements should be considered. HIV-infected patients are heterogeneous with respect to immunologic status and body mass. In examining the underlying effect of HIV-1 on metabolic and body composition parameters, stratification by various immunologic and body mass categories may give divergent results that would not be detected otherwise.

METHODS

Thirty male participants were categorized into four cohorts: non-wasting HIV-seronegative controls, non-wasting HIV-infected patients with relatively intact immune function (CD4 cell count > 500 x 10(6)/l); non-wasting individuals with AIDS (CD4 cell count < 200 x 10(6)/l); and individuals with AIDS wasting.

RESULTS

Increased fasting plasma insulin and waist-to-hip ratios were found specifically in non-wasting individuals with AIDS compared with HIV-negative controls.

CONCLUSIONS

Our study emphasises the importance of both body mass and immune function in studying metabolic and body composition abnormalities associated with HIV-1 infection. The association of increased waist-to-hip ratios and hyperinsulinemia suggestive of insulin resistance in non-wasting individuals with AIDS suggest that the tendency towards these metabolic abnormalities may be related to the HIV infectious process or to factors associated with immunologic dysfunction.

Elevated glutathione biosynthetic capacity in the chloroplasts of transgenic tobacco plants paradoxically causes increased oxidative stress

Glutathione (GSH), a major antioxidant in most aerobic organisms, is perceived to be particularly important in plant chloroplasts because it helps to protect the photosynthetic apparatus from oxidative damage. In transgenic tobacco plants overexpressing a chloroplast-targeted gamma-glutamylcysteine synthetase (gamma-ECS), foliar levels of GSH were raised threefold. Paradoxically, increased GSH biosynthetic capacity in the chloroplast resulted in greatly enhanced oxidative stress, which was manifested as light intensity-dependent chlorosis or necrosis. This phenotype was associated with foliar pools of both GSH and gamma-glutamylcysteine (the immediate precursor to GSH) being in a more oxidized state. Further manipulations of both the content and redox state of the foliar thiol pools were achieved using hybrid transgenic plants with enhanced glutathione synthetase or glutathione reductase activity in addition to elevated levels of gamma-ECS. Given the results of these experiments, we suggest that gamma-ECS-transformed plants suffered continuous oxidative damage caused by a failure of the redox-sensing process in the chloroplast.

Theoretical and experimental investigations of electrostatic effects on acetylcholinesterase catalysis and inhibition

The role of electrostatics in the function of acetylcholinesterase (AChE) has been investigated by both theoretical and experimental approaches. Second-order rate constants (kE = k(cat)/Km) for acetylthiocholine (ATCh) turnover have been measured as a function of ionic strength of the reaction medium for wild-type and mutant AChEs. Also, binding and dissociation rate constants have been measured as a function of ionic strength for the respective charged and neutral transition state analog inhibitors m-(N,N,N-trimethylammonio)trifluoroacetophenone (TMTFA) and m-(t-butyl)trifluoroacetophenone (TBTFA). Linear free-energy correlations between catalytic rate constants and inhibition constants indicate that kE for ATCh turnover is rate limited by terminal binding events. Comparison of binding rate constants for TMTFA and TBTFA attests to the sizable electrostatic discrimination of AChE. Free energy profiles for cationic ligand release from the active sites of wild-type and mutant AChEs have been calculated via a model that utilizes the structure of T. californica AChE, a spherical ligand, and energy terms that account for electrostatic and van der Waals interactions and chemical potential. These calculations indicate that EA and EI complexes are not bound with respect to electrostatic interactions, which obviates the need for a 'back door' for cationic ligand release. Moreover, the computed energy barriers for ligand release give linear free-energy correlations with log(kE) for substrate turnover, which supports the general correctness of the computational model.

Symptom control in patients with hay fever in UK general practice: how well are we doing and is there a need for allergen immunotherapy?

BACKGROUND

Seasonal allergic rhinitis is often regarded as a trivial condition which patients should treat themselves. However, a significant proportion of sufferers are not fully controlled on standard hay fever medication, either because they do not use it properly or because their symptoms are resistant to standard therapy. The latter group may be suitable for allergen immunotherapy, which was once widely available in UK general practice but is now only available through specialist centres.

AIMS

To describe the symptom control of patients with hay fever, to assess concordance with prescribed medication, and to estimate the number of patients who may benefit from referral for allergen immunotherapy.

SETTING

General practices in Hampshire and Dorset, UK.

METHOD

Survey of adult hay fever sufferers prescribed a non-sedating antihistamine and nasal steroid spray by their general practitioner. A postal questionnaire was sent to all eligible patients aged 16-64 registered with 16 general practices. Self-assessment of symptom control and reported compliance with medication were used to identify those patients who were suboptimally controlled and might therefore benefit from immunotherapy.

RESULTS

Eight hundred and forty-six out of 62500 registered patients aged 16-64 (1.4%) were receiving both drugs, and responses were received from 627 (74.1%); 526 of these met the full entry criteria. One hundred and forty-two patients (27.0%) were using both types of drug regularly. Of the 142 patients using optimum pharmacotherapy, 54 (38.0%) reported good control of their hay fever symptoms. The remaining 62.0% experienced troublesome residual symptoms and described symptom control as partial or poor. Among those using suboptimal pharmacotherapy, 181/376 (48.1%) reported good control.

CONCLUSION

Many patients are using treatment inappropriately. Current guidelines need to be applied better but there is also a significant burden of residual symptoms, even among those receiving current optimal therapy. This indicates a need for patients with severe summer hay fever to receive specialist assessment.

Andersen's syndrome: a distinct periodic paralysis

A previous study of 4 patients defined Andersen's syndrome (AS) as a triad of potassium-sensitive periodic paralysis, ventricular dysrhythmias, and dysmorphic features. AS appears to be distinct in terms of its genetic defect from the alpha-subunit of skeletal muscle sodium channel and the cardiac potassium channel responsible for most long QT syndromes (LQT1). We studied 11 additional patients with AS from 5 kindreds. Spontaneous attacks of paralysis were associated with hypokalemia, normokalemia, or hyperkalemia. All 11 patients had similar dysmorphic features. The QT interval was prolonged in all patients although only 4 were symptomatic. Genetic linkage studies excluded linkage to the alpha-subunit of the skeletal muscle sodium channel and to four distinct LQT loci. In addition, none of the common dihydropyridine receptor mutations responsible for hypokalemic periodic paralysis were present. We conclude that (1) AS is a genetically unique channelopathy affecting both cardiac and skeletal membrane excitability, (2) attacks of paralysis may be either hypokalemic or hyperkalemic, (3) a prolonged QT interval is an integral feature of this syndrome, and (4) a prolonged QT interval may be the only sign in an individual from an otherwise typical AS kindred. This may be confused with more common, potentially lethal LQT syndromes.

MR imaging of dedifferentiated chondrosarcoma

MR imaging of a dedifferentiated chondrosarcoma of the humerus is presented and correlated with gross and microscopic histology from the surgical specimen. The classification of chondrosarcoma and specific MR signal characteristics that suggest dedifferentiation are discussed.

Molecular recognition by cholesterol esterase of active site ligands: structure-reactivity effects for inhibition by aryl carbamates and subsequent carbamylenzyme turnover

Interactions of mammalian pancreatic cholesterol esterases from pig and rat with a family of aryl carbamates CnH2n+1NHCOOAr [n = 4-9; Ar = phenyl, p-X-phenyl (X = acetamido, bromo, fluoro, nitro, trifluoromethyl), 2-naphthyl, 2-tetrahydronaphthyl, estronyl] have been investigated, with an aim of delineating the ligand structural features which lead to effective molecular recognition by the active site of the enzyme. These carbamates inhibit the catalytic activity of CEase by rapid carbamylation of the active site, a process that shows saturation kinetics. Subsequent slow decarbamylation usually leads to full restoration of activity, and therefore aryl carbamates are transient inhibitors, or pseudo-substrates, of CEase. Structural variation of carbamate inhibitors allowed molecular recognition in the fatty acid binding and steroid binding loci of the extended active site to be probed, and the electronic nature of the carbamylation transition state to be characterized. Optimal inhibitory activity is observed when the length of the carbamyl function is n = 6 and n = 7 for porcine and rat cholesterol esterases, respectively, equivalent to eight- and nine-carbon fatty acyl chains. In contrast, inhibitory activity increases progressively as the partial molecular volume of the aromatic fragment increases. Hammett plots for p-substituted phenyl-N-hexyl carbamates indicate that the rate-determining step for carbamate inhibition is phenolate anion expulsion. Effects of the bile salt activator taurocholate on the kinetically resolved phases of the pseudo-substrate turnover of aryl carbamates were also studied. Taurocholate increases the affinity of the carbamate for the active site of cholesterol esterase in the reversible, noncovalent complex that precedes carbamylation and increases the rate constants of the serial carbamylation and decarbamylation steps. Structural variation of the N-alkyl chain and of the aryl fused-ring system provides an accounting of bile salt modulation of the fatty acid and steroid binding sites, respectively. In that pseudo-substrate turnover of aryl carbamates proceeds by a three-step mechanism that is analogous to that for rapid turnover of lipid ester substrates, these investigations illuminate details of ligand recognition by the extended active site of cholesterol esterase that are prominent determinants of the substrate specificity and catalytic power of the enzyme.

Resolution of the neutropenia of Felty's syndrome by longterm administration of recombinant granulocyte colony stimulating factor

Felty's syndrome is characterized by neutropenia, splenomegaly, and recurrent infection in patients with rheumatoid arthritis. We used recombinant granulocyte colony stimulating factor (rGCSF) in a patient with Felty's syndrome and recurrent sepsis. rGCSF induced a statistically significant increase in the patient's absolute neutrophil and total white blood cell counts. During 14 months of followup taking rGCSF, disseminated varicella zoster was the only infectious complication. Except mild thrombocytopenia and a transient flare of arthritis, no serious adverse effects occurred. rGCSF may be a safe and effective therapy for Felty's syndrome in selected patients.