The evolution of the doctrine of consent

The doctrine of informed consent is evolving. It has taken different routes in different jurisdictions. However, these different paths are converging to a general consensus. The Bolam test, which has been the primary exposition of this doctrine in this country, sets the standard of care as a matter of medical judgement. However, recent cases, particularly Rogers v Whitaker, shift the perspective in favour of warning the patient of material risks inherent to proposed treatment. Whether this information is sufficient to give consent is not a question the answer to which depends upon standards of medical practice. There is no doubt that this is the evolving global trend. Whilst this might seem more onerous the doctrine is of constructive use in securing public awareness in organ donation and in the effectiveness of public health policies.

Histone deacetylases and cancer: causes and therapies

Together, histone acetyltransferases and histone deacetylases (HDACs) determine the acetylation status of histones. This acetylation affects the regulation of gene expression, and inhibitors of HDACs have been found to cause growth arrest, differentiation and/or apoptosis of many tumours cells by altering the transcription of a small number of genes. HDAC inhibitors are proving to be an exciting therapeutic approach to cancer, but how do they exert this effect?

Intramuscular fluid collections and their association with longitudinal rotator cuff tears

This study draws attention to the association between intramuscular fluid collections occurring at the myo-tendinous junction of the rotator cuff secondary to longitudinal tears of their tendons.

Exercise and the heart: risks, benefits, and recommendations for providing exercise prescriptions

Considerable research from the Ochsner Heart and Vascular Institute has focused on the effects of exercise training in patients with coronary heart disease. In this review, the authors discuss the risks and benefits of exercise training in general patients, as well as those with known vascular disease, and provide suggestions for exercise prescriptions for these patients, including modes of exercise and intensity, duration, and frequency of exercise sessions.

Production and characterization of an antiserum which recognizes the native receptor for thyrotropin-releasing hormone

Despite attempts in several laboratories, it has been difficult to prepare antiserum to the thyrotropin-releasing hormone receptor (TRHR). We have prepared a polyclonal anti-rat TRHR antiserum by immunization of rabbits with a synthetic peptide corresponding to the C-terminus of the TRHR. The specificity of the antiserum was assessed by enzyme-linked immunosorbent assay. The affinity-purified antibody recognized a major broad band at 50-60 kDa and a minor broad band at 100-120 kDa in Western blot analysis of membrane proteins from TRHR-transfected, but not control, HEK293t cells. Binding to both bands was abolished by preincubation with the immunizing peptide but not control peptide. The approach was repeated with rat pituitary F4C1 cells, which lack endogenous TRHRs; membranes from F4C1 cells transfected with TRHR cDNA, but not control cells, showed specific binding by Western blot. Using laser confocal microscopy, the TRHR was visualized on the plasma membrane of transfected, but not control, F4C1 cells. Similar confocal findings were observed in TRHR-transfected HEK293t cells. Within 5 min after TRH addition, the TRHR signal translocated from the plasma membrane to the cytoplasm of F4C1 cells transfected with TRHR cDNA. Ten minutes after TRH addition, the TRHR signal formed aggregates in the cytoplasm. Thirty minutes after TRH treatment, both cytoplasmic and plasma membrane localizations were observed, suggesting recycling of some TRHRs back to the plasma membrane. These observations are consistent with our previous findings using an epitope-tagged TRHR. In conclusion, we have prepared an antiserum that recognizes the native TRHR by Western blot analysis and confocal microscopy.

Disclosure of HIV diagnosis to children: when, where, why, and how

Despite recent recommendations by the American Academy of Pediatrics that strongly encourage disclosure of human immunodeficiency virus (HIV) infection to school-age children, health care providers vary widely in their actual disclosure practices. Concrete guidelines for accomplishing disclosure are not currently available. Nondisclosure can result in a variety of problems, including anxiety, depression, phobias, and exclusion from peer support groups and medical camps. This article reviews the available literature on disclosure of HIV infection to children and describes the disclosure process used in a large, urban pediatric HIV clinic.

Ependymoma of the neurohypophysis

There are two reported cases of ependymomas arising in the pituitary fossa; one in a human, the other in a horse. Both died during their stay in hospital. The case presented here is the first published case of a patient who is well 3 months after surgery.

Safety, efficacy and acceptability of a new power toothbrush: a 3-month comparative clinical investigation

PURPOSE

To compare the safety and efficacy of a new power toothbrush (Braun Oral-B D17) with an ADA reference manual toothbrush.

MATERIALS AND METHODS

110 healthy subjects, 18-65 yrs of age, with a mean plaque index of > or = 1.80 and a gingival index of > or = 1.00, were enrolled in this 3-month, randomized, parallel-group, examiner-blind study. Oral soft and hard tissues were examined for safety, and plaque, gingivitis and bleeding were measured to evaluate efficacy. Measurements were made at baseline and after 1 and 3 months of product use. Following the baseline visit and randomization, subjects were instructed to brush twice daily for 2 mins with their assigned brush.

RESULTS

101 subjects completed the study with evaluable data for all time periods, 52 in the D17 group and 49 in the manual group. None of the nine withdrawals from the study were related to product use and no product-related adverse effects were reported. There was no clinically significant soft or hard tissue abrasion observed at any time point in either group. After 1 and 3 months, significant reductions from baseline in whole mouth and interproximal plaque, gingivitis and bleeding were observed in both groups. A comparison of the two groups revealed that the whole mouth and approximal plaque indices were reduced to a significantly greater extent in the D17 group after both 1 and 3 months. The whole mouth gingival index was also reduced to a greater extent in the D17 group at 1 and 3 months, but a difference in the approximal gingival index was only apparent after 3 months. With respect to the bleeding index, there was a significant difference between the two groups for the whole mouth at both 1 and 3 months, but the differences in favor of the D17 for approximal values did not achieve statistical significance. In conclusion, the D17 was found to be safe and had increased efficacy with respect to reduction of plaque and gingivitis, compared with a manual toothbrush.

Use of a non-penetrating staple device for spinal dural closure

Closure of the spinal dura by suture can be technically demanding and a watertight closure is rarely achieved. A method of dural closure using non-penetrating staples is described which permits rapid watertight closure of the dura even in confined spaces.

Acute neurologic deterioration following lumbar puncture in an epidural abscess occurring 14 months after epidural catheter placement

We report the case of a 19-year-old girl admitted to the hospital with a 2-month history of back pain and a 1-week history of severe weakness, who underwent a diagnostic lumbar puncture which was swiftly followed by acute neurologic deterioration requiring ventilation. She was subsequently shown to have an epidural abscess extending from the second cervical to the fifth lumbar vertebrae. She had received uneventful epidural analgesia for childbirth 14 months previously. The case is unusual in both the acute deterioration following lumbar puncture, and also in the length of time from epidural siting to abscess formation, if this were indeed the source of the infection.

Ruptured spinal arteriovenous malformation causing cauda equina syndrome: case report

We describe the case of an acute cauda equina syndrome secondary to a confined subarachnoid bleed from a spinal arteriovenous malformation. The patient was elderly and made a complete neurological recovery following surgery.

Impact of heterogeneity within cultured cells on bacterial invasion: analysis of Pseudomonas aeruginosa and Salmonella enterica serovar typhi entry into MDCK cells by using a green fluorescent protein-labelled cystic fibrosis transmembrane conductance regulator receptor

The cystic fibrosis transmembrane conductance regulator (CFTR) is a chloride ion channel that also serves as a receptor for entry of Pseudomonas aeruginosa and Salmonella enterica serovar Typhi into epithelial cells. To evaluate heterogeneity in CFTR protein expression in cultured cells and the effect of heterogeneity on internalization of different P. aeruginosa and serovar Typhi strains, we used two-color flow cytometry and confocal laser microscopy to study bacterial uptake by Madin-Darby canine kidney (MDCK) type I epithelial cells stably expressing a green fluorescent protein (GFP)-CFTR fusion construct (MDCK-GFP-CFTR cells). We found a strong correlation between cell size and GFP-CFTR protein expression, with 60 to 70% of cells expressing low levels of GFP-CFTR protein, 20 to 30% expressing intermediate levels, and <10% expressing high levels. The cells were sorted into low-, intermediate-, or high-level producers of CFTR protein; in vitro growth of each sorted population yielded the same distribution of CFTR protein expression as that in the original population. Cells expressing either low or high levels of CFTR protein internalized bacteria poorly; maximal bacterial uptake occurred in the cells expressing intermediate levels of CFTR protein. Treatment of MDCK cells with sodium butyrate markedly enhanced the production of CFTR protein without increasing cell size; butyrate treatment also increased the proportion of cells with internalized bacteria. However, there were fewer bacteria per butyrate-treated cell and, for P. aeruginosa, there was an overall decrease in the total level of bacterial uptake. The most highly ingested bacterial strains were internalized by fewer total MDCK-GFP-CFTR cells, indicating preferential bacterial uptake by a minority of epithelial cells within a given culture. Confocal fluorescence microscopy showed that P. aeruginosa and serovar Typhi induced cytoplasmic accumulation of CFTR protein close to the plasma membrane where the bacteria were adherent. These results show that within a population of MDCK-GFP-CFTR cells, there are cells with markedly different abilities to ingest bacteria via CFTR, the majority of the P. aeruginosa and serovar Typhi cells are ingested by the one-fourth to one-third of the cells that exhibit an intermediate size and level of CFTR protein expression, and overexpression of the CFTR receptor does not increase total bacterial uptake but rather allows more epithelial cells to ingest fewer total bacteria.

Aetiology and outcome in 53 cases of native valve staphylococcal endocarditis

Within the last 30 years the profile of infective endocarditis has altered considerably with regard to microbiological causation, clinical features, and natural history. A contributory factor has undoubtedly been the development of potent antibiotics and their sometimes indiscriminate use. The increase in intravenous drug abuse in urban centres, the use of immunosuppressive agents, and the use of prosthetic heart valves have also all contributed. Although cardiac surgery in the uninfected heart provides a perfect environment for infective endocarditis, the improved design of prosthetic valves and the enhanced long-term survival and decreased immediate operative risk, means that surgery is viewed as the best option in many cases. In a series of 53 cases of staphylococcal endocarditis from a national endocarditis survey, those risk factors which influenced outcome were analysed. Thirty out of 53 patients had predisposing heart disease. Mortality was 39.6%. Statistical analysis revealed that attributable mortality was significantly associated with skin infection, systemic embolisation, and inappropriate therapy. Interestingly, surgical treatment was associated with better outcome.

Meningioma recurrence at a different site masquerading as a subdural hematoma. Case report

It is unusual for a meningioma to recur at a distant site. It is more unusual for a meningioma to present as a subdural hematoma. The authors report a unique case in which both of these events occurred in the same patient during a 4-year period. The authors discuss the pathogenesis of these rare events with regard to meningiomas.

Statin prescribing in Nottingham general practices: a cross-sectional study

BACKGROUND

The aim of the study was to determine the effect of deprivation on variations in statin prescribing in Nottingham general practices. Deprivation is used as a measure of population cardiovascular morbidity and need for statin treatment. The setting was all 118 general practices in contract with Nottingham Health Authority.

METHODS

A cross-sectional study was undertaken. Statin prescribing in general practice during 1996 was related to indices of practice deprivation based on enumeration district (ED) level data from the 1991 Census. The relationship between statin prescribing per 1000 patients aged 35-69 and practice deprivation (measured both as Townsend score and as Jarman UPA(8) score) with additional adjustment for practice characteristics (number of partners, training status, total list size, fundholding status) cardiovascular prescribing costs net of lipid prescribing and hospital activity (total and medical admissions and new general practitioner total and medical out-patient referrals) for each practice.

RESULTS

The prescription of statins during 1996 varied between nil and 14.1 'statin-years' of prescribing per 1000 patients aged 35-69. There was a significant inverse relationship between the rate of statin prescribing and the level of deprivation of that practice (p < 0.0001). Deprivation, as measured by Townsend index, accounted for 13 per cent of the total variability in statin prescribing, which rose to 19 per cent after adjustment. The prescribing of other lipid lowering agents of the fibrate class was positively associated with statin prescribing (p=0.001) and this association persisted after adjusting for deprivation. None of the other practice characteristics were found to be significantly associated with rates of statin prescribing.

CONCLUSIONS

General practices with high deprivation indices serve more deprived populations with a higher prevalence of cardiovascular disease, and may be assumed to have a greater need for statins. Despite this, practices with higher deprivation indices prescribed fewer statins to their patients than less deprived practices. It was not possible to identify whether the more deprived general practices had successfully identified at risk individuals but it is likely that special efforts are needed to increase the uptake of effective health care in their patients.