Evaluation of an acute trust Domestic Abuse Coordinator role: Impact findings and a budget impact model

Domestic Abuse Coordinators (DACs) work strategically across National Health Service (NHS) hospital and other off-site clinical settings to support clinical staff in domestic abuse enquiry and response, and to co-lead the development and implementation of effective clinical policies and procedures for the management of domestic abuse and the support of survivors. Drawing on data from a large NHS acute trust in central London, we analyse the impact of the DAC role in increasing the rate of referrals of high-risk domestic abuse cases, and generate plausible estimates of the budget impact of the DAC role in respect of costs accrued to NHS trusts. Using eight quarters of clinical data and an interrupted time series design, we find that evidence that implementation of a DAC role is linked with an increase in the rate of high-risk referrals of between 18% and 21% per quarter, indicating improved responses to victim-survivors at highest risk of imminent harm. Under a range of reasonable assumptions, initiation of the DAC role is shown to be cost-saving to an employing acute trust. Future work should seek to quantify the direct impacts to survivor health and wellbeing of the implementation of the DAC role.

Drug-induced liver injury secondary to increased levonorgestrel exposure in a patient taking ritonavir

We report the first published case of a drug induced liver injury (DILI) presumed secondary to a drug-drug interaction between ritonavir and levonorgestrel progestogen-only emergency contraception (POEC). Our patient is a 25-year-old female living with human immunodeficiency virus (HIV), taking antiretroviral therapy (ART) containing tenofovir alafenamide/emtricitabine and darunavir/ritonavir. She was found to have elevated transaminases at a routine clinic appointment consistent with hepatocellular DILI. Further investigation found the most likely cause of this was a drug-drug interaction (DDI) between the ritonavir component of her ART and recent use of levonorgestrel POEC 3 days earlier. Evidence suggests that ritonavir increases levonorgestrel exposure, yet our patient received double the usual dose as per dispensing guidance at the time. We review the pharmacokinetics of ritonavir-levonorgestrel DDIs and highlight the need for consistent guidelines on this topic.

Identifying demographics of high risk male and LGBTQ+ survivors of domestic abuse from acute London hospital referrals - case review

BACKGROUND

Heterosexual men, and lesbians, gay men, bisexual, transgender and queer (LGBTQ+) people are under-described in research and resources relating to domestic abuse (DA), compared to heterosexual cisgender female survivors. Many of the identified DA cases within our hospital organisation that warrant onward multidisciplinary referral, due to ongoing high harm risk, are for male and LGBTQ+ survivors. We aimed to describe demographics and risk patterns of these cases, to inform and equip our specialist Independent Domestic Violence Advocacy (IDVA) service.

METHOD

We performed a retrospective case-note review of all Multi-Agency Risk Assessment Conferences (MARAC) referrals for DA, featuring male & LGBTQ+ subjects, across Chelsea and Westminster Hospital NHS Foundation Trust (CWFT), London, UK between April 2019 - December 2020. We recorded demographic data of referral subjects and perpetrators; the origin of referral; the nature of the initial presenting complaint and whether the DA was identified by the subject or by the healthcare provider on enquiry; and recorded rates of co-marginalising and harm risk factors (dependent children, disability, mental health comorbidity, HIV status, drug use, homelessness).

RESULTS

We identified 33 cases: 10.2% of CWFT's total MARAC referrals were for men, and 6.7% for LGBTQ+ people (cf. national figures from the same period: 0.1% and 1.3% respectively). Nearly half (48.5%, 16) of the referrals came from sexual health services, just under half (45.5%, 15) from Emergency Departments. 42% (14) disclosures were elicited incidentally during routine enquiry. Six (18%) subjects were also known survivors of sexual violence in addition to DA. The majority (79%, 26) of perpetrators were current or ex-intimate partners. Eight (24%) of the subjects had children under 18. High rates of co-marginalisation factors were present, including use of recreational drugs (45.5%, 15), belonging to an ethnic minority (39.4%, 13), living with HIV (24.2%, 8), living with a disability (18%, 6), mental health comorbidity (27.3%, 9), and experience or risk of homelessness (9%, 3).

CONCLUSIONS

Our trust reports a high rate of male and LGBTQ+ high-risk DA referrals, and amongst these there is a high rate of intersecting disadvantages and risk factors. This underlines a need for inclusivity for marginalised groups, inbuilt into domestic abuse health responses. The high rate of disclosure during routine enquiry for domestic abuse supports the use of DA routine enquiry in sexual health settings, and points towards the utility of selective enquiry in other settings (for example, heterosexual males presenting with injuries to emergency departments). We hope that by working with a specialised LGBTQ+ IDVA, we will improve both prompt identification and better outcomes for more GSM patients.

The Lady Garden Club: supporting women with vulval conditions and their partners

BACKGROUND

Vulval conditions have been shown to have a significant impact on patients' quality of life and can affect their relationships. The Lady Garden Club (LGC) is peer support group that was set up by patients with vulval conditions and is supported by the vulval clinic physicians at Chelsea & Westminster Hospital.

OBJECTIVES

Our aim was to assess the efficacy of this peer support group and the physician contribution to it. We also aimed to assess potential unmet needs of partners, which in turn could affect our patients' experience and quality of life.

METHODS

An anonymized online Survey Monkey link was sent to LGC members. Questions included a Dermatology Life Quality Index (DLQI) section.

RESULTS

The response rate was 60% (26). Over half (54%) were members >2 years. Diagnoses included 85% (22) lichen sclerosus, lichen planus, 8% (two) eczema/psoriasis, warts 8% (two), vulval cancer 4% (one) and vulvodynia 8% (two). All valued a vulval specialist leading the LGC. Women benefitted from: open member questioning (84%), learning from others (81%), self-help tips (81%), more patient information (77%), latest research updates (69%), sharing concerns and fears (65%), sharing personal experiences (62%), peer support network (62%), and discussion about sex and relationships (35%). A third used the buddy system by phone, 19% soon after diagnosis. The average DLQI was 6.84 (range 0-25). Half reported depression and 59% anxiety. Two thirds (68%) felt women with other vulval conditions would benefit from the LGC. Over half (54%) felt there was an unmet need for helping partners understand their genital conditions.

CONCLUSION

The survey concluded that the LGC provides several additional benefits to women with vulval conditions, within a safe forum led by a vulval specialist. It also demonstrated a potential unmet need to support women's partners that can now be addressed.

Primary care and the National Strategy for Sexual Health and HIV: an evaluation of one primary care trust

Windsor, Ascot, Maidenhead (WAM) primary care trust (PCT) currently has no specialist sexual health services. We researched the level of sexual health service provision in WAM compared with targets set out in the National Strategy for Sexual Health and HIV and assessed support for level 2 service expansion.

We found practices were already providing much of level 1 and parts of level 2 services. Gaps centred on male and asymptomatic female screening and sexual health promotion. Ten out of 22 practices expressed interest for service development within the PCT, but obstacles cited included lack of resources, training and prioritization of the strategy.

The study has identified strengths and weaknesses across the PCT that have guided recent initiatives. This model could be used by other PCTs to ascertain their needs and acknowledge their achievements.

Patient-delivered partner medication in the UK: an unlawful but popular choice

Current methods of contact tracing are only partially effective. Patient-delivered partner medication (PDPM), in which patients are dispensed antibiotics for their sexual partner(s), has been shown to reduce persistent and recurrent infections. We performed a questionnaire to canvass opinions of UK staff and patients about PDPM. The response rate was 72% (88/122) for staff and 90% (473/525) for patients. The majority of staff (81%) thought that PDPM would be acceptable to patients, and should be combined with written information and a recommendation to attend a clinic. Patients were mostly (59%) in favour of PDPM, 87% thought it would make it easier to abstain from sex during treatment, and 94% indicated that after being given antibiotics by a partner, they would attend a clinic for tests. Concerns expressed by staff and patients included drug allergies, potential lack of information provided to partners, management of complicated infection, pregnancy and medicolegal implications.

Microscopy and culture for Trichomonas vaginalis: are both required?

Many genitourinary medicine clinics have stopped routinely performing both wet preparation microscopy and cultures to diagnose Trichomonas vaginalis (TV). Our directorate stopped microscopy when screening asymptomatic women. This audit considers whether both tests continue to be warranted for symptomatic female patients. The discrepancy between microscopy and culture results leads us to recommend that both remain necessary. Sampling standardization and improved documentation are discussed.

Surgical management of bilateral parotid lipomatosis in a patient with HIV

BACKGROUND

The long-term use of highly active antiretroviral therapy (HAART) in patients with human immunodeficiency virus (HIV) has led to sequelae including lipodystrophy syndrome (LDS). We present the first published case of surgical management of bilateral parotid lipomatosis in a patient with HIV on long-term HAART.

METHODS

We undertook review of the case notes from the time of diagnosis with HIV and literature review of this topic.

RESULTS

A 45-year-old man with HIV on HAART presented with a 4-year history of increasing bilateral facial swelling. He was asymptomatic apart from the stigmatizing cosmetic deformity. MRI revealed the parotid glands had been replaced by fat. He elected for surgery and parotid lipomatosis was diagnosed on histopathological examination.

CONCLUSION

Lipohypertrophy in LDS is rare in the literature and this presentation of bilateral parotid lipomatosis secondary to HAART is only the third reported case, and the first to undergo surgical resection.

Interventions to increase access to STI services: a study of England's 'high-impact changes' across three central London clinics

BACKGROUND

Increasing access to sexual health services is a key objective for the Department of Health in England and Wales. In 2006 it published 10 high-impact changes (HICs) designed to enhance 48 h access to genitourinary medicine services. However, there is limited evidence on the effectiveness of the proposed interventions.

OBJECTIVE

To evaluate the implementation of five HICs in three sexual health clinics over 4 years. These HICs included a text message results service, nurse-delivered asymptomatic service, clinic refurbishment, a centralised booking service and an electronic appointment system.

METHODS

The effect of HICs was evaluated by measuring clinical activity, number of sexual health screens performed, and patients seen within 48 h. These data were obtained from the clinic database, mandatory reports and Health Protection Agency waiting time surveys, respectively.

RESULTS

The median number of new patients seen per month increased from 3635 to 4263 following the implementation of the five HICs. The follow-up/new patient ratio fell from 0.67 to 0.21 during the study. The biggest fall corresponded to a rise in patients receiving results by text message, from 0% to 40%. Only the centralised booking service was associated with a significant increase in the number of new patients seen.

DISCUSSION

Providing results by text message was associated with a reduced number of follow-up patients, while implementation of a centralised booking service coincided with a significant increase in patient access. Further research is required to evaluate the relative importance of the other HICs.

Sexual health of adults working in pornographic films

We report the frequency of sexually transmitted infections (STIs) diagnosed in performers in the adult pornographic film industry. Over a 13 month period, 445 STI screens were performed in 115 patients, 56 women and 59 men. All reported unprotected sex during filming. Seventy-five percent (86) had at least one sexual partner outside work, and 90% used condoms inconsistently with them. Women worked exclusively with women (23%), men only (38%) or both genders (39%). Almost all men (97%) worked exclusively heterosexually. Thirty-eight percent (44/115) were diagnosed with 77 STIs, including non-specific urethritis (51), gonorrhoea (10), chlamydia (6) and genital warts (6). Gonorrhoea was found exclusively at the pharynx in three heterosexual men. There were no cases of HIV, syphilis, hepatitis B or hepatitis C. Monthly screening and certification is a working requirement for this population but STIs are common in an industry where unprotected sex is the norm.

Time to use text reminders in genitourinary medicine clinics

Faced with a national 48-hour waiting time target and high non-attendance rates for booked appointments, our sexual health service sought patient preferences for appointment reminders. Questionnaires were distributed to 350 consecutive genitourinary medicine clinic attendees. Eighty-eight percent of respondents approved of appointment reminders, with text messaging being the preferred option. Automated voicemail reminders to mobile phones were acceptable to 84%. Patients would generally choose a voicemail reminder to their mobile phone as opposed to home or work phone, and this preference was more pronounced in younger patients ( P = 0.03). The majority of patients considered reminders two or three days in advance sufficient notice, with 98% owning a mobile phone. Text or voicemail reminders may significantly reduce non-attendance rates and their associated costs, improve accessibility and reduce waiting times.

Is it time for the virtual chaperone in genitourinary medicine clinics?

The General Medical Council recommends that chaperones must be offered during intimate examinations. Implementation of these guidelines may serve to protect both patients and staff within the genitourinary (GU) medicine clinic, but is likely to have major ramifications from a practical, financial and staffing perspective. The Virtual Chaperone (VC) is an objective device making audio and visual recordings of patients' consultations and examinations. Information cannot be manipulated and is encrypted for security. It would not replace the human chaperone. This study investigated the attitudes of GU medicine staff and patients to the VC in an inner city sexual health clinic. Voluntary, anonymized questionnaires were distributed to all members of the multidisciplinary team and 200 patients. The patient response rate was 90% (n = 180). Only 40% of respondents felt the VC was acceptable in GU medicine clinics. Two-thirds felt unsure or were against the VC recording during consultations, and fewer wished the examination to be recorded. Most opted to switch off the video entirely. Almost 50% of respondents felt that the VC was designed to protect staff, whereas only 41% thought it would protect patients. The staff response rate was 69% (n = 35). Almost three-quarters of respondents were unsure or felt the device was unacceptable. Less than half would feel comfortable with the VC recording during consults. Overall, three-quarters of respondents were either unsure or did not support the introduction of the VC. There was a clear feeling (>80%) that the VC would protect staff and patients, 71% indicating that the trust would also benefit. Despite its success in other outpatient specialties, GU medicine staff and patients do not favour the introduction of the VC.

Combined surgery and chemoradiation as a treatment for the Buschke-Löwenstein tumour

BACKGROUND

The Buschke-Löwenstein tumour (BLT) or giant condyloma acuminata is a rare disease which affects the anogenital region. Although histologically benign, it behaves in a malignant fashion, infiltrating the surrounding tissues. The morbidity and mortality from this tumour is high, as is the risk of recurrence following treatment. It lies on the continuum between the benign condylomata acuminata and squamous cell carcinoma. The human papillomavirus is implicated in its aetiology. Treatment is controversial, with topical chemotherapy, radiotherapy, immunotherapy and radical surgery all having been employed. Chemoradiation remains the mainstay of treatment for anal cancers but has not been routinely employed in the management of the BLT without squamous cell carcinoma transformation.

METHODS

Two cases of extensive perineal BLT treated with chemoradiation and subsequent surgical excision are presented.

RESULTS

The first patient had a good symptomatic response to the chemoradiation but unfortunately died of recurrent disease following surgery. The second patient had a macroscopically complete response to chemoradiation and remains well following abdominoperineal excision.

CONCLUSION

Pre-operative chemoradiation has proved to be useful in management for histologically proven benign BLT

Increasing detection of asymptomatic syphilis in HIV patients

BACKGROUND/OBJECTIVES

The burden of new syphilis diagnoses in London has mainly been in men who have sex with men (MSM), many of whom are co-infected with HIV. Our HIV unit introduced regular serological screening for syphilis during routine follow up care to detect patients who may be at risk of asymptomatic infection. We assessed if this remained an effective and necessary strategy in the second year since introduction.

METHODS

All HIV outpatients with newly positive syphilis serology between 1 May 2002 and 30 April 2003 were identified using a prospectively collected database. Only patients who were asymptomatic at the time of screening were included (cohort B). They were compared to patients in the exact preceding year (cohort A).

RESULTS

2655 patients had at least one CD4 count measured in the period (surrogate marker for patients having routine follow up bloods), of whom 2389 (90%) had syphilis serology performed. 40 individuals were found to have early asymptomatic infection (two were re-infections), compared to 26 patients in cohort A. These 40 patients represented 36% of all patients with infectious syphilis treated within our department and 56% of those who were HIV positive. The event rate in cohort B was 7.3 per 1000 patient years (CI 5.2 to 9.9) compared to 2.8 (CI 1.8 to 4.0) in cohort A.

CONCLUSION

Routine screening is effective and has detected increasing numbers of HIV outpatients with early asymptomatic syphilis. Our department will continue this strategy for all HIV patients during their follow up care. We recommend that other units adopt similar initiatives that assist with regional control of the UK syphilis epidemic.

Sexual trauma associated with fisting and recreational drugs

There is a rising trend in high risk sexual behaviour among men who have sex with men (MSM), with concomitant use of recreational drugs. Activities include fisting and unprotected anal intercourse with a partner who is HIV serodiscordant or of unknown status. We describe three cases of HIV positive MSM who have recently attended our unit as a result of complications secondary to fisting.

Taking charge. The role of nursing administrators in removing restraints

The leadership and commitment of nursing administrators play a pivotal role in minimizing the use of restraints and maintaining a restraint-free environment. This article describes the role of nursing administrators in reducing the use of physical restraints as part of a 2-year, national nursing home restraint-reduction project. It reviews important information about restraint-free care the benefits of restraint-free care, and strategies to reduce the use of restraints in nursing homes, much of which is applicable to settings other than nursing homes.

Long-term enteral feeding of aged demented nursing home patients

The terminal phase of dementia is initiated by the inability to swallow. New techniques of enteral alimentation permit more effective, longer intubation. To assess the application of these new techniques to late-stage demented aged patients, all current intubations in a teaching nursing home were reviewed. Of 52 feeding intubations, 26 had been in situ for more than 1 year. A randomly selected comparison group of nonintubated patients was also studied. Weight increased for 48% of the intubated group versus 17% of the nonintubated group (P less than .01). Aspiration pneumonia occurred more often in the intubated group (58%) than in the nonintubated group (17%) (P less than .01). Decubitus ulcers were also more common in the intubated group (21%) than in the nonintubated group (14%). Restraints were used more in the intubated group (71%) than in the nonintubated group (56%). These differences did not reach statistical significance. All of the intubated patients were severely demented, with MMSE scores of zero. Seventy-one percent of the nonintubated group were demented, with MMSE scores of less than 23. Prolongation of the terminal phase of dementia in the aged by tube feeding is now feasible. The implications of this change in the life-span of demented nursing home patients need attention by families, nursing homes, and those who make public health policy.

Monoclonal antibodies as probes to study the human growth hormone-binding domain to lactogenic rat liver receptors

A set of monoclonal antibodies (MAb) to human GH (hGH) was used to study the hormone binding orientation to its receptors (R) from female rat liver. The hGH antigenic region left exposed after its binding to liver microsomes was detected by measuring the ability of various [125I]MAb to bind to the preformed hGH-R complexes. Results indicated that a cluster of epitopes defined by the MAb, termed AE5, AC8, and AE12, remains accessible in the hGH-R complex whereas overlapping epitopes 3C11 and HG3 would define a hGH region involved in the binding site. Supporting these findings, solubilization and HPLC gel filtration of [125I]MAb-hGH-R complexes showed a radioactive peak of about 450,000 mol wt for MAb AE5 or AC8, but not for MAb 3C11 or HG3. [125I]MAb AE12 behaved differently, suggesting that epitope AE12 may be masked or altered in hGH-R-solubilized complexes. MAb directed to the putative hGH-binding site (MAb 3C11, HG3, and the closely related MAb 10C1 and NA71) failed to inhibit binding of the preformed [125I]MAb AE5-hGH complex to the receptors, suggesting a hormone modification after MAb AE5 binding. Accordingly competition experiments indicated an increase in the affinity of hGH for its receptors induced by this MAb. A higher hGH concentration was required to obtain 50% [125I]hGH binding to liver microsomes in the presence of MAb AE5 than in its absence. As the MAb used define epitopes that were previously correlated with the hGH structure, we concluded that a high flexible region (sequences 134-150) is exposed in the hGH-R complex. Furthermore, some MAb directed to this region enhance the hormone affinity for its rat liver receptors, probably through an induced conformational change.

Chloroplast Biogenesis 34: SPECTROFLUOROMETRIC CHARACTERIZATION IN SITU OF THE PROTOCHLOROPHYLL SPECIES IN ETIOLATED TISSUES OF HIGHER PLANTS

The fluorescence emission and excitation properties of protochlorophyll in etiolated cucumber (Cucumis sativus L.) cotyledons and primary bean (var. Red Kidney) leaves were characterized at 77 K. Contrary to previous studies, it appears that the short-wavelength protochlorophyll emission band consists of four fluorescent components, instead of only one nonphototransformable protochlorophyll. It was demonstrated that etiolated cucumber cotyledons synthesize and accumulate nontransformable protochlorophyll (E(440), F(630)) as well as short-wavelength phototransformable protochlorophyll (E(433), F(633)), (E(444), F(636)), and (E(445), F(640)). Long-wavelength phototransformable protochlorophyll (E(450), F(657)) is also formed. In this context, E refers to the Soret excitation maxima and F refers to the red emission maxima of the protochlorophylls.IN ETIOLATED BEAN LEAVES, THE CORRESPONDING SPECIES WERE: nontransformable protochlorophyll (E(440), F(630)), short-wavelength phototransformable protochlorophylls (E(441), F(633)), (E(442), F(636)), and (E(443), F(640)), and long-wavelength phototransformable protochlorophyll (E(447), F(657)).

Chloroplast Biogenesis: XXII. Contribution of Short Wavelength and Long Wavelength Protochlorophyll Species to the Greening of Higher Plants

The contribution of short and long wavelength membrane-bound fluorescing protochlorophyll species to the over-all process of chlorophyll formation was assessed during photoperiodic growth. Protochlorophyll forms were monitored spectrofluorometrically at 77 K during the first six light and dark cycles in homogenates of cucumber (Cucumis sativus L.) cotyledons grown under a 14-hour light/10-hour dark photoperiodic regime, and in cotyledons developing in complete darkness. In the etiolated tissue, short wavelength protochlorophyll having a broad emission maximum between 630 and 640 nm appeared within 24 hours after sowing. Subsequently, the long wavelength species fluorescing at 657 nm appeared, and accumulated rapidly. This resulted in the preponderance of the long wavelength species which characterizes the protochlorophyll profile of etiolated tissues. The forms of protochlorophyll present in etiolated cucumber cotyledons resembled those in etiolated bean leaves in their absorption, fluorescence, and phototransformability. A different pattern of protochlorophyll accumulation was observed during the dark cycles of photoperiodic greening. The short wavelength species appeared within 24 hours after sowing. Subsequently, the long wavelength form accumulated and disappeared. The long wavelength to short wavelength protochlorophyll emission intensity ratio reached a maximum (~3:1) during the second dark cycle, then declined during subsequent dark cycles. Short wavelength species were continuously present in the light and dark. Primary corn and bean leaves exhibited a similar pattern of protochlorophyll accumulation. In cucumber cotyledons, both the short and long wavelengths species appeared to be directly phototransformable at all stages of photoperiodic development. It thus appears that whereas the long wavelength protochlorophyll species is the major chlorophyll precursor during primary photoconversion in older etiolated tissues, both long wavelength and short wavelength species seem to contribute to chlorophyll formation during greening under natural photoperiodic conditions.

Chloroplast Biogenesis: XX. Accumulation of Porphyrin and Phorbin Pigments in Cucumber Cotyledons during Photoperiodic Greening

A study of greening in cucumber (Cucumis sativus L.) cotyledons grown under a light (14-hour) dark (10-hour) photoperiodic regime was undertaken. The pools of protoporphyrin IX, Mg-protoporphyrin IX monoester, protochlorophyllide, and protochlorophyllide ester were determined spectrofluorometrically. Chlorophyll a and b were monitored spectrophotometrically. Pigments were extracted during the 3rd hour of each light period and at the end of each subsequent dark period during the first seven growth cycles. Protoporphyrin IX did not accumulate during greening. Mg-protoporphyrin IX monoester and longer wavelength metalloporphyrins accumulated during the light cycles and disappeared in the dark. Their disappearance was accompanied by the accumulation of protochlorophyll. Higher levels of protochlorophyll were observed in the dark than in the light, and the greatest accumulation occurred during the third and fourth dark cycles. Protochlorophyllide was present in 3- to 10-fold excess over protochlorophyllide ester; it was detectable during the period of net chlorophyll accumulation as well as afterward. In contrast, protochlorophyllide ester was observable only during the first four photoperiodic cycles, suggesting that it was a metabolic intermediate only during the early stages of chlorophyll accumulation. Between the third and fourth growth cycles, a rapid increase in area and fresh weight per cotyledon began. This was accompanied by a 250-fold increase in the level of chlorophyll a + b during the three subsequent growth cycles. No lag period in the accumulation of chlorophyll b was observed, and at all stages of greening, the chlorophyll a/b ratio was approximately 3.

Changing ratios of phototransformable protochlorophyll and protochlorophyllide of bean seedlings developing in the dark

Protochlorophyll (Pchl) and protochlorophyllide (Pchlide) are at comparable levels in 2-day-old (young) etiolated bean leaves (Phaseolus vulgaris L. var. Red Kidney). During subsequent development in the dark, both pigments increase, but the rate of Pchlide increase is greater than that of Pchl, leading to the commonly observed predominance of Pchlide beyond 7 days (old leaves). Both protopigments are phototransformable to their respective chlorophyll(ide) photoproducts throughout dark development. The rate of protopigment regeneration in young leaves after illumination is rapid and displays no lag, whereas this process in old leaves begins slowly and achieves only about one-fifth the rate of younger leaves. The rate of chlorophyllide esterification is also faster in the younger tissue. Since the proplastid-related properties of young bean leaves are quite similar to those of Euglena, young leaves and Euglena may represent an evolutionarily primitive case compared with older bean leaves which contain etioplasts. Since Euglena and young beans green perfectly well when exposed to light, the extensive modifications associated with prolonged dark growth do not seem to be obligatory for plastid development. The properties of older beans are viewed as being the consequence of prolonged etiolation which may provide a faster rate of plastid development and appearance of photosynthesis as the plant nears the limits of its stored reserves.