Discrimination in the dark. Resolving the interplay between metabolic and physical constraints to phosphoenolpyruvate carboxylase activity during the crassulacean acid metabolism cycle

A model defining carbon isotope discrimination (delta13C) for crassulacean acid metabolism (CAM) plants was experimentally validated using Kalanchoe daigremontiana. Simultaneous measurements of gas exchange and instantaneous CO2 discrimination (for 13C and 18O) were made from late photoperiod (phase IV of CAM), throughout the dark period (phase I), and into the light (phase II). Measurements of CO2 response curves throughout the dark period revealed changing phosphoenolpyruvate carboxylase (PEPC) capacity. These systematic changes in PEPC capacity were tracked by net CO2 uptake, stomatal conductance, and online delta13C signal; all declined at the start of the dark period, then increased to a maximum 2 h before dawn. Measurements of delta13C were higher than predicted from the ratio of intercellular to external CO2 (p(i)/p(a)) and fractionation associated with CO2 hydration and PEPC carboxylations alone, such that the dark period mesophyll conductance, g(i), was 0.044 mol m(-2) s(-1) bar(-1). A higher estimate of g(i) (0.085 mol m(-2) s(-1) bar(-1)) was needed to account for the modeled and measured delta18O discrimination throughout the dark period. The differences in estimates of g(i) from the two isotope measurements, and an offset of -5.5 per thousand between the 18O content of source and transpired water, suggest spatial variations in either CO2 diffusion path length and/or carbonic anhydrase activity, either within individual cells or across a succulent leaf. Our measurements support the model predictions to show that internal CO2 diffusion limitations within CAM leaves increase delta13C discrimination during nighttime CO2 fixation while reducing delta13C during phase IV. When evaluating the phylogenetic distribution of CAM, carbon isotope composition will reflect these diffusive limitations as well as relative contributions from C3 and C4 biochemistry.

Hearing threshold assessment post grommet insertion. Is it reliable?

We aimed to investigate whether auditory brainstem response (ABR), assessed immediately after grommet insertion, was an accurate measure of hearing threshold.

Ten children were recruited (20 ears). Patients underwent transient evoked otoacoustic emission (TEOAE) and ABR tests before and after grommet insertion under general anaesthetic. A third assessment was conducted at a six-week review, without anaesthetic or sedation. The hearing threshold in dB and the presence of TEOAE were recorded by senior audiologists. The results of each investigation were compared. At review, only 15 ABR and 17 TEOAE tests, of a possible 20, were recorded.

Transient evoked otoacoustic emissions were recorded in 30 per cent of ears pre-operatively, 20 per cent of ears post-operatively and 82 per cent of ears at six-week review. The average ABR thresholds were 23.75 dB (range 10–45 dB) pre-operatively, 27.25 (range 15–40 dB) post-operatively and 15 dB (range 5–25 dB) at six-week review. Comparing pre- and post-operative assessment, decreased thresholds were seen in six ears and elevated thresholds in 11. Comparing the six-week review ABR with the post-operative ABR, 13 ears had decreased thresholds, by as much as 20 dB. Thresholds of 35 dB or greater were measured in six ears immediately after grommet insertion (maximum 40 dB). Threshold shifts of 15 dB or greater was observed in seven ears. The intra-subject variation was shown to be significant (p<0.001) when repeated measures analysis of variance was applied.

We conclude that there is evidence that ABR can be inaccurate after grommet insertion, overestimating hearing thresholds. We believe that the mechanism by which the error is realised is temporary threshold shift.

Manual handling risk management: critical care beds and support systems

This article examines the reduction of manual handling risk to nurses through discussion of the technical and ergonomic features of critical care beds and support systems. It describes the features of different types of manual handling equipment, in particular trolleys, beds and patient platform support surfaces.

Competition for pulsed resources: an experimental study of establishment and coexistence for an arid-land grass

In arid environments, episodically-pulsed resources are important components of annual water and nutrient supply for plants. This study set out to test whether seedlings have an increased capacity for using pulsed resources, which might then improve establishment when in competition with older individuals. A second aim was to determine whether there is a trade-off in competitive strategies when resources are supplied continuously at low concentrations, or as pulses with pronounced inter-pulse periods. A glasshouse experiment used a target-neighbour design of size-asymmetric competition, with juveniles of Panicum antidotale (blue panicgrass) introduced into contrasting densities of adult plants. Stable isotopes of nitrogen were used for measuring plant resource uptake from pulses, and tolerance to inter-pulse conditions was assessed as the mean residence time (MRT) of nitrogen. A higher root/shoot ratio and finer root system enhanced the capacity of juveniles to use resources when pulsed, rather than when continuously supplied. Higher resource uptake during pulses improved the establishment of juvenile Panicum in mixed cultures with older individuals. However, a trade-off was observed in plant strategies, with juveniles showing a lower MRT for nitrogen, which suggested reduced tolerance to resource deficit during inter-pulse periods. Under field conditions, higher utilization of pulsed resources would lead to the improved seedling establishment of Panicum adjacent to "nurse" plants, whereas mature plants with well-developed roots, exploiting a greater soil volume, maintain more constant resource uptake and retention during inter-pulse periods.

Positioning critically ill patients in hospital

Although moving and handling is an important aspect of nurse training, the emphasis is often more on the health and safety of the nurse than on the importance of the correct therapeutic positioning of patients. This article outlines optimum patient positioning in different critical care settings and for different medical conditions.

The use of ezetimibe in achieving low density lipoprotein lowering goals in clinical practice: position statement of a United Kingdom consensus panel

There is no doubt that lowering serum cholesterol levels reduces the risk of major coronary events. This evidence has led treatment guidelines to set progressively lower targets for low density lipoprotein cholesterol (LDL-C). However, despite widespread use of statins, substantial numbers of patients do not achieve the LDL-C goals. Using higher doses of statins in an attempt to achieve these targets may increase the risk of serious adverse effects. Furthermore, the use of combination therapy with agents such as bile acid sequestrants, niacin and fibrates has been limited by increased potential for side effects, drug interactions and poor compliance. Ezetimibe, a selective cholesterol transport inhibitor, reduces the intestinal uptake of cholesterol without affecting absorption of triglycerides or fat-soluble vitamins. In clinical studies, ezetimibe 10 mg, in combination with statins or as monotherapy, was well tolerated and reduced LDL-C by 34-53% and 17-18%, respectively. The available evidence for ezetimibe is reviewed. The role of ezetimibe in increasing the proportion of patients attaining LDL-C treatment goals is discussed.

A comparison of sensors for minimizing the primary signal in planar-array magnetic induction tomography

In magnetic induction tomography reducing the influence of the primary excitation field on the sensors can provide a significant improvement in SNR and/or allow the operating frequency to be reduced. For the purposes of imaging, it would be valuable if all, or a useful subset, of the detection coils could be rendered insensitive to the primary field for any excitation coil activated. Suitable schemes which have been previously suggested include the use of axial gradiometers and coil-orientation methods (Bx sensors). This paper examines the relative performance of each method through computer simulation of the sensitivity profiles produced by a single sensor, and comparison of reconstructed images produced by sensor arrays. A finite-difference model was used to determine the sensitivity profiles obtained with each type of sensor arrangement. The modelled volume was a cuboid of dimensions 50 cmx50 cmx12 cm with a uniform conductivity of 1 S m-1. The excitation coils were of 5 cm diameter and the detection coils of 5 mm diameter. The Bx sensors provided greater sensitivity than the axial gradiometers at all depths, other than on the surface layer of the volume. Images produced using a single-planar array were found to contain distortion which was reduced by the addition of a second array.

Design and performance of a planar-array MIT system with normal sensor alignment

In this study the performance of a planar array for magnetic induction tomography (MIT) was investigated and the results of measurements to determine the precision and sensitivity of the sensor were undertaken. A planar-array MIT system utilizing flux-linkage minimization for the primary field has been constructed and evaluated. The system comprises 4 printed excitation coils of 4 turns which were shielded, 8 surface-mount inductors of inductance 10 microH as sensor, mounted such that in principle no primary-field flux threads them, and a calibration coil to produce a strong primary field. The excitation current was multiplexed via relays to drive the excitation and reference coils. The noise values were similar in real and imaginary components in the lower frequencies and the factor to which the primary field could be reduced was greatest in the nearest coil. Methods for determining the true real and imaginary components and for flux-linkage minimization for the primary field for variations in channel sensitivities are described and the results of measurements of the system's noise and drift are given. A SNR of 47 dB was observed at 4 MHz when a 0.3 Sm-1 saline filled tank of dimensions 20 cmx20 cmx10 cm was placed centrally over the array. Finally, images were reconstructed from measurements of saline samples in a free space background, with the samples moved past the array in 21 1 cm steps to emulate mechanical scanning of the array. The image reconstruction characteristics of the planar array in conjunction with the reconstruction technique employed are discussed.

A primary field compensation scheme for planar array magnetic induction tomography

In biomedical magnetic induction tomography (MIT), measurement precision may be improved by incorporating some form of primary field compensation/cancellation scheme. Schemes which have been described previously include gradiometric approaches and the use of 'back-off' coils. In each of these methods, however, the primary field cancellation was achieved only for a single transmitter/receiver combination. For the purpose of imaging, it would be desirable for a fully electronically scanned MIT system to provide a complete set of measurements, all with the primary field cancelled. A single channel suitable for incorporation into an MIT system with planar-array geometry is described. The transmitter is a 6-turn coil of wire 5 cm in diameter. The receiver is a surface mount inductor, of inductance 10 microH, mounted such that, in principle, no net primary field flux threads it. The results of measurements carried out with the single channel system suggest that the signal due to the primary excitation field can be reduced on average by a factor of 298 by the sensor geometry over the operating frequency range 1-10 MHz. The standard deviation and drift of the signal with the system adjusted for maximum primary field cancellation, expressed as a percentage of the signal when the receiver coil was rotated until its axis of sensitivity lay along the primary field, were 0.0009% and 0.009%, respectively. The filter time constant used was 30 ms.

Parapharyngeal abscess: diagnosis, complications and management in adults

Parapharyngeal abscess may cause life-threatening complications. Peritonsillar abscess and tonsillitis may result in parapharyngeal abscess. Since the introduction of antibiotics, the incidence of parapharyngeal abscess secondary to tonsillitis and peritonsillar abscess has decreased dramatically. We present five cases of parapharyngeal abscess resulting from tonsillitis and peritonsillar infection extending to the parapharyngeal space in adult patients. Two were complicated by mediastinitis despite early treatment by wide spectrum antibiotics. We believe that early diagnosis and aggressive antibiotic treatment with early surgical drainage in cases associated with pus collection are the key points in preventing serious and fatal complications. We emphasize the diagnostic role of computerized tomography (CT) scan and the importance of early and proper drainage of these abscesses.

Nurse prescribing: developing the evaluation agenda

Nurse prescribing raises complex issues, including erosion of the medical monopoly on control of medication management, compensation for physician shortage and the introduction of guideline-driven prescribing (Jordan and Hughes 1996, McCartney et al 1999). This article sets the recent UK developments in context and discusses the evaluation agenda.

Normal complement C4 values do not exclude hereditary angioedema

This report describes a patient with hereditary angioedema (HAE) in whom complement C4 values were consistently normal. There was a family history of HAE, for which the patient had previously been screened, but in view of her normal C4 values she was deemed unaffected. However, at 10 years of age she presented with an eight month history of episodes of swelling affecting her hands and recurrent episodes of abdominal pain over the previous few months. In view of the recent clinical history of swellings and the family history of HAE, C4 and C1 inhibitor (C1inh) were measured. The C4 concentration was found to be within the normal range but the C1inh value was low (0.07 g/litre; normal range, 0.18-0.37). The patient was started on tranexamic acid and at an outpatient review three months later her episodes of swelling were occurring less often and were less severe. Although recent papers have suggested that the diagnosis of HAE can be excluded if complement C4 concentrations are normal, this case highlights the fact that C4 concentrations can be normal in this condition, and it is recommended that both C4 and C1inh concentrations should be measured to exclude HAE.

Administration of medicines. Part 2: Pharmacology

In the second part of this article, the authors examine the biological consequences for patients of changes in drug formulation, non-adherence to drug administration schedules and failure to accommodate drug/food interactions.

Administration of medicines. Part 1: The law and nursing

The authors outline the legal and professional consequences for nurses of failing to adhere to the law relating to the administration of medications. Part 2, next week, will look at the biological consequences for patients of non-adherence to drug administration schedules.

Does asbestos cause laryngeal cancer?

Asbestos is a known carcinogen. Its role in the aetiology of laryngeal cancer has been investigated and debated for the last three decades. Here, we consider much of the published evidence from post-mortem studies, cross-sectional, case-control and cohort studies. We feel that the weight of evidence does not support a causal association for asbestos with laryngeal cancer. The 'positive studies' raise important questions regarding an association; the opportunity may present itself to answer some of these as the incidence of asbestos-related malignancy is increasing in the UK and Europe.

Physiological responses of the CAM epiphyte Tillandsia usneoides L. (Bromeliaceae) to variations in light and water supply

In an effort to understand the mechanisms that sustain rootless atmospheric plants, the modulation of Crassulacean acid metabolism (CAM) in response to variations in irradiance and water supply was investigated in the epiphyte Tillandsia usneoides. Plants were acclimated to three light regimes, i.e. high, intermediate and low, with integrated photon flux densities (PFD) of 14.40, 8.64 and 4.32 mol m-2 d-1 equivalent to an instantaneous PFD of 200, 100, and 50 mumol m-2 s-1, respectively. Daily watering was then withdrawn from half of the plants at each PFD for 7 d prior to sampling. In response to the three PFD treatments, chlorophyll content increased in plants acclimated to lower irradiances. Light response curves using non-invasive measurements of chlorophyll fluorescence demonstrated that photosystem II efficiency (phi PSII) was maintained in high PFD acclimated plants, as they exhibited a larger capacity for non-photochemical dissipation (NPQ) of excess light energy than low PFD acclimated plants. Net CO2 uptake increased in response to higher PFD, reflecting enhanced carboxylation capacity in terms of phosphoenolpyruvate carboxylase (PEPc) and ribulose 1,5-bisphosphate carboxylase/oxygenase (Rubisco) activities. After water was withdrawn, nocturnal net CO2 uptake and accumulated levels of acidity declined in all PFD treatments, concomitant with increased respiratory recycling of malate. Examining the strategies employed by epiphytes such as T. usneodies to tolerate extreme light and water regimes has demonstrated the importance of physiological mechanisms that allow flexible carboxylation capacity and continued carbon cycling to maintain photosynthetic integrity.