An audit of clinical practice in the management of head injured patients following the introduction of the Scottish Intercollegiate Guidelines Network (SIGN) recommendations

A prospective study was conducted by the Scottish Trauma Audit Group (STAG) in A&E of Edinburgh Royal Infirmary to examine clinical practices in the management of head injured patients pre- and post-inception of the SIGN guidelines published in August 2000.1607 patients attended the department in two separate one month periods at equal intervals pre- and post-guidelines publication. The majority of patients with a SIGN indication for admission were admitted (93% pre- and 92% post-guidelines). For skull x ray (SXR) requests, in the pre-guidelines group, 92% of admitted patients with a SIGN indication for x ray had a SXR: this figure dropped to 79% post-guidelines. 36% of patients with a SIGN indication for CT actually had a scan pre-guidelines: this figure increased to 64% post-guidelines.57% of patients pre-guidelines and 44% of patients post-guidelines were discharged from A&E in accordance with the SIGN recommendations. Of patients admitted for neurological observations, this increased from 50% pre- to 88% post-guidelines. Of patients who were discharged "inappropriately", only one re-presented and was subsequently admitted but required no neurosurgical intervention. Despite publication of the SIGN guidelines and positive reinforcement in A&E and at ward level, practice has not changed significantly. Where our practice did not adhere to SIGN recommendations, there was no untoward sequelae. For published national guidelines to be effective, a formal audit structure with regular feedback is necessary to ensure a continued change in clinical practices.

Attitudes towards second hand smoke amongst a highly exposed workforce: survey of London casino workers

STUDY OBJECTIVE

To examine knowledge, attitudes and experiences of London casino workers regarding exposure to second hand smoke (SHS) in the workplace.

DESIGN

Postal survey of 1568 London casino workers in 25 casinos who were members of the TGWU or GMB Trade Unions.

MAIN RESULTS

Of the workers, 559 responded to the survey (36% response), 22% of whom were current smokers. Of the respondents, 71% report being nearly always exposed to heavy levels of SHS at work, and most (65%) want all working areas in their casino to be smoke-free. The majority (78%) are bothered by SHS at work, while 91% have wanted to move away from where they are working because of it. Fifty-seven per cent believe their health has suffered as a result of SHS. Of the workers who smoke at work, 59% believe that they would try to quit smoking if no one was allowed to smoke in the casino.

CONCLUSIONS

The majority of responders are bothered by SHS, and many are concerned about the health impacts. Most want all working areas in their casino to be smoke-free. Despite difficulties in generalizing from this limited sample, these findings add weight to the argument that the legislation on smoking in public places in England should encompass all workplaces, without exemption.

Strain distribution in an elastic substrate vibrated in a bioreactor for vocal fold tissue engineering

A bioreactor previously described was used to quantify the shear strain along a bioengineered tissue scaffold driven at low audio frequencies (20-200 Hz). Standing wave patterns were calculated analytically by solving a classical boundary value problem for a vibrating string under tension and bending stiffness. Boundary conditions were non-traditional in that small pivot arms at the endpoints allowed neither the displacement nor the velocity to go to zero. The calculations were corroborated with stroboscopic measurement of the motion of the material in the bioreactor. Results indicate that shear strains up to 0.2 can be obtained at low frequencies (20 Hz), with a gradual decrease at higher frequencies due to the decaying amplitude response of the mechanical driver. The bioreactor may be useful for approximating the Young's modulus of the material in situ by probing for resonance frequencies in the standing wave pattern. A yet unsolved problem is a variable drag coefficient along the length of the material due to fluid turbulence in the culture medium.

Suppression of Raman gain in single-transverse-mode dual-hole-assisted fiber

Measurements of backscattered Raman amplified spontaneous emission in single-mode dual-hole-assisted fiber indicate suppression of Raman gain by more than two orders of magnitude compared to SMF. These results imply that fiber lasers based on the dual-hole-assisted fiber design are effectively immune to SRS, thus enabling significant power scaling beyond current limits from a single-mode core.

A survey of the specialist public health workforce in the UK in 2003

OBJECTIVES

To identify the number and distribution of public health specialists in the UK.

STUDY DESIGN

Cross-sectional survey.

METHODS

Postal survey of UK members and fellows of the Faculty of Public Health and primary care trust directors of public health in England in October 2003.

RESULTS

Of 1993 individuals surveyed, 1566 (78%) responded, of whom 1331 reported working as consultants or specialists in public health in the UK. Of the 1331, 891 (67%) were on the General Medical Council Specialist Register, 53 (4%) were on the General Dental Council Register, and 92 (7%) were in the process of applying for the Voluntary Register; 295 (22%) did not appear to be on any professional register or in the process of applying to the Voluntary Register. This equated to a total UK rate of 14.1 per million 'service' public health. There was substantial variation by region from 9.3 per million population in Wales and the South West to 18.0 per million population in the West Midlands and 19.5 per million population in London. An increase of 218 (21%) additional consultants and specialists in public health across the UK would be required to bring other regions up to the level of the highest region.

CONCLUSIONS

This survey, although limited, being based on a survey of members and fellows of the Faculty of Public Health, shows that specialist public health is under capacity, is resourced in a highly variable manner, and needs to be built up to meet the challenges we face. A comprehensive workforce plan for public health is urgently needed.

The molecular diversity of the methanogenic community in a hypereutrophic freshwater lake determined by PCR-RFLP

AIMS

To combine database-held sequence information with a programme of experimental molecular ecology to define the methanogenic community of a hypereutrophic lake by a PCR-restriction fragment length polymorphism (RFLP) analysis.

METHODS AND RESULTS

Methanogen diversity in a hypereutrophic freshwater lake was analysed using 16S rDNA PCR-RFLP. Database-held 16S rRNA gene sequences for 76 diverse methanogens were analysed for specific restriction sites that permitted unequivocal differentiation of methanogens. Restriction digestion and agarose gel electrophoresis of the 16S rDNA from selected methanogen pure cultures generated observed restriction profiles that corroborated the expected patterns. This method was then tested by analysing methanogen diversity in samples obtained over 1 year from sediment and water samples taken from the same sampling site.

CONCLUSIONS

Restriction analysis of the 16S rRNA gene sequences from 157 methanogen clones generated from lakewater and sediment samples showed that over 50% were similar to Methanoculleus spp. Furthermore, a total of 16 RFLP types (1-16) were identified, eight of which contained no cultured representative archaeal 16S rRNA gene sequences.

SIGNIFICANCE AND IMPACT OF THE STUDY

This RFLP strategy provides a robust and reliable means to rapidly identify methanogens in the environment.

Vaskul�re Ver�nderungen in der Pathogenese der systemischen Sklerose

Systemic sclerosis (SSc, scleroderma) is a connective tissue disease of unknown etiology. Perivascular inflammatory infiltrates and endothelial apoptosis with an impaired angiogenesis are observed in early stages of the disease, whereas later stages are characterized by an excessive accumulation of extracellular matrix proteins in the skin and various internal organs. Consistent with the ongoing endothelial cell damage, various markers of endothelial cells such as endothelin-1, sICAM-1, s-VCAM-1 and thrombomodulin are found in high levels in the serum of SSc patients. Surprisingly, the vascular endothelial growth factor (VEGF), a potent angiogenic molecule, is overexpressed in the skin of patients with SSc despite insufficient angiogenesis. Interestingly, patients suffering from diffuse SSc and patients without finger tip ulcers show higher VEGF levels compared to age- and sex-matched controls. These results indicate that a controlled overexpression of VEGF might help to protect against the manifestation of ischemic conditions. On the other hand, data from animal models indicate that a long-term, uncontrolled overexpression of VEGF might have paradox effects on the formation of new vessels leading to capillary changes similar to those observed in SSc. In addition to the impaired angiogenesis, defective vasculogenesis might contribute to the vascular symptoms of SSc.

Lack of evidence for significant neuronal loss in laminae I-III of the spinal dorsal horn of the rat in the chronic constriction injury model

Peripheral nerve injury leads to structural and functional changes in the spinal dorsal horn, and these are thought to be involved in the development of neuropathic pain. In the chronic constriction injury (CCI) model, abnormal 'dark' neurons and apoptotic nuclei have been observed in laminae I-III of the dorsal horn in the territory innervated by the injured sciatic nerve. These findings have been taken as evidence that there is significant neuronal death in this model, and it has been suggested that loss of inhibition resulting from death of GABAergic inhibitory interneurons contributes to the neuropathic pain. However, loss of neurons from the dorsal horn has not been directly demonstrated in neuropathic models, even though this issue is of considerable importance for our understanding of the mechanisms that underlie neuropathic pain. In this study, we have looked for evidence of neuronal death by using a stereological method (the optical disector) with NeuN-immunostaining, and examining spinal cords of naïve rats, and of rats that had undergone CCI or sham operations. All of the CCI animals showed clear signs of thermal hyperalgesia. However, the numbers of neurons in laminae I-III of the ipsilateral dorsal horn in these animals did not differ significantly from those on the contralateral side, nor from those of sham-operated or naïve animals. These results do not, therefore, support the suggestion that there is significant neuronal death in the dorsal horn in this model.

Increased skeletal muscle expression of PKC-theta but not PKC-alpha mRNA in type 2 diabetes: inverse relationship with in-vivo insulin sensitivity

BACKGROUND

Increases in PKC-theta (the major isoenzymic form of PKC in skeletal muscle) protein and isozyme activity have been reported in skeletal muscle from patients with type 2 diabetes mellitus (T2DM) and dietary-induced rodent models of insulin resistance, but the underlying biochemical mechanism is unclear and muscle PKC-theta mRNA expression has not been previously reported in patients with T2DM or in relation to in-vivo measurements of insulin sensitivity.

METHODS

Diet-only treated patients with T2DM (n=7) and healthy nondiabetic controls (n=7) of similar BMI attended the clinical research unit on two occasions, 1 week apart, for a skeletal muscle biopsy 2 h after a 75-g oral glucose load and measurement of whole-body insulin sensitivity using the euglycaemic hyperinsulinaemic clamp.

RESULTS

Type 2 DM patients were insulin resistant (M-value 3.0 +/- 0.4 vs. 8.6 +/- 0.8 mg glucose kg(-1) min(-1)) with fasting hyperinsulinaemia (306 +/- 116 vs. 34 +/- 9 pmol L(-1), P<0.001) and hypertriglyceridaemia (3.6 +/- 0.7 vs. 1.3 +/- 0.3 mmol L(-1), P<0.01) relative to controls. Semi-quantitative RT-PCR showed that expression of PKC-theta mRNA (relative to GAPDH mRNA) was 6-fold higher in T2DM subjects (0.63 + 0.25% vs. 0.09 + 0.07%, P<0.001), whereas there was no difference in expression of PKC-alpha mRNA between the two groups. Expression of PKC-theta mRNA was inversely correlated with insulin sensitivity (M) and positively correlated with fasting serum insulin concentration (P<0.02).

CONCLUSIONS

This is the first clinical study of PKC-theta mRNA expression in human diabetic skeletal muscle. The results indicate that transcriptional up-regulation of PKC-theta may at least partly contribute to the increased muscle PKC-theta signalling in T2DM, and that PKC-theta mRNA may be inversely related to in-vivo insulin sensitivity.

Effects of rosiglitazone and oleic acid on UCP-3 expression in L6 myotubes

AIMS

The regulation of uncoupling protein-3 (UCP-3) expression in muscle remains unclear, specifically in relation to dietary and drug treatments. The present study evaluated the effects of oleic acid and rosiglitazone on UCP-3 mRNA expression in differentiated L6 myotubes.

METHODS

L6 myocytes were cultured and differentiated prior to exposure to rosiglitazone 10 micro mol/l, oleic acid 100 micro mol/l, or the combination, for 24 h, prior to semiquantitative evaluation of UCP-3 mRNA relative to GAPDH mRNA by RT-PCR.

RESULTS

Exposure to oleic acid produced a significant increase in UCP-3 mRNA (0.012 +/- 0.007 vs. 0.0011 +/- 0.0006 for untreated cells, relative to GAPDH mRNA, p < 0.001). Rosiglitazone alone had no effect on UCP-3 expression and nor did the glitazone affect oleic-acid-induced upregulation of UCP-3.

CONCLUSIONS

In L6 myotubes, 24-h exposure to oleic acid produced a 10-fold increase in UCP-3 mRNA expression, but rosiglitazone had no effect. Oleic-acid-induced upregulation of UCP-3 was not affected (positively or negatively) by glitazone exposure.

Rosiglitazone and pulmonary oedema: an acute dose-dependent effect on human endothelial cell permeability

AIMS/HYPOTHESIS

Peripheral and pulmonary oedema has emerged as the most common drug-related side effect of rosiglitazone in clinical practice, but the underlying mechanisms are not clear. Fluid retention and changes in vascular tone could contribute to oedema formation, but the interpretation of clinical and in vivo studies is particularly difficult and the direct effects of thiazolidinediones on endothelial barrier function have not been previously reported.

METHODS

Human pulmonary artery endothelial cells were seeded and grown on 0.4 microm collagen-coated filters to form a tight monolayer (transendothelial electrical resistance 9-11 ohms.cm(-2) after 2-3 days). Transendothelial albumin flux (expressed as the percentage clearance of albumin relative to control) was measured using Evans blue-labelled albumin after exposure to rosiglitazone 1-100 micromol/l for 1 h to 48 h, and after removal of drug from the monolayer.

RESULTS

Incubation of pulmonary artery endothelial cells with rosiglitazone for 4 h produced immediate concentration-dependent increases in transendothelial albumin flux: e.g., relative to control (100%), 113%+/-13% (1 micromol/l), 215%+/-37% (10 micromol/l, p=0.01) and 461%+/-96% (100 micromol/l, p=0.002) (n=12). There was no effect after 1 h. The acute hyperpermeability response to rosiglitazone, maximal after 4 h, was fully reversible after washing the monolayer. After incubation for 24 to 48 h the effect of rosiglitazone on pulmonary endothelial permeability tended to subside: e.g., 210%+/-59% (24 h) for rosiglitazone 100 micromol/l (p=0.06).

CONCLUSION/INTERPRETATION

Exposure to high-therapeutic concentrations of rosiglitazone causes a reversible fourfold increase in pulmonary endothelial permeability which could be clinically relevant especially at higher doses and at times of peak plasma drug concentration.

Evaluating integrated urban water systems alternatives for Brisbane, Australia

The Brazil Development Study investigates the feasibility of alternative approaches to providing sustainable water services to a 226 ha mixed residential and industrial greenfield development within the city of Brisbane, Australia. The alternatives include techniques such a the use of rainwater tanks, water use efficiency, a local wastewater treatment plant for recycling of reclaimed water and composting toilets amongst others. This paper evaluates a series of urban development scenarios against the objectives of the study. The insights gained into the drivers for cost and environmental impact for this particular site are discussed as well as a number of issues of concern and challenges to Council and the community.

Wastewater services for small communities

Connection to centralised regional sewage systems has been too expensive for small-dispersed communities, and these townships have traditionally been serviced by on-site septic tank systems. The conventional on-site system in Australia has consisted of an anaerobic holding tank followed by adsorption trenches. This technique relies heavily on the uptake of nutrients by plants for effective removal of nitrogen and phosphorus from the effluent, and is very seasonal in its efficiency. Hence, as these small communities have grown in size, the environmental effects of the septic tank discharges have become a problem. In locations throughout Australia, such as rural Victoria and along the Hawkesbury-Nepean River, septic tanks as being replaced with the transport of sewage to regional treatment plants. For some isolated communities, this can mean spending 20,000 dollars-40,000 dollars/household, as opposed to more common connection prices of 7,000 dollars/household. This paper explores some alternative options that might be suitable for these small communities, and attempts to identify solutions that provide acceptable environmental outcomes at lower cost. The types of alternative systems that are assessed in the paper include local treatment systems, separate blackwater and greywater collection and treatment systems both with and without non-potable water recycling, a small township scale treatment plant compared to either existing septic tank systems or pumping to a remote regional treatment facility. The work demonstrated the benefits of a scenario analysis approach for the assessment of a range of alternative systems. It demonstrated that some of the alternatives systems can achieve better than 90% reductions in the discharge of nutrients to the environment at significantly lower cost than removing the wastewater to a remote regional treatment plant. These concepts allow wastewater to be retained within a community allowing for local reuse of treated effluent.

Antidepressant prescribing in nursing homes: is there a place for tricyclics?

OBJECTIVE

To deduce a model describing physicians' choice of antidepressants for treating elderly nursing home patients.

METHODS

Subjects were geriatric residents of 137 skilled nursing facilities who regularly received an antidepressant medication for at least one month (n = 3,440, 28% of all residents). Reasons for prescribing antidepressants and physicians' diagnoses of depression and dementia were identified by medical record audit. Residents were grouped by dementia and antidepressant target symptoms (depression, or one or more non-psychiatric symptoms, i.e. insomnia, pain, incontinence, itching).

RESULTS

Selective serotonin reuptake inhibitors (SSRIs) were prescribed preferentially over tricyclic antidepressants (TCAs) for treating depression in both demented and non-demented residents, but TCAs were nine times more likely to be prescribed for treating non-psychiatric target symptoms alone. When non-psychiatric target symptoms were present without depression or dementia, both amitriptyline and nortriptyline prescribing was increased, but amitriptyline appeared to be the antidepressant of choice. In all subgroups examined, its use was two to five times more prevalent when such symptoms were present. In patients with dementia, amitriptyline prescribing declined whether or not non-psychiatric target symptoms were present, but nortriptyline prescribing did not; nortriptyline was three times more likely than amitriptyline to be prescribed in the presence of dementia.

CONCLUSIONS

Physicians prescribe anticholinergic TCAs principally to treat common non-depressive symptoms in nursing home residents, preferring SSRIs for uncomplicated depression and depression with dementia. They tend to avoid prescribing anticholinergic TCAs other than nortriptyline when they recognize a patient as demented. The data suggest that physicians employ a decision model for antidepressant prescribing that simultaneously recognizes the utility of TCAs in treating non-psychiatric symptoms and the anticholinergic vulnerability of older, especially demented, patients. Whether or not this model leads to optimal patient management requires further study.

Does the angiotensin-converting enzyme (ACE) gene polymorphism affect rate of abdominal aortic aneurysm expansion?

OBJECTIVES

the tissue renin-angiotensin system (RAS), which plays an important role in vascular structure and function, is regulated in part by an insertion-deletion polymorphism of the angiotensin converting enzyme (ACE) gene. We hypothesised that ACE genotype might affect rate of AAA expansion via modulating long-term structural changes associated with RAS activation.

METHODS

fifty-eight patients (50 M, mean age 70 years, mean initial aneurysm size 4.3 cm) with current or previous AAA and serial (>3) annual ultrasound measurements of antero-posterior AAA size provided a sample of leucocyte DNA for ACE genotyping. AAA expansion rate (cm per year) for individual subjects was calculated by linear regression.

RESULTS

median AAA expansion rate was 0.28 cm/year (range 0-1.8 cm/year), and the genotype distribution included DD (n=14), DI (n=29) and II (n=15). Corresponding median AAA expansion rates for each of the three genetic subgroups were 0.22, 0.32 and 0.30 cm/year, respectively (p=0.6, nonparametric).

CONCLUSIONS

the wide inter-individual variability in AAA expansion rate is likely to reflect complex genetic and environmental interactions, but the lack of any relationship with ACE genotype suggests that differences in vascular ACE activity in aortic tissue are not major determinants of the variability in rate of AAA dilatation.

Characterization of humoral and cellular immune responses elicited by meningococcal carriage

In order to study the immune response elicited by asymptomatic carriage of Neisseria meningitidis, samples of serum, peripheral blood mononuclear cells (PBMCs), and saliva were collected from a cohort of more than 200 undergraduate students in Nottingham, United Kingdom, who were subject to high rates of acquisition and carriage of meningococci. Serum immunoglobulin G levels were elevated following increases in the rate of carriage, and these responses were specific for the colonizing strains. In order to investigate T-cell responses, PBMCs from 15 individuals were stimulated with a whole-cell lysate of the H44/76 meningococcal strain (B:15:P1.7,16), stained to detect cell surface markers and intracellular cytokines, and examined by flow cytometry. The cells were analyzed for expression of CD69 (to indicate activation), gamma interferon (IFN-gamma) (a representative T-helper 1 subset [Th1]-associated cytokine), and interleukin-5 (IL-5) (a Th2-associated cytokine). Following a brief meningococcal stimulation, the numbers of CD69(+) IFN-gamma(+) CD56/16(+) NK cells were much higher than cytokine-positive CD4(+) events. Both IFN-gamma(+) and IL-5(+) events were detected among the CD69(+) CD4(+) population, leading to the conclusion that an unbiased T-helper subset response was elicited by meningococcal carriage.

Tissue- and time-dependent effects of endothelin-1 on insulin-stimulated glucose uptake

Hyperendothelinaemia is associated with various insulin-resistant states, e.g., diabetes, obesity and heart failure, but whether endothelin-1 (ET-1) has a direct effect on insulin-mediated glucose uptake is unclear because the interpretation of in vivo metabolic studies is complicated by ET-1 effects on muscle blood flow and insulin secretion. This study investigated the effects of ET-1 (1-10 nM) on basal and insulin-stimulated 2-deoxy-D-[3H]glucose (2-DOG) uptake in cultured L6 myoblasts and 3T3-adipocytes. RT-PCR analysis showed that both cell types express ET(A) but not ET(B) receptors. ET-1 had no effect on basal (non-insulin-mediated) glucose transport, but there was evidence of a tissue- and time-dependent inhibitory effect of ET-1 on insulin-stimulated glucose uptake. Specifically, ET-1 10 nM had a transient (0.5 h) inhibitory effect on glucose uptake in 3T3 cells (C(I-150) [dose of insulin required to increase glucose uptake by 50%, relative to control 100%] increased from 89 +/- 14 nM to 270 +/- 12 nM at 30 mins, P < 0.05) but no effect on insulin sensitivity in L6 myoblasts (C(I-150) was 56 +/- 14 nM [control], 43 +/- 14 [30 mins] and 26 +/- 16 [2 h]). In conclusion, the inhibitory effect of ET-1 on insulin-stimulated glucose uptake is transient and occurs in 3T3-L1 adipocytes but not skeletal muscle-derived cells, perhaps reflecting tissue differences in ET(A)-receptor signaling. It is therefore unlikely that chronic hyperendothelinaemia has a direct insulin-antagonist effect contributing to peripheral (ie muscle/fat) insulin resistance in vivo.

Are routine chest X-rays for students entering university worthwhile?

Mass radiographic screening for tuberculosis has lost favour in many countries. The aim of this study was to determine whether the continued practice of such screening of prospective students at the University of the West Indies was warranted by assessing the yield and the cost of the programme in our setting. In a cross- sectional retrospective study, 12,662 chest X-ray reports collected over the period 1989-1997 were studied. No active case of tuberculosis was detected. Three students reported a previous history of tuberculosis and 10 students had a positive family history of tuberculosis. Three hundred and ninety-nine clinically insignificant abnormalities were reported, such as mild scoliosis and calcified foci. Routine radiological screening of prospective students at the University of the West Indies for tuberculosis has an extremely low yield, places the students at unnecessary risk of radiation exposure and should be discontinued.