Molecular evidence of anteroposterior patterning in adult echinoderms

The origin of the pentaradial body plan of echinoderms from a bilateral ancestor is one of the most enduring zoological puzzles1,2. Because echinoderms are defined by morphological novelty, even the most basic axial comparisons with their bilaterian relatives are problematic. To revisit this classical question, we used conserved anteroposterior axial molecular markers to determine whether the highly derived adult body plan of echinoderms masks underlying patterning similarities with other deuterostomes. We investigated the expression of a suite of conserved transcription factors with well-established roles in the establishment of anteroposterior polarity in deuterostomes3-5 and other bilaterians6-8 using RNA tomography and in situ hybridization in the sea star Patiria miniata. The relative spatial expression of these markers in P. miniata ambulacral ectoderm shows similarity with other deuterostomes, with the midline of each ray representing the most anterior territory and the most lateral parts exhibiting a more posterior identity. Strikingly, there is no ectodermal territory in the sea star that expresses the characteristic bilaterian trunk genetic patterning programme. This finding suggests that from the perspective of ectoderm patterning, echinoderms are mostly head-like animals and provides a developmental rationale for the re-evaluation of the events that led to the evolution of the derived adult body plan of echinoderms.

Opsin evolution in the Ambulacraria

Opsins--G-protein coupled receptors involved in photoreception--have been extensively studied in the animal kingdom. The present work provides new insights into opsin-based photoreception and photoreceptor cell evolution with a first analysis of opsin sequence data for a major deuterostome clade, the Ambulacraria. Systematic data analysis, including for the first time hemichordate opsin sequences and an expanded echinoderm dataset, led to a robust opsin phylogeny for this cornerstone superphylum. Multiple genomic and transcriptomic resources were surveyed to cover each class of Hemichordata and Echinodermata. In total, 119 ambulacrarian opsin sequences were found, 22 new sequences in hemichordates and 97 in echinoderms (including 67 new sequences). We framed the ambulacrarian opsin repertoire within eumetazoan diversity by including selected reference opsins from non-ambulacrarians. Our findings corroborate the presence of all major ancestral bilaterian opsin groups in Ambulacraria. Furthermore, we identified two opsin groups specific to echinoderms. In conclusion, a molecular phylogenetic framework for investigating light-perception and photobiological behaviors in marine deuterostomes has been obtained.

Clinical medication review by a pharmacist of patients on repeat prescriptions in general practice

Focal points

cDNA sequences for transcription factors and signaling proteins of the hemichordate Saccoglossus kowalevskii: efficacy of the expressed sequence tag (EST) approach for evolutionary and developmental studies of a new organism

We describe a collection of expressed sequence tags (ESTs) for Saccoglossus kowalevskii, a direct-developing hemichordate valuable for evolutionary comparisons with chordates. The 202,175 ESTs represent 163,633 arrayed clones carrying cDNAs prepared from embryonic libraries, and they assemble into 13,677 continuous sequences (contigs), leaving 10,896 singletons (excluding mitochondrial sequences). Of the contigs, 53% had significant matches when BLAST was used to query the NCBI databases (< or = 10(-10)), as did 51% of the singletons. Contigs most frequently matched sequences from amphioxus (29%), chordates (67%), and deuterostomes (87%). From the clone array, we isolated 400 full-length sequences for transcription factors and signaling proteins of use for evolutionary and developmental studies. The set includes sequences for fox, pax, tbx, hox, and other homeobox-containing factors, and for ligands and receptors of the TGFbeta, Wnt, Hh, Delta/Notch, and RTK pathways. At least 80% of key sequences have been obtained, when judged against gene lists of model organisms. The median length of these cDNAs is 2.3 kb, including 1.05 kb of 3' untranslated region (UTR). Only 30% are entirely matched by single contigs assembled from ESTs. We conclude that an EST collection based on 150,000 clones is a rich source of sequences for molecular developmental work, and that the EST approach is an efficient way to initiate comparative studies of a new organism.

Hox gene expression in the hemichordate Saccoglossus kowalevskii and the evolution of deuterostome nervous systems

The evolutionary origins of the chordate central nervous system remain uncertain. Conclusions drawn from classical morphological comparisons and from a broad range of metazoan phyla conflict with the new molecular genetic information from developmental model systems characterized by central nervous systems. This has led to debate as to the nature of the ancestral deuterostome nervous system. Hemichordates as basal deuterostomes occupy a phylogenetically critical position for addressing hypotheses on the evolution of the chordate nervous system. Characterizing the molecular basis of the development of their diffuse nervous system offers insights into the role of conserved body patterning genes in the evolution of specific neural anatomies. We present a description of hox gene expression during the development of the direct-developing hemichordate Saccoglossus kowalevskii. The nested ectodermal expression of these genes in a hemichordate suggest that they play a general patterning role in the anterior/posterior regionalization of the ectoderm of bilaterians rather than being uniquely associated with the development and evolution of central nervous systems.

Randomised controlled trial of clinical medication review by a pharmacist of elderly patients receiving repeat prescriptions in general practice

OBJECTIVE

To determine whether a pharmacist can effectively review repeat prescriptions through consultations with elderly patients in general practice.

DESIGN

Randomised controlled trial of clinical medication review by a pharmacist against normal general practice review.

SETTING

Four general practices.

PARTICIPANTS

1188 patients aged 65 or over who were receiving at least one repeat prescription and living in the community.

INTERVENTION

Patients were invited to a consultation at which the pharmacist reviewed their medical conditions and current treatment.

MAIN OUTCOME MEASURES

Number of changes to repeat prescriptions over one year, drug costs, and use of healthcare services.

RESULTS

590 (97%) patients in the intervention group were reviewed compared with 233 (44%) in the control group. Patients seen by the pharmacist were more likely to have changes made to their repeat prescriptions (mean number of changes per patient 2.2 v 1.9; difference=0.31, 95% confidence interval 0.06 to 0.57; P=0.02). Monthly drug costs rose in both groups over the year, but the rise was less in the intervention group (mean difference 4.72 pound sterling per 28 days, - 7.04 pound sterling to - 2.41 pound sterling); equivalent to 61 pound sterling per patient a year. Intervention patients had a smaller rise in the number of drugs prescribed (0.2 v 0.4; mean difference -0.2, -0.4 to -0.1). There was no evidence that review of treatment by the pharmacist affected practice consultation rates, outpatient consultations, hospital admissions, or death rate.

CONCLUSIONS

A clinical pharmacist can conduct effective consultations with elderly patients in general practice to review their drugs. Such review results in significant changes in patients' drugs and saves more than the cost of the intervention without affecting the workload of general practitioners.

"No thank you": why elderly patients declined to participate in a research study

OBJECTIVES

To compare the population consenting for a study of the effectiveness of a pharmacist-run medication review clinic with the population not consenting for patients aged over 65 years old with respect to age, sex and number of repeat medicines. To explore the reasons why some patients declined to consent to the study.

METHODS

Letters were sent to 2,403 patients aged 65 and over and taking at least one repeat medicine from 4 general practices. If no reply was received to a second letter they were followed up by telephone. If they declined to consent they were asked for their reasons. Data for consenting and non-consenting patients was collected on the stratification factors: age, sex and number of repeat medicines. Multiple logistic regression was used to assess the association of each factor with consent rates.

RESULTS

Consenting patients were dissimilar to non-consenting patients. Patients were less likely to consent if they were older, OR (95% CI) = 0.54 (0.46, 0.64), or female, OR (95% CI) = 0.74 (0.63, 0.88). Patients were more likely to consent if on 5 or more repeat medicines: OR (95% CI) = 1.3 (1.1, 1.5). Ten broad categories of reasons why patients did not wish to participate were identified from the patient interviews.

CONCLUSIONS

Patients were less likely to give their consent if they were elderly, female and on fewer repeat medicines. A number of administrative and behavioural factors were identified which reduced the chances of informed consent being given. These factors need to be addressed to maximise numbers of consenting patients in medication review studies.

Effects of a medicine review and education programme for older people in general practice

AIMS

To determine whether a medicine review and education programme influences the compliance and knowledge of older people in general practice.

METHODS

Older people taking at least three medicines were randomly allocated to a control or intervention group. Both groups received three visits from a clinical pharmacist: Visit 1: Assessment and patients' medicines rationalized in intervention group. Visit 2: Intervention group given medicines education. Visit 3: Knowledge and compliance in both groups assessed by structured questionnaire

RESULTS

Compliance in the intervention group was 91.3%, compared with 79.5% in the control group (P < 0.0001). The number of intervention group patients correctly understanding the purpose of their medicines increased from 58% to 88% on the second visit, compared with 67% to 70% in the control group (P < 0.0005).

CONCLUSIONS

A general practice based medication review and education programme improved medicine compliance and knowledge of older people in the short term.

Development of a method for clinical medication review by a pharmacist in general practice

Medication review of patients on long-term treatment in general practice in the UK has been reported to be inadequate. Proposals followed suggesting that pharmacists could use their expertise to lead such a medication review in conjunction with the general practitioner. This paper describes the concept of clinical medication review by a pharmacist based in general practice. We describe the development of a method for a structured and systematic process for undertaking such a review in clinics conducted by a pharmacist. The method was developed for a nationally funded study in the UK. We provide a definition of clinical medication review and suggests a structure for the process through data gathering, evaluation and implementation.

Developmental regulatory genes and echinoderm evolution

Modified interactions among developmental regulatory genes and changes in their expression domains are likely to be an important part of the developmental basis for evolutionary changes in morphology. Although developmental regulatory genes are now being studied in an increasing number of taxa, there has been little attempt to analyze the resulting data within an explicit phylogenetic context. Here we present comparative analyses of expression data from regulatory genes in the phylum Echinodermata, considering the implications for understanding both echinoderm evolution as well as the evolution of regulatory genes in general. Reconstructing the independent evolutionary histories of regulatory genes, their expression domains, their developmental roles, and the structures in which they are expressed reveals a number of distinct evolutionary patterns. A few of these patterns correspond to interpretations common in the literature, whereas others have received little prior mention. Together, the analyses indicate that the evolution of echinoderms involved: (1) the appearance of many apomorphic developmental roles and expression domains, some of which have plesiomorphic bilateral symmetry and others of which have apomorphic radial symmetry or left-right asymmetry; (2) the loss of some developmental roles and expression domains thought to be plesiomorphic for Bilateria; and (3) the retention of some developmental roles thought to be plesiomorphic for Bilateria, although with modification in expression domains. Some of the modifications within the Echinodermata concern adult structures; others, transient larval structures. Some changes apparently appeared early in echinoderm evolution (> 450 Ma), whereas others probably happened more recently (< 50 Ma). Cases of likely convergence in expression domains suggest caution when using developmental regulatory genes to make inferences about homology among morphological structures of distantly related taxa.

Radical alterations in the roles of homeobox genes during echinoderm evolution

Echinoderms possess one of the most highly derived body architectures of all metazoan phyla, with radial symmetry, a calcitic endoskeleton, and a water vascular system. How these dramatic morphological changes evolved has been the subject of extensive speculation and debate, but remains unresolved. Because echinoderms are closely related to chordates and postdate the protostome/deuterostome divergence, they must have evolved from bilaterally symmetrical ancestors. Here we report the expression domains in echinoderms of three important developmental regulatory genes (distal-less, engrailed and orthodenticle), all of which encode transcription factors that contain a homeodomain. Our findings show that the reorganization of body architecture involved extensive changes in the deployment and roles of homeobox genes. These changes include modifications in the symmetry of expression domains and the evolution of several new developmental roles, as well as the loss of roles conserved between arthropods and chordates. Some of these modifications seem to have evolved very early in the history of echinoderms, whereas others probably evolved during the subsequent diversification of adult and larval morphology. These results demonstrate the evolutionary lability of regulatory genes that are widely viewed as conservative.

Hepatocellular carcinoma presenting as a pancreatic head mass: report of an unusual case

Hepatocellular carcinoma (HCC) spreading to the pancreas is rare and, when it does occur, is most often detected as a late finding at autopsy. We report the first case of HCC initially presenting as a pancreatic mass. Computed tomography (CT) scan showed a 7-cm mass in the dome of the liver and a 3-cm pancreatic head mass causing biliary and duodenal obstruction. Palliative surgery was performed to bypass the pancreatic obstruction. During the operation, fine needle aspiration (FNA) was performed on the pancreatic mass. The liver mass was sampled by percutaneous ultrasound-guided biopsy. Postoperatively, the patient's obstructive symptoms were relieved. The histologic studies showed that both the liver and the pancreatic masses consisted of poorly differentiated HCC that stained positive for alpha-fetoprotein. The rarity and the implications of this presentation are discussed.

Effects of self medication programme on knowledge of drugs and compliance with treatment in elderly patients

OBJECTIVE

To determine whether a programme of self medication for inpatients improves compliance with treatment and knowledge of their drugs after discharge from hospital.

DESIGN

Patients were prospectively recruited from four wards: two with a self medication programme and two acting as controls. Ten days after discharge the patients were visited at home. They were questioned about their drugs, and a tablet count was undertaken.

SETTING

The pharmacy department and four medical wards with an interest in elderly patients at a district general hospital, and the patients' homes.

PATIENTS

88 patients discharged to their own homes who were regularly taking one or more drugs.

INTERVENTION

A hospital self medication programme in which patients are educated about their medicines and given increasing responsibility for taking them in hospital.

MAIN OUTCOME MEASURES

Compliance with and knowledge of the purpose of their medicines 10 days after discharge from hospital.

RESULTS

The mean compliance score in patients taking part in the self medication programme was 95% compared with 83% in the control group (difference 12%, 95% confidence interval 4% to 21%; P < 0.02). Of the patients in the self medication group, 90% (38/42) knew the purpose of their drugs compared with 46% (17/37) in the control group (difference 44%, 26% to 63%; P < 0.001).

CONCLUSION

A self medication programme is an effective aid for improving compliance with and knowledge of patients' drugs after discharge.

Boiler fuel from waste

This article describes a unique, self-initiated scheme for the installation of a new boiler at Chorley and District Hospital fueled by waste. The system described is applicable to smaller sites and, since it answers many of the traditional incineration/heat recovery problems, the principle employed is relevant for all sizes of plant. Several Regional Health Authorities have already visited the site and shown a high degree of interest in this pilot project, Terry Finch, the Works Officer, previously worked for Preston Health Authority. He won the Institute of Hospital Engineering's Energy Conservation Competition in 1980. Chris Lowe has worked in hospitals in Chorley for over twelve years and has contributed to many innovative projects throughout that time.