Workforce participation among international medical graduates in the National Health Service of England: a retrospective longitudinal study

BACKGROUND

Balancing medical workforce supply with demand requires good information about factors affecting retention. Overseas qualified doctors comprise 30% of the National Health Service (NHS) workforce in England yet little is known about the impact of country of qualification on length of stay. We aimed to address this need.

METHODS

Using NHS annual census data, we calculated the duration of 'episodes of work' for doctors entering the workforce between 1992 and 2003. Survival analysis was used to examine variations in retention by country of qualification. The extent to which differences in retention could be explained by differences in doctors' age, sex and medical specialty was examined by logistic regression.

RESULTS

Countries supplying doctors to the NHS could be divided into those with better or worse long-term retention than domestically trained doctors. Countries in the former category were generally located in the Middle East, non-European Economic Area Europe, Northern Africa and Asia, and tended to be poorer with fewer doctors per head of population, but stronger economic growth. A doctor's age and medical specialty, but not sex, influenced patterns of retention.

CONCLUSION

Adjusting workforce participation by country of qualification can improve estimates of the number of medical school places needed to balance supply with demand. Developing countries undergoing strong economic growth are likely to be the most important suppliers of long stay medical migrants.

434. Identification of differentially expressed proteins in ovine chorion rupture sites at preterm and term using proteomics

Introduction: A significant number of babies are delivered preterm and many of these deliveries are due to spontaneous rupture of fetal membranes. However, the mechanisms underlying fetal membrane rupture are not well defined. The sheep has proved to be a valuable model for elucidating the physiology of birth, with many of the findings clearly relevant to human parturition. In the current study we have used the sheep model to investigate changes in protein expression in the chorion in relation to the onset of spontaneous full term labour. Methods: Proteomic analysis was used to compare the protein profiles at the chorion rupture site between mid/late gestation (136 days, n = 6) and term delivery (145days, n = 6). Proteins were solubilised and separated into soluble and insoluble fractions which were separated by 2D-electrophoresis. Relative protein expression was quantified using the PROGENESIS software and protein spots were picked and identified using Matrix Assisted Laser Desorption Ionisation-Time of Flight (MALDI-TOF) mass spectrometry. Data-mining used gene ontology (GO terms) for each protein and these were clustered into networks using DAVID bioinformatics resource (http://david.abcc.ncifcrf.gov/home.jsp). Results: A total of 150 protein spots were identified of which 60 proteins were found to differ by more than 2-fold between preterm and term samples. This group was significantly enriched for proteins from the several functional GO categories including; Oxidoreductase activity (7 proteins); negative regulation of apoptosis (4); structural molecule activity (7); protease inhibitor activity (7); Carbohydrate metabolism (10); Glucose metabolism (5); Glycolysis (5); response to stress (8) and heat shock (3). Of the differentially regulated proteins, 10 were found to be significantly upregulated at term (ANOVA P < 0.05) including isocitrate dehydrogenase, glutamate dehydrogenase 1, malate dehydrogenase 2. A further 10 proteins, including serpin peptidase inhibitor SERPINA12, serpin peptidase inhibitor SERPINH1 precursor and heat shock protein 90 kDa β were found to be downregulated.

Predicting grade of cerebral glioma using vascular-space occupancy MR imaging

BACKGROUND AND PURPOSE

MR imaging can measure tissue perfusion and the integrity of the blood-brain barrier. We hypothesize that a combined measure of cerebral blood volume and vascular permeability using vascular-space occupancy (VASO) MR imaging, a recently developed imaging technique, is of diagnostic value for predicting tumor grade.

MATERIALS AND METHODS

Thirty-nine patients (9 World Health Organization [WHO] grade II, 20 grade III, and 10 grade IV as determined by histopathologic assessment) were examined using VASO MR imaging, and regions-of-interest analysis was performed in tumoral regions, as well as in regions contralateral to the tumor. A Mann-Whitney test was conducted on the resulting VASO indices for a pairwise comparison across tumor grades. Nominal logistic regression was used to evaluate the use of VASO parameters for predicting group membership (by the percentage of correct classifications).

RESULTS

The ratio between tumor side and contralateral side, VASO(Ratio), showed significant differences in all 3 of the pairwise comparisons (P < .01). VASO values in the tumoral regions, VASO(Tumor), showed significant difference between grade II and III and between II and IV but not between III and IV. Both VASO(Tumor) and VASO(Ratio) were found to be significant predictors of tumor grade, giving diagnostic accuracies of 66.7% and 71.8%, respectively. When testing to discriminate grade II tumors from higher grade tumors, the areas under the receiver operating characteristic curve were found to be 0.974 and 0.985 for VASO(Tumor) and VASO(Ratio), respectively.

CONCLUSION

VASO MR imaging can be used for noninvasive tumor grade prediction based on cerebral blood volume and vascular permeability. VASO is more effective in separating WHO grade II from higher grades than in separating grade III from grade IV.

Validation of the beck depression inventory-II in a Jamaican university student cohort

OBJECTIVE

This project explores the internal consistency reliability and the concurrent and discriminant validity of the Beck Depression Inventory-II (BDI-II) using a wide cross-section of the student population attending the University of the West Indies, Kingston, Jamaica.

SUBJECTS AND METHODS

Students enrolled in UWI Foundation courses during the first and second semesters of the 2005/2006 academic year (n = 690; 77% females, 23% males; mean age = 23.4 +/- 7.4 years) were administered the BDI-II along with the Brief Screen for Depression (BSD), the Centre for Epidemiological Studies--Depression Scale (CES-D) and the UCLA Loneliness Scale--Revised.

RESULTS

Overall, the BDI-II was found to have an acceptable degree of reliability (alpha = 0.90). The scale also had reasonably good concurrent validity as evidenced by high correlations with scores on the BSD (r = 0.74) and the CES-D (r = 0.71) and acceptable discriminant validity as demonstrated through moderate correlations with the UCLA Loneliness Scale (r = 0.50). This pattern of scores suggests that the majority of the variance underlying the BDI-II assesses depression (50% to 55%) while a smaller degree of the variability (25%) measures a conceptually similar but distinct concept.

CONCLUSION

The BDI-II is a reliable and valid measure for assessing depression within the Jamaican population.

Histogram analysis versus region of interest analysis of dynamic susceptibility contrast perfusion MR imaging data in the grading of cerebral gliomas

BACKGROUND AND PURPOSE

Histogram analysis can be applied to dynamic susceptibility contrast (DSC) perfusion MR imaging datasets and can be as effective as traditional region-of-interest (ROI) measurements of relative cerebral blood volume (rCBV), an operator-dependent method. We compare the routine ROI method with histogram analysis in the grading of glial neoplasms.

MATERIALS AND METHODS

Ninety-two patients underwent conventional and DSC MR imaging. Routine rCBV (rCBVmax) measurements were obtained from ROIs of the maximal abnormality within the glioma. Histogram analysis rCBVT was performed with an ROI drawn around the maximal tumor diameter. Spearman rank correlations measured associations among glioma grade, rCBVmax, and histogram measures. Mann-Whitney tests compared grade with respect to rCBV and histogram measures. Logistic regression and McNemar test compared the utility of rCBVmax and histogram measures for detecting high grade gliomas.

RESULTS

Routine rCBVmax analysis showed significant correlation with grade (r = 0.734, P < .001). Histogram rCBVT metrics showed significant correlation with grade (P < .008); the 3 highest were rCBVT SD, SD50, and mean25 (r = 0.718, 0.684, and 0.683, respectively). Grade could be predicted by rCBVmax (P < .001) as well as rCBV(T) (P < .008). Three rCBVT histogram measures (SD, SD25, and SD50) detected high-grade glioma with significantly higher specificity than rCBVmax when the diagnostic tests were constrained to have at least 95% sensitivity.

CONCLUSION

rCBVT histogram analysis is as effective as rCBVmax analysis in the correlation with glioma grade. Inexperienced operators may obtain perfusion metrics using histogram analyses that are comparable with those obtained by experienced operators using ROI analysis.

Comparing perfusion metrics obtained from a single compartment versus pharmacokinetic modeling methods using dynamic susceptibility contrast-enhanced perfusion MR imaging with glioma grade

BACKGROUND AND PURPOSE

Numerous different parameters measured by perfusion MR imaging can be used for characterizing gliomas. Parameters derived from 3 different analyses were correlated with histopathologically confirmed grade in gliomas to determine which parameters best predict tumor grade.

METHODS

Seventy-four patients with gliomas underwent dynamic susceptibility contrast-enhanced MR imaging (DSC MR imaging). Data were analyzed by 3 different algorithms. Analysis 1 estimated relative cerebral blood volume (rCBV) by using a single compartment model. Analysis 2 estimated fractional plasma volume (V(p)) and vascular transfer constant (K(trans)) by using a 2-compartment pharmacokinetic model. Analysis 3 estimated absolute cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) by using a single compartment model and an automated arterial input function. The Mann-Whitney U test was used make pairwise comparisons. Binary logistic regression was used to assess whether rCBV, V(p), K(trans), CBV, CBF, and MTT can discriminate high- from low-grade tumors.

RESULTS

rCBV was the best discriminator of tumor grade ype, followed by CBF, CBV, and K(trans). Spearman rank correlation factors were the following: rCBV = 0.812 (P < .0001), CBF = 0.677 (P < .0001), CBV = 0.604 (P < .0001), K(trans) = 0.457 (P < .0001), V(p) = 0.301 (P =.009), and MTT = 0.089 (P = .448). rCBV was the best single predictor, and K(trans) with rCBV was the best set of predictors of high-grade glioma.

CONCLUSION

rCBV, CBF, CBV K(trans), and V(p) measurements correlated well with histopathologic grade. rCBV was the best predictor of glioma grade, and the combination of rCBV with K(trans) was the best set of metrics to predict glioma grade.

Randomized phase II study comparing 4 monthly doses of ipilimumab (MDX-010) as a single agent or in combination with a single dose of docetaxel in patients with hormone-refractory prostate cancer

4609

Background: Ipilimumab is a fully human anti-CTLA-4 IgG1 monoclonal antibody that blocks CTLA-4 and augments immune responses. The current study evaluated the safety and activity of ipilimumab alone or with a single dose of docetaxel in hormone-refractory prostate cancer (HRPC). Methods: 43 chemotherapy naïve patients (pts) with HRPC, were treated; 23 were in arm A (ipilimumab at 3 mg/kg q 4 weeks × 4 doses) and 20 in arm B (ipilimumab as in Arm A and one dose of 75 mg/m2 of docetaxel on day 1). Results: Six pts, 3 in each arm, demonstrated a decrease in PSA of > 50%. Three pts, 2 in arm A, and 1 in arm B had confirmed PSA responses with durations of 79+ days, 169+ days, and 280 days, respectively. There were no radiologic responses with these PSA responses. Thirty-six (84%) of the 43 pts experienced 1 or more adverse events considered to be related to treatment with ipilimumab. The most common adverse events included fatigue (44%), pruritus (26%), nausea (19%), rash (12%), constipation (12%), and weight loss (12%). Serious adverse events (SAEs) occurred in 18 patients (42%), who experienced 52 SAEs. The majority (42 out of 52, 81%) were judged by the Investigator to be unrelated or unlikely to be related to treatment with ipilimumab. Five of the 52 SAEs reported in 3 pts were considered to be possible immune breakthrough events (IBEs), associated with drug exposure and consistent with an immune-based mechanism of action. These were adrenal insufficiency (1), diarrhea, colitis, and melena (all in one patient) and colitis (1). One of these pts had a confirmed PSA response. Conclusions: Ipilimumab was well tolerated in this group of pts with HRPC. Three pts overall (6%) experienced an IBE, a phenomenon that has been correlated in other studies with efficacy. There were several confirmed responses as assessed by PSA, one of which was correlated with an IBE. There was no apparent enhancement of activity by coadministration of a single dose of docetaxel. Further studies exploring ipilimumab in prostate cancer are warranted, either as monotherapy at higher doses, or in combination with immune modulators or vaccines.

[Table: see text]

Can the laboratory affect the investigation and diagnosis of primary biliary cirrhosis?

BACKGROUND

Primary biliary cirrhosis (PBC) is an autoimmune liver disease characterised by the presence of various laboratory abnormalities but the precise role of laboratory staff in initiating clinical referral and subsequent biopsy is not clear.

OBJECTIVE

To examine the impact of laboratory abnormalities in the investigation of PBC.

METHODS

In a retrospective study of laboratory results over nine years from 1996, computer records were reviewed to identify how many referrals for biopsy were initiated and subsequent diagnoses made as a result of clinical signs, raised serum alkaline phosphatase activity (ALP), raised IgM concentration, or positive mitochondrial antibodies accompanied by a clinical comment from the laboratory suggesting further action.

RESULTS

22 diagnoses of PBC were confirmed by histopathology. Eleven had high ALP activity which had follow up tests initiated by the laboratory (mitochondrial antibodies or IgM or both) and a comment added suggesting further investigation into the possibility of PBC. Seven had abnormal liver antibodies and one had a high polyclonal IgM concentration which prompted the relevant follow on testing and comments. One had an earlier diagnosis made on serological/clinical grounds and the biopsy was a confirmatory measure. One had no liver related antibodies. One had a request by laboratory staff for follow on tests but these were not asked for in subsequent samples by the requesting clinician.

CONCLUSIONS

There is a positive role for laboratory staff in the diagnosis of PBC. Unexplained rises in ALP activity, positive mitochondrial antibodies, or raised IgM concentrations should be investigated more fully by laboratory staff and advice given to prompt a clinical referral for review and biopsy.

Diagnosis and management of thyroid disease and the critically ill patient

OBJECTIVE

To review current concepts in the diagnosis and management of thyroid disease in the critically ill patient.

DATA SOURCES

A review of articles reported on thyroid disease and the acutely ill patient.

SUMMARY OF REVIEW

Normal thyroid function depends on an integrated response between the pituitary and thyroid gland to provide an appropriate circulating T4 level which is converted to T3 by peripheral tissues. Thyroid hormone increases oxygen consumption and regulates lipid and carbohydrate metabolism and normal growth and maturation of tissues. In patients with a severe non-thyroidal illness, the thyroid stimulating hormone (TSH), free thyroxine (FT4) and free 3,5,3-triiodo-L-thyronine (FT3) levels decrease. Dopamine, dobutamine or corticosteroid therapy may also reduce TSH levels. The TSH and T4 levels often return to low normal levels, although with continued severe illness they may remain low. The clinically euthyroid state is maintained in the presence of a reduction in FT3 levels partly due to an increase in synthesis of tissues T3 receptors. During the recovery phase of the illness, there is often a transient elevation in the TSH level until the FT4 and FT3 levels are returned to normal. There are no clinical data that have shown a consistent reduction in mortality with thyroid hormone treatment in the critically ill patient. In general, in the absence of clinical signs of thyroid disease, abnormal thyroid function tests should not be treated in the critically ill patient and thyroid function studies should be repeated after the acute illness has resolved. Hypothyroid and hyperthyroid states may present with acute cardiorespiratory failure. Treatment that includes cardiorespiratory resuscitation and thyroid hormone replacement in hypothyroid states and beta adrenergic blockers in hyperthyroid states will often allow correction of the underlying disorder to be achieved successfully.

CONCLUSIONS

Abnormal thyroid function tests are commonly found in the critically ill patient and do not require treatment. However, hypothyroid and hyperthyroid states may present with acute cardiorespiratory failure and require careful and specific management strategies to resolve the thyroid disorder.

Prognostic indicators for gastrointestinal stromal tumours: a clinicopathological and immunohistochemical study of 108 resected cases of the stomach

AIMS

Whether immunohistochemical markers increase accuracy in predicting prognosis for gastrointestinal stromal tumours (GISTs) remains uncertain. However, past studies have used only small, heterogeneous patient groups. Our aim was to test previously studied and more novel morphological features as well as four immunohistochemical markers as prognostic indicators amongst a large cohort of surgically resected, gastric GISTs.

METHODS AND RESULTS

Tissues from 127 gastric mesenchymal tumours were collected retrospectively and subjected to repeat histological assessment and immunophenotyping. Further immunohistochemistry was performed for Ki67, p53, Bcl-2 and cyclin D1. Complete follow-up data were collected for 108 patients with immunophenotyped diagnoses of GIST (i.e. c-kit+ tumours). At the census point, 52 patients were alive, 24 had died from their GISTs and the remainder of other causes. Univariate analysis showed the following predicted for shorter disease-specific survival: size > or =50 mm; necrosis, no intratumoral lymphocytes; mitotic count > or =5/50 high power fields; Ki67 labelling index > or =5%; p53 immunopositivity. Of these variables, multivariate analyses showed only mitotic count and, to a lesser extent, Ki67 labelling to be independent prognostic indicators.

CONCLUSIONS

Mitotic count remains the best predictor of outcome following surgical resection of gastric GISTs. Ki67 immunohistochemistry does not provide better prognostication and p53, Bcl-2 and cyclin D1 immunohistochemistry provide no additional prognostication.

Pressures within air-filled tracheal cuffs at altitude - an in vivo study

Aeromedical transport of mechanically ventilated critically ill patients is now a frequent occurrence. However, the performance of the air filled tracheal tube cuff at altitude has not been studied in vivo. We measured the tracheal cuff pressures at ground level and at 3000 ft, in 10 intubated patients. With air providing the seal in the cuff the mean rise in cuff pressure was 23 cmH2O, which took the pressures above the critical perfusion pressure of the tracheal mucosa. This could lead to tracheal injury.

Current concepts in the management of heart failure

OBJECTIVE

To review current concepts in the management of patients with heart failure.

DATA SOURCES

A review of articles reported on acute and chronic heart failure.

SUMMARY OF REVIEW

Heart failure has been defined as that state which occurs when the heart fails to maintain the needs of the body despite a satisfactory venous return. While it has been divided functionally into high-output failure and low-output failure, it is often used to describe patients with left ventricular low-output failure and is divided into systolic or diastolic heart failure, depending on left ventricular ejection fraction. The clinical features are due largely to venous congestion and reduction in cardiac output with symptoms of fatigue, orthopnoea, paroxysmal nocturnal dyspnoea and peripheral oedema being common complaints. Plasma natriuretic peptide levels are elevated in patients with symptomless left ventricular failure and have been useful in diagnosing heart failure in patients admitted with acute dyspnea. Treatment of heart failure is aimed at correcting both the underlying disorder as well as the precipitating cause (e.g. ischaemia, valvular heart disease, anaemia, thyrotoxicosis, etc), as well as reducing cardiac work, enhancing myocardial contractility and treating the complications (e.g. reducing salt and water retention, and neurohumoral activation). Angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor antagonists, beta-blockers and spironolactone have all been associated with a reduction in mortality in patients with chronic heart failure. While digoxin and diuretics are used to reduce the number of episodes of pulmonary oedema, they have not been associated with a significant reduction in mortality. Surgery (e.g. transplantation, mechanical assist devices) has a definite place in young patients with chronic dilated cardiomyopathy with severe heart failure although other therapeutic agents (e.g. growth hormone, thyroxine and antioxidants) are yet to be shown to be of benefit.

CONCLUSIONS

Heart failure is a common condition caused by many disorders leading to left ventricular dysfunction. Management of the underlying disorder (e.g. ischaemia, valvular disease, hypertension) maintenance of sinus rhythm, as well as reducing excessive neurohumoral activation (ACE inhibitors, angiotensin receptor antagonists, beta-blockers, spironolactone) can reduce mortality and improve morbidity in patients with chronic heart failure.

MR-trackable intramyocardial injection catheter

There is growing interest in delivering cellular agents to infarcted myocardium to prevent postinfarction left ventricular remodeling. MRI can be effectively used to differentiate infarcted from healthy myocardium. MR-guided delivery of cellular agents/therapeutics is appealing because the therapeutics can be precisely targeted to the desired location within the infarct. In this study, a steerable intramyocardial injection catheter that can be actively tracked under MRI was developed and tested. The components of the catheter were arranged to form a loopless RF antenna receiver coil that enabled active tracking. Feasibility studies were performed in canine and porcine myocardial infarction models. Myocardial delayed-enhancement (MDE) imaging identified the infarcted myocardium, and real-time MRI was used to guide left ventricular catheterization from a carotid artery approach. The distal 35 cm of the catheter was seen under MRI with a bright signal at the distal tip of the catheter. The catheter was steered into position, the distal tip was apposed against the infarct, the needle was advanced, and a bolus of MR contrast agent and tissue marker dye was injected intramyocardially, as confirmed by imaging and postmortem histology. A pilot study involving intramyocardial delivery of magnetically labeled stem cells demonstrated the utility of the active injection catheter system.

Prognostic indicators for gastrointestinal stromal tumours: a clinicopathological and immunohistochemical study of 108 resected cases of the stomach

AIMS

Whether immunohistochemical markers increase accuracy in predicting prognosis for gastrointestinal stromal tumours (GISTs) remains uncertain. However, past studies have used only small, heterogeneous patient groups. Our aim was to test previously studied and more novel morphological features as well as four immunohistochemical markers as prognostic indicators amongst a large cohort of surgically resected, gastric GISTs.

METHODS AND RESULTS

Tissues from 127 gastric mesenchymal tumours were collected retrospectively and subjected to repeat histological assessment and immunophenotyping. Further immunohistochemistry was performed for Ki67, p53, Bcl-2 and cyclin D1. Complete follow-up data were collected for 108 patients with immunophenotyped diagnoses of GIST (i.e. c-kit+ tumours). At the census point, 52 patients were alive, 24 had died from their GISTs and the remainder of other causes. Univariate analysis showed the following predicted for shorter disease-specific survival: size > or =50 mm; necrosis, no intratumoral lymphocytes; mitotic count > or =5/50 high power fields; Ki67 labelling index > or =5%; p53 immunopositivity. Of these variables, multivariate analyses showed only mitotic count and, to a lesser extent, Ki67 labelling to be independent prognostic indicators.

CONCLUSIONS

Mitotic count remains the best predictor of outcome following surgical resection of gastric GISTs. Ki67 immunohistochemistry does not provide better prognostication and p53, Bcl-2 and cyclin D1 immunohistochemistry provide no additional prognostication.

Seasonal pseudohyperkalaemia

AIMS

To investigate the relation between ambient temperature and serum potassium concentrations in samples from primary care.

METHODS

Potassium concentrations were estimated on general practitioner and hospital ward samples taken over a two year period using serum obtained from gel separator samples. The number of samples analysed from general practice during each month varied from 5093 to 8978 (mean of 7068 samples/month).

RESULTS

As the temperature fell in winter, the mean daily serum potassium concentration rose in samples from general practice, with the inverse occurring during the warmer summer months. This effect was restricted to samples coming from general practice, with inpatient samples seemingly unaffected.

CONCLUSIONS

These results indicate that exposure of the samples to variations in ambient temperature during their transport to the laboratory profoundly affects measured serum potassium concentrations.

A comparative analysis: storm water pollution policy in California, USA and Victoria, Australia

Urban drainage systems historically were developed on principles of hydraulic capacity for the transport of storm water to reduce the risk of flooding. However, with urbanization the percent of impervious surfaces increases dramatically resulting in increased flood volumes, peak discharge rates, velocities and duration, and a significant increase in pollutant loads. Storm water and urban runoff are the leading causes of the impairment of receiving waters and their beneficial uses in Australia and the United States today. Strict environmental and technology controls on wastewater treatment facilities and industry for more than three decades have ensured that these sources are less significant today as the cause of impairment of receiving waters. This paper compares the approach undertaken by the Environmental Protection Authority Victoria for the Melbourne metropolitan area with the approach implemented by the California Environmental Protection Agency for the Los Angeles area to control storm water pollution. Both these communities are largely similar in population size and the extent of urbanization. The authors present an analysis of the different approaches contrasting Australia with the USA, comment on their comparative success, and discuss the relevance of the two experiences for developed and developing nations in the context of environmental policy making to control storm water and urban runoff pollution.

Adult mesenchymal stem cells: potential for muscle and tendon regeneration and use in gene therapy

The expansion potential and plasticity of stem cells, adult or embryonic, offer great promise for their use in medical therapies. Recent provocative data suggest that the differentiation potential of adult stem cells may extend to lineages beyond those usually associated with the germ layer of origin. In this review, we describe recent developments related to adult stem cell research and in particular, in the arena of mesenchymal stem cell (MSC) research. Research demonstrates that transduced MSCs injected into skeletal muscle can persist and express secreted gene products. The ability of the MSC to differentiate into cardiomyocytes has been reported and their ability to engraft and modify the pathology in infarcted animal models is of great interest. Research using MSCs in tendon repair provides information on the effects of physical forces on phenotype and gene expression. In turn, MSCs produce changes in their matrix environment in response to those biomechanical forces. Recent data support the potential of MSCs to repair tendon, ligament, meniscus and other connective tissues. Therapeutic applications of adult stem cells are approaching clinical use in several fields, furthering the possibility to regenerate damaged and diseased tissue.

Calmodulin-binding and autoinhibitory domains of Acanthamoeba myosin I heavy chain kinase, a p21-activated kinase (PAK)

The sequence homology between Acanthamoeba myosin I heavy chain kinase (MIHCK) and other p21-activated kinases (PAKs) is relatively low, including only the catalytic domain and a short PAK N-terminal motif (PAN), and even these regions are not highly homologous. In this paper, we report the expression in insect cells of full-length, fully regulated Acanthamoeba MIHCK and further characterize the regulation of this PAK by Rac, calmodulin, and autoinhibition. We map the autoinhibitory region of MIHCK to its PAN region and show that the PAN region inhibits autophosphorylation and kinase activity of unphosphorylated full-length MIHCK and its expressed catalytic domain but has very little effect on either when they are phosphorylated. These properties are similar to those reported for mammalian PAK1. Unlike PAK1, MIHCK is activated by Rac only in the presence of phospholipid. However, peptides containing the PAN region of MIHCK bind Rac in the absence of lipid, and Rac binding reverses the inhibition of the MIHCK catalytic domain by PAN peptides. Our data suggest that a region N-terminal to PAN is required for optimal binding of Rac. Also unlike mammalian PAK, phospholipid stimulation of Acanthamoeba MIHCK and Dictyostelium MIHCK) (which is also a PAK) is inhibited by Ca(2+)-calmodulin. In contrast to Dictyostelium MIHCK, however, Ca(2+)-calmodulin also inhibits Rac-induced activity of Acanthamoeba MIHCK. The basic region N-terminal to PAN is essential for calmodulin binding.

Hand preference, sexual preference, and transsexualism

Atypical handedness patterns, i.e., persons being less exclusively right-handed, have been found previously in large samples of male and female homosexuals and in small samples of male and female transsexuals compared to controls. The posited role of prenatal androgen influencing both cerebral hemispheric dominance and psychosexual development warrants further study with large samples of transsexuals. 443 male-to-female transsexuals and 93 female-to-male transsexuals were studied for their use of the right or left hand in six common one-handed tasks. Both male and female transsexuals were more often nonright-handed than male and female controls were. Results suggest an altered pattern of cerebral hemispheric organisation in male and female transsexuals.

IMRT (intensity modulated radiation therapy): progress in technology and reimbursement

For a new treatment technology to become widely accepted in today's healthcare environment, the technology must not only be effective but also financially viable. Intensity modulated radiation therapy (IMRT), a technology that enables radiation oncologists to precisely target and attack cancerous tumors with higher doses of radiation using strategically positioned beams while minimizing collateral damage to healthy cells, now meets both criteria. With IMRT, radiation oncologists for the first time have obtained the ability to divide the treatment field covered by each beam angle into hundreds of segments as small as 2.5 mm by 5 mm. Using the adjustable leaves of an MLC to shape the beam and by controlling exposure times, physicians can deliver a different dose to each segment and therefore modulate dose intensity across the entire treatment field. Development of optimal IMRT plans using conventional manual treatment planning methods would take days. To be clinically practical, IMRT required the development of "inverse treatment planning" software. With this software, a radiation oncologist can prescribe the ideal radiation dose for a specific tumor as well as maximum dose limits for surrounding healthy tissue. These numbers are entered into the treatment planning program which then calculates the optimal delivery approach that will best fit the oncologist's requirements. The radiation oncologist then reviews and approves the proposed treatment plan before it is initiated. The most recent advance in IMRT technology offers a "dynamic" mode or "sliding window" technique. In this more rapid delivery method, the beam remains on while the leaves of the collimator continually re-shape and move the beam aperture over the planned treatment area. This creates a moving beam that saturates the tumor volume with the desired radiation dose while leaving the surrounding healthy tissue in a protective shadow created by the leaves of the collimator. In the dynamic mode, an IMRT treatment session generally can be initiated and completed within the traditional 15-minute appointment window for radiation oncology clinics. In addition to being comforting for the patient, this rapid treatment delivery mode satisfies a key financial issue for hospitals and clinics by giving them the ability to handle high patient loads and achieve a more rapid return on their investment in an IMRT system. New IMRT reimbursement codes have been issued under the pass-through provisions of Medicare's Outpatient Prospective Payment System (OPPS), which authorize special or increased reimbursement levels for promising new developments in healthcare technology that previous reimbursement procedures did not address. These pass-through payments are generally applicable for defined periods during a promising new technology's early stage of adoption. In the case of codes G0174 and G0178, the effective period has been left open-ended. While the CMS adoption of these new IMRT reimbursement codes certainly paves the economic road for the diffusion of this technology by flattening out some of the economic obstacles, there are still bumps to overcome. The most obvious one is the investment in hardware and software that may be required. However, the added demands on staff and the cost of training cannot be ignored. IMRT is a treatment process involving FDA-approved medical devices, offering the hope of improved treatment outcomes with fewer complications for patients and higher reimbursement rates for hospital providers. By the end of the year 2001, there will probably be more than 75 hospitals with IMRT capabilities in place.

Discriminative stimulus properties of alpha-ethyltryptamine optical isomers

alpha-Ethyltryptamine (alpha-ET) possesses central stimulant and hallucinogenic activity. Also, in tests of stimulus generalization using rats trained to discriminate the controlled substance analog (i.e., designer drug) N-methyl-1-(3,4-methylenedioxyphenyl)-2-aminopropane (MDMA) from vehicle, alpha-ET substituted for MDMA. These previous studies employed racemic alpha-ET. Because psychoactive phenylalkylamines with abuse potential can produce one or more of three distinct stimulus effects (i.e., amphetamine-, DOM- and/or PMMA-like effects) in animals trained to discriminate either the stimulant (+)amphetamine, the hallucinogen 1-(2,5-dimethoxy-4-methylphenyl)-2-aminopropane (DOM), or N-methyl-1-(4-methoxyphenyl)-2-aminopropane (PMMA) from vehicle, and because these effects can be stereoselective, the individual optical isomers of alpha-ET were examined in groups of animals trained to discriminate (+)amphetamine, DOM, PMMA and MDMA from saline vehicle. (-)alpha-ET (ED(50)=7.8 mg/kg), but not (+)alpha-ET (maximum of 53% drug-appropriate responding), substituted for (+)amphetamine, whereas (+)alpha-ET (ED(50)=2.7 mg/kg), but not (-)alpha-ET (maximum of 33% drug-appropriate responding), substituted for DOM. Both optical isomers of alpha-ET substituted for PMMA and MDMA with ED(50) values of 1.6 and 1.4 mg/kg (PMMA-trained animals) and 1.3 and 2.0 mg/kg (MDMA-trained animals) for (-)alpha-ET and (+)alpha-ET, respectively. The results of this investigation suggest that both optical isomers of alpha-ET are capable of producing an MDMA/PMMA-like effect at nearly comparable doses, and that the stimulant or amphetamine-like nature of alpha-ET resides primarily with its (-)isomer whereas hallucinogenic or DOM-like character resides primarily with the (+)enantiomer.

Ion mobility spectrometry of hydrazine, monomethylhydrazine, and ammonia in air with 5-nonanone reagent gas

Hydrazine (HZ) and monomethylhydrazine (MMH) in air were monitored continuously using a hand-held ion mobility spectrometer equipped with membrane inlet, 63Ni ion source, acetone reagent gas, and ambient temperature drift tube. Response characteristics included detection limit, 6 ppb; linear range, 10-600 ppb; saturated response, >2 ppm; and stable response after 15-30 min. Ammonia interfered in hydrazines detection through a product ion with the same drift time as that for MMH and HZ. Acetone reagent gas was replaced with 5-nonanone to alter drift times of product ions and separate ammonia from MMH and HZ. Patterns in mobility spectra, ion identifications from mass spectra, and fragmentation cross-sections from collisional-induced dissociations suggest that drift times are governed by ion-cluster equilibria in the drift region of the mobility spectrometer. Practical aspects including calibration, stability, and reproducibility are reported from the use of a hand-held mobility spectrometer on the space shuttle Atlantis during mission STS-37.

Small intestinal motor patterns in critically ill patients after major abdominal surgery

OBJECTIVES

In patients who have had major surgery or trauma, early enteral feeding is safer and more effective than parenteral or nasogastric feeding but is frequently associated with diarrhea. Limited recordings have shown that the patterning of duodenal interdigestive motor activity is frequently abnormal after surgery or in patients who are critically ill. The aims of this study were to evaluate the effects of major abdominal surgery on small intestinal motility, and to elucidate the motor patterns that occur postoperatively in critically ill patients in response to enteral feeding.

METHODS

The effects of elective aortic aneurysm repair on small intestinal motility were studied in 11 patients aged 63-77 yr. A 3.5-mm diameter multilumen extrusion was used to monitor pressures at 12 points, distributed between the antrum and 100 cm distal to the pylorus. An additional lumen allowed enteral feeding into the duodenum. Recordings commenced immediately postoperatively and continued for up to 4 days. Data are given as means and SEMs.

RESULTS

Bursts (frequency > 10/min) of small intestinal pressure waves that resembled phase III interdigestive motor activity occurred in all patients immediately after surgery. During mechanical ventilation, the timing of bursts along the segment evaluated was frequently abnormal for true interdigestive phase III activity, with simultaneous onset in multiple channels (46%), multiple or distal origins (8%), or retrograde migration (20%). When patients were not being ventilated, the migration pattern of the bursts was more typical of interdigestive phase III activity. The interval between bursts was unusually short for interdigestive motor activity, although it increased from 30+/-12 min on day 1 to 41+/-18 min on day 3 (p < 0.05). A phase II pattern of pressure waves was virtually absent in all patients on all study days. In six patients who received postoperative enteral nutrition, the bursts of pressure waves were not abolished by feeding, contrary to normal phase III activity.

CONCLUSIONS

Small intestinal pressure wave bursts are seen immediately after elective aortic aneurysm repair, but the migration of these bursts is frequently abnormal for phase III interdigestive activity. Duodenal nutrient delivery did not interrupt the occurrence of these bursts. Persistence of pressure wave bursts in this setting may be important in the delivery of enteral nutrition.

An ancient player unmasked: T4 rI encodes a t-specific antiholin

Phage T4 effects lysis by its holin T and its endolysin E. Lysis is inhibited (LIN) if the infected cell is subjected to secondary infections by T4 phage particles. The T4 rI gene is required for LIN in all hosts tested. Here, we show that a cloned rI gene can impose a T-specific LIN on T-mediated lysis in the context of the phage lambda infective cycle, in the absence of other T4 genes and without secondary infection by T4. Moreover, it is shown that the T holin accumulates in the membrane during LIN, forming SDS-resistant oligomers. We show by cross-linking experiments that a T-RI heterodimer is formed during LIN, demonstrating that RI belongs to the functional class of antiholins, such as the S107 protein of lambda, which heterodimerizes with its cognate holin, S105. Finally, we show that the addition of Ni(2+) ions to the medium can block lysis by a T protein hexahistidine-tagged at its C-terminus, suggesting that liganding of the periplasmic domain is sufficient to impose lysis inhibition. The results are discussed in terms of a model in which the LIN-inducing signal of the secondary infecting phage influences a conformational equilibrium assumed by RI in the periplasm.

Holins kill without warning

Holins comprise the most diverse functional group of proteins known. They are small bacteriophage-encoded proteins that accumulate during the period of late-protein synthesis after infection and cause lysis of the host cell at a precise genetically programmed time. It is unknown how holins achieve temporal precision, but a conserved feature of their function is that energy poisons subvert the normal scheduling mechanism and instantly trigger membrane disruption. On this basis, timing has been proposed to involve a progressive decrease in the energized state of the membrane until a critical triggering level is reached. Here, we report that membrane integrity is not compromised after the induction of holin synthesis until seconds before lysis. The proton motive force was monitored by the rotation of individual cells tethered by a single flagellum. The results suggest an alternative explanation for the lysis "clock," in which holin concentrations build to a critical level that leads to formation of an oligomeric complex that disrupts the membrane.

Prostaglandin receptor EP(4) mediates the bone anabolic effects of PGE(2)

Prostaglandin (PG) E(2) is a potent inducer of cortical and trabecular bone formation in humans and animals. Although the bone anabolic action of PGE(2) is well documented, the cellular and molecular mechanisms that mediate this effect remain unclear. This study was undertaken to examine the effect of pharmacological inactivation of the prostanoid receptor EP(4), one of the PGE(2) receptors, on PGE(2)-induced bone formation in vivo. We first determined the ability of EP(4)A, an EP(4)-selective ligand, to act as an antagonist. PGE(2) increases intracellular cAMP and suppresses apoptosis in the RP-1 periosteal cell line. Both effects were reversed by EP(4)A, suggesting that EP(4)A acts as an EP(4) antagonist in the cells at concentrations consistent with its in vitro binding to EP(4). We then examined the effect of EP(4) on bone formation induced by PGE(2) in young rats. Five- to 6-week-old rats were treated with PGE(2) (6 mg/kg/day) in the presence or absence of EP(4)A (10 mg/kg/day) for 12 days. We found that treatment with EP(4)A suppresses the increase in trabecular bone volume induced by PGE(2). This effect is accompanied by a suppression of bone formation indices: serum osteocalcin, extent of labeled surface, and extent of trabecular number, suggesting that the reduction in bone volume is due most likely to decreased bone formation. The pharmacological evidence presented here provides strong support for the hypothesis that the bone anabolic effect of PGE(2) in rats is mediated by the EP(4) receptor.

Physiological and regulatory roles of activin A in late pregnancy

Unexplained fetal death in utero in late pregnancy represents an increasing proportion of perinatal deaths. It has been assumed that critical hypoxia is the likely mechanism underlying these losses, but the lack of a physiological marker has hampered both confirmation and prediction which could lead to timely intervention. In this paper, we report studies on hypoxia that we have performed in chronically cannulated late pregnant sheep, complemented by parallel investigations undertaken in human pregnancies. Our initial studies were directed towards determining activin secretion in the fetus and mother during late gestation, and immediately after fetal surgery using a sheep model. This led us to propose that there may be a relationship between hypoxia and activin A, follistatin and prostaglandin (PG) release from the feto-placental unit. Subsequent studies have been directed towards examining this potential relationship in sheep and in humans with compromised pregnancies. As a result of these studies, we have identified a potential mechanism by which activin A may be involved in regulating the response of the fetus to hypoxic insult. Activin A and follistatin concentrations increased in late gestation in ovine maternal plasma and in fetal fluids. Feto-placental hypoxemia or maternal isocapnic hypoxemia, leading to fetal hypoxia, were specific triggers for an acute increase in fetal activin A and follistatin concentrations during late gestation. The source and secretion of activin A, follistatin, and the associated release of PGE(2,) from within the feto-placental unit varied according to the site of the insult. The concomitant secretion of activin A and PGE(2) into the fetal circulation and amniotic fluid during reduced uterine blood flow provides an insight into the physiological regulatory mechanisms that might be involved. Changes observed in maternal activin A concentrations in mid and late gestation in the human may also be associated with fetal compromise. In human pregnancies, elevated activin A concentrations were observed in maternal plasma in mid and late gestation, in association with severe pre-eclampsia and with severe fetal growth restriction, compared to those observed in pregnancies with constitutionally small, healthy fetuses. Activin A was also elevated in maternal and arterial cord plasma in women at term during labour and immediately prior to undergoing emergency Caesarean section for failure to progress. These findings offer exciting new possibilities to gain insights into the mechanisms that underlie the maintenance of fetal wellbeing and provide a rationale for the potential that activin A may prove to be a useful clinical marker of fetal distress.

A protein antibiotic in the phage Qbeta virion: diversity in lysis targets

A(2), a capsid protein of RNA phage Qbeta, is also responsible for host lysis. A(2) blocked synthesis of murein precursors in vivo by inhibiting MurA, the catalyst of the committed step of murein biosynthesis. An A(2)-resistance mutation mapped to an exposed surface near the substrate-binding cleft of MurA. Moreover, purified Qbeta virions inhibited wild-type MurA, but not the mutant MurA, in vitro. Thus, the two small phages characterized for their lysis strategy, Qbeta and the small DNA phage phiX174, effect host lysis by targeting different enzymes in the multistep, universally conserved pathway of cell wall biosynthesis.

Functional analysis of the phage T4 holin in a lambda context

Phage lambda hybrids were constructed by inserting the t gene of phage T4 in place of the lambda holin gene, S. Induction of the hybrid phage resulted in lysis that was just as abrupt as, but occurred much earlier in the vegetative cycle than, that obtained with lambda, indicating that t is indeed a holin gene. Moreover, it was possible to impose lysis inhibition (LIN) on induction of the hybrid phage, but not of the parental lambda phage, by superinfection with LIN-competent T4. The imposition of the LIN state was found to depend on the allelic state of the rI and t genes of the superinfecting T4 phage, indicating that the LIN-sensitive state of the T holin is transient. Finally, induction of lysogens carrying both holin genes was shown to result in earlier triggering of lysis than with either holin gene alone. This result suggests that the two very dissimilar holins contribute additively to the physiology of the timing mechanism, or, less likely, that they interact to form one mass-action pool. In either case, these results imply a common pathway for holin timing and function.

Dynamic complex wave-front modulation with an analog spatial light modulator

A method of producing an arbitrary complex field modulation by use of two pixels of an analog ferroelectric spatial light modulator (SLM) is demonstrated. The method uses the gray-scale modulation capabilities of a SLM to spatially encode the complex data on two pixels. A spatial filter is used to remove the carrier signal. This technique gives fast gray-level amplitude and phase modulation.

Long-term outcome of medical and surgical therapies for gastroesophageal reflux disease: follow-up of a randomized controlled trial

CONTEXT

Severe gastroesophageal reflux disease (GERD) is a lifelong problem that can be complicated by peptic esophageal stricture and adenocarcinoma of the esophagus.

OBJECTIVE

To determine the long-term outcome of medical and surgical therapies for GERD.

DESIGN AND SETTING

Follow-up study conducted from October 1997 through October 1999 of a prospective randomized trial of medical and surgical antireflux treatments in patients with complicated GERD. Mean (median) duration of follow-up was 10.6 years (7.3 years) for medical patients and 9.1 years (6.3 years) for surgical patients.

PARTICIPANTS

Two hundred thirty-nine (97%) of the original 247 study patients were found (79 were confirmed dead). Among the 160 survivors (157 men and 3 women; mean [SD] age, 67 [12] years), 129 (91 in the medical treatment group and 38 in the surgical treatment group) participated in the follow-up.

MAIN OUTCOME MEASURES

Use of antireflux medication, Gastroesophageal Reflux Disease Activity Index (GRACI) scores, grade of esophagitis, frequency of treatment of esophageal stricture, frequency of subsequent antireflux operations, 36-item Short Form health survey (SF-36) scores, satisfaction with antireflux therapy, survival, and incidence of esophageal adenocarcinoma, compared between the medical antireflux therapy group and the fundoplication surgery group. Information on cause of death was obtained from autopsy results, hospital records, and death certificates.

RESULTS

Eighty-three (92%) of 90 medical patients and 23 (62%) of 37 surgical patients reported that they used antireflux medications regularly (P<.001). During a 1-week period after discontinuation of medication, mean (SD) GRACI symptom scores were significantly lower in the surgical treatment group (82.6 [17.5] vs 96.7 [21.4] in the medical treatment group; P =.003). However, no significant differences between the groups were found in grade of esophagitis, frequency of treatment of esophageal stricture and subsequent antireflux operations, SF-36 standardized physical and mental component scale scores, and overall satisfaction with antireflux therapy. Survival during a period of 140 months was decreased significantly in the surgical vs the medical treatment group (relative risk of death in the medical group, 1.57; 95% confidence interval, 1.01-2.46; P =.047), largely because of excess deaths from heart disease. Patients with Barrett esophagus at baseline developed esophageal adenocarcinomas at an annual rate of 0.4%, whereas these cancers developed in patients without Barrett esophagus at an annual rate of only 0.07%. There was no significant difference between groups in incidence of esophageal cancer.

CONCLUSION

This study suggests that antireflux surgery should not be advised with the expectation that patients with GERD will no longer need to take antisecretory medications or that the procedure will prevent esophageal cancer among those with GERD and Barrett esophagus.

PMMA-stimulus generalization to the optical isomers of MBDB and 3,4-DMA

Psychoactive phenylisopropylamines can produce one or more of several different stimulus effects in animals. These effects are typified by the hallucinogen 1-(2,5-dimethoxy-4-methylphenyl)-2-aminopropane (DOM), the central stimulant amphetamine, and by N-methyl-1-(4-methoxyphenyl)-2-aminopropane (PMMA), an agent whose actions are not yet well understood. The optical isomers of two phenylisopropylamines known to lack DOM and amphetamine-stimulus character, that is N-methyl-1-(3,4-methylenedioxyphenyl)-2-aminobutane (MBDB) and 1-(3,4-dimethoxyphenyl)-2-aminopropane (3,4-DMA), were examined in rats trained to discriminate 1.25 mg/kg of PMMA from vehicle. The PMMA stimulus (ED(50)=0.4 mg/kg) generalized to all four agents: S(+)-MBDB (ED(50)=0.8 mg/kg), R(-)-MBDB (ED(50)=2.0 mg/kg), S(+)-3,4-DMA (ED(50)=2.6 mg/kg) and R(-)-3,4-DMA (ED(50)=3.9 mg/kg). The results show that these agents produce stimulus effects similar to those produced by PMMA. Both isomers of MBDB have been previously demonstrated to substitute for N-methyl-1-(3,4-methylenedioxyphenyl)-2-aminopropane (MDMA) in rats trained to discriminate MDMA from vehicle, but MBDB-trained animals failed to recognize DOM or amphetamine. Similar results were obtained with the 3,4-DMA optical isomers in the present investigation using rats trained to discriminate MDMA, DOM or (+)-amphetamine from vehicle; both isomers of 3,4-DMA substituted for an MDMA stimulus, but not for a DOM or amphetamine stimulus. Taken together, the evidence suggests that PMMA, S(+)-MBDB, R(-)-MBDB, S(+)-3,4-DMA, R(-)-3,4-DMA, and S(+)-MDMA can produce common stimulus effects in rats. The present findings also better define the PMMA stimulus and the structural requirements necessary to produce this type of stimulus effect.

Nail apparatus melanoma

Nail apparatus melanoma is a relatively rare variant of melanoma with a disproportionately high mortality when compared with melanoma elsewhere. The aetiology and natural history remain poorly understood. There is no clear epidemiological association with race, skin type or sun exposure. Universally accepted clinical and histological criteria for the diagnosis of early nail apparatus melanoma have not been defined. The two cardinal clinical signs are melanonychia striata and Hutchinson's sign. These are useful but not pathognomonic of melanoma. Diagnostic delay is frequent and patients commonly have advanced disease at the time of diagnosis. Surgical excision is advocated for treatment of stage I disease; however, the most appropriate re-excision margins, including the level of amputation where required, have not been determined. Early diagnosis and excision of the tumour is the only treatment known to increase survival. Adjuvant systemic chemotherapy, isolated limb perfusion, and routine elective lymph node dissection have been used, but no survival benefit has been demonstrated.

Experimental implementation of a Wiener filter in a hybrid digital--optical correlator

We present the implementation of a clutter-tolerant filter in a hybrid correlator system. Wiener filters were mapped with a complex encoding technique onto a smectic A(*) liquid-crystal spatial light modulator (SLM). The technique overcomes the problem of representing high-dynamic-range data on SLM's that have limited modulation capabilities. It also provides a compact image recognition system that is robust enough for many real-world applications. Experimental results are presented.

Genetic analysis of the T4 holin: timing and topology

The t protein of bacteriophage T4 shares with other holins the ability to cause the formation of a lethal membrane lesion which allows the phage endolysin to attack the peptidoglycan. Moreover, T, like other holins, acts in a saltatory manner at a precisely programmed time in the vegetative cycle. Unlike other holins, however, T has the unique ability to postpone its lethal function in response to a secondary infection by a T-even phage during the vegetative cycle. A signal transduction system that responds to the secondary infection is thought to be encoded by some of the numerous r genes, defined by mutations that abolish this lysis-inhibition (LIN) response. The primary structure of T differs from two main structural patterns found in more than 30 orthologous groups of holins. Genetic approaches were taken to probe the t sequence for features involved in membrane localization, functional timing and LIN regulation. Gene fusion analysis indicates that T has a single TMD near the N-terminus, with the bulk of the protein residing in the periplasm. Mapping and phenotypic analysis of deletion and point mutations in t indicates that the periplasmic domain of T is the major determinant of the timing mechanism and is involved in the LIN response.

The lysis protein E of phi X174 is a specific inhibitor of the MraY-catalyzed step in peptidoglycan synthesis

Coliphage phi X174 encodes a single lysis protein, E, a 91-amino acid membrane protein. Dominant mutations have been isolated in the host gene mraY that confer E resistance. mraY encodes translocase I, which catalyzes the formation of the first lipid intermediate in bacterial cell wall synthesis, suggesting a model in which E inhibits MraY and promotes cell lysis in a manner analogous to cell wall synthesis inhibitors like penicillin. To test this model biochemically, we monitored the effect of E on cell wall synthesis in vivo and in vitro. We find that expression of Emyc, encoding an epitope-tagged E protein, from a multicopy plasmid inhibits the incorporation of [(3)H]diaminopimelic acid into cell wall and leads to a profile of labeled precursors consistent with MraY inhibition. Moreover, we find that membranes isolated after Emyc expression are drastically reduced in MraY activity, whereas the activity of Rfe, an enzyme in the same superfamily, was unaffected. We therefore conclude that E is indeed a cell wall synthesis inhibitor and that this inhibition results from a specific block at the MraY-catalyzed step in the pathway.

Effect of carbon dioxide on the Oriental cockroach Blatta orientalis

Exposure to high concentrations of carbon dioxide (CO2) killed adult and nymphal stages of the oriental cockroach Blatta orientalis L. (Dictyoptera: Blattidae) with LT50 values of 11.5-16.2 h for 60% CO2 in air and 5.7-7.1 h for 100% CO2 at 20 degrees C; corresponding LT50s at 28 degrees C were 2.8-4.6 h for 60% CO2 in air and 2.3-3.6 h for 100% CO2. Complete kill of mobile stages was obtained within 24 h using 60% CO2 at 20 degrees C. Survivors of treatments with 100% CO2 at 28 degrees C remained completely paralysed for up to 3 days post-treatment and took up to 5 days to regain normal movement, but adult females then resumed production of oothecae with no significant loss in fecundity. Oothecae 5 or 30 days after deposition required 60-84 h exposure to 60% CO2 at 20 degrees C to prevent emergence of nymphs but less time using 100% CO2 at 28 degrees C. At 28 degrees C, when adult females were treated with 100% CO2 and 52% r.h. for 6 h (giving 100% mortality) loss of weight was significantly greater than that following treatment with air at 52% r.h. for 6 h (giving no mortality). However, significantly greater weight loss also occurred when they were treated with dried air (< 10% r.h.) for 6 h, also with no mortality. The toxicity of CO2 to mobile stages of the oriental cockroach appeared to result from irreversible effects on the nervous system, rather than from water loss during exposure.