A challenge to the evidence behind noise guidelines for UK hospitals

BACKGROUND

Teams assessing hospital noise against international guidelines regularly find that noise exceeds perceived safe levels in clinical settings. The care of sick people may be inherently noisy but recent efforts to tackle the problem propose a wider scope to identify sources and qualities of noise as well as more precision with noise recording.

AIMS

We sought to challenge the scientific evidence cited in the four major documents pertaining to hospital noise in the UK to clarify if evidence of harm from noise included in guidelines is available, contemporary and of high quality.

METHODS

Our team of hearing-health clinicians, acoustic scientists and acoustic engineers have conducted a narrative scoping review focused on critically appraising four of the most cited guidelines against which noise is measured in healthcare settings in the UK.

RESULTS

There is a lack of high-quality evidence for commonly accepted consequences of noise cited in current guidelines.

CONCLUSIONS

The current evidence base for noise guidelines in a healthcare setting is largely based on subjective heterogeneous and inconclusive research. Whilst reduced noise is not disputed as potentially beneficial for patient care, further hypothesis-driven research and interventions assessing the benefits or outcomes of any such intervention should be sought to produce high-quality evidence of relevance on the clinical coalface.

How Lifestyle Changes during the COVID-19 Global Pandemic Affected the Pattern and Symptoms of the Menstrual Cycle

This research investigated the implications that the COVID-19 pandemic had on the menstrual cycle and any contributing factors to these changes. A questionnaire was completed by 559 eumenorrheic participants, capturing detail on menstrual cycle symptoms and characteristics prior to and during the COVID-19 pandemic lockdown period. Over half of all participants reported to have experienced lack of motivation (61.5%), focus (54.7%) and concentration (57.8%). 52.8% of participants reported an increase in cycle length. Specifically, there was an increase in the median cycle length reported of 5 days (minimum 2 days, maximum 32 days), with a median decrease of 3 days (minimum 2 days and maximum 17 days). A lack of focus was significantly associated with a change in menstrual cycle length (p = 0.038) reported to have increased by 61% of participants. Changes to eating patterns of white meat (increase p = 0.035, decrease p = 0.003) and processed meat (increase p = 0.002 and decrease p = 0.001) were significantly associated with a change in menstrual cycle length. It is important that females and practitioners become aware of implications of environmental stressors and the possible long-term effects on fertility. Future research should continue to investigate any long-lasting changes in symptoms, as well as providing education and support for females undergoing any life stressors that may implicate their menstrual cycle and/or symptoms.

Prevalence and frequency of menstrual cycle symptoms are associated with availability to train and compete: a study of 6812 exercising women recruited using the Strava exercise app

OBJECTIVES

The menstrual cycle can affect sports participation and exercise performance. There are very few data on specific menstrual cycle symptoms (symptoms during various phases of the cycle, not only during menstruation) experienced by exercising women. We aimed to characterise the most common symptoms, as well as the number and frequency of symptoms, and evaluate whether menstrual cycle symptoms are associated with sporting outcomes.

METHODS

6812 adult women of reproductive age (mean age: 38.3 (8.7) years) who were not using combined hormonal contraception were recruited via the Strava exercise app user database and completed a 39-part survey. Respondents were from seven geographical areas, and the questions were translated and localised to each region (Brazil, n=892; France, n=1355; Germany, n=839; Spain, n=834; UK and Ireland, n=1350; and USA, n=1542). The survey captured exercise behaviours, current menstrual status, presence and frequency of menstrual cycle symptoms, medication use for symptoms, perceived effects of the menstrual cycle on exercise and work behaviours, and history of hormonal contraception use. We propose a novel Menstrual Symptom index (MSi) based on the presence and frequency of 18 commonly reported symptoms (range 0-54, where 54 would correspond to all 18 symptoms each occurring very frequently).

RESULTS

The most prevalent menstrual cycle symptoms were mood changes/anxiety (90.6%), tiredness/fatigue (86.2%), stomach cramps (84.2%) and breast pain/tenderness (83.1%). After controlling for body mass index, training volume and age, the MSi was associated with a greater likelihood of missing or changing training (OR=1.09 (CI 1.08 to 1.10); p≤0.05), missing a sporting event/competition (OR=1.07 (CI 1.06 to 1.08); p≤0.05), absenteeism from work/academia (OR=1.08 (CI 1.07 to 1.09); p≤0.05) and use of pain medication (OR=1.09 (CI 1.08 to 1.09); p≤0.05).

CONCLUSION

Menstrual cycle symptoms are very common in exercising women, and women report that these symptoms compromise their exercise participation and work capacity. The MSi needs to be formally validated (psychometrics); at present, it provides an easy way to quantify the frequency of menstrual cycle symptoms.

The effect of the menstrual cycle on running economy

BACKGROUND

The aim of this study was to examine the effect of the menstrual cycle on running economy (RE).

METHODS

Using a repeated-measures design, ten eumenorrheic, trained female runners (age: 32±6 yrs, V̇O2max: 59.7±4.7 mL·kg-1·min-1) completed four, weekly, identical sub-maximal and maximal incremental step tests on a treadmill to measure physiological responses across a full menstrual cycle. For phase comparison, the results from the trials that fell in the early follicular (low estrogen, low progesterone), late follicular (high estrogen, low progesterone) and mid-luteal (high estrogen, high progesterone) phases were used.

RESULTS

There was a significant effect of menstrual cycle phase on RE (P=0.001), with RE in the mid-luteal (ML) phase being worse than that of the early follicular (EF) (+2.33 mL·kg-1·min-1; P=0.026) and late follicular (LF) (+2.17 mL·kg-1·min-1; P=0.011) phases. The ML phase also resulted in elevated core temperature versus the EF (+0.51 ºC; P=0.001) and LF (+0.66 ºC; P=0.037) phases, and elevated minute ventilation versus the EF phase (+3.83 L·min-1; P=0.003). No significant effects of menstrual cycle phase were found on body mass, heart rate, ratings of perceived exertion, time-to-exhaustion, maximal oxygen consumption, or blood lactate concentration.

CONCLUSIONS

In the ML phase, which causes increased core temperature and minute ventilation, RE is impaired at exercise intensities that are applicable to training and performance. In physiologically stressful environments, this impairment in RE may have a significant impact on training and performance.

Intelligence is universal in life

Behaviorists assume that living things memorize random atoms of information (engrams), "reinforced" by success, just as in the neo-Darwinian mutation-selection process. On the contrary we have to recognize the existence of organized and systematic responses in the learning process (Krechevsky). The animals seek desperately to "understand the meaning" of the world around them, by widening its context. Intelligence is not an exclusive prerogative of human mind. The minds of insects operate in the same way as that of man. Even a cell has a sort of intelligence (Cuenot). Consciousness is a state of awareness associated with enhanced mental activity. It occurs also in other "higher" animals (Thorpe). However human themselves are non conscious of their basic underlying motivations. Unconscious or ineffable knowledge plays a great role in shaping our world-view and in determining our influence on the Gaian hierarchy.

Principles underlying a model policy on relationships between staff and service recipients in a mental health system

OBJECTIVE

The authors participated in a work group to produce a model policy addressing the boundaries of relationships between staff and recipients of service in a public mental health system that provides and regulates services in a variety of treatment settings.

METHODS

The chief medical officer of the New York State Office of Mental Health assembled a work group of administrators, clinicians, state officials, and a representative of service recipients. The group reviewed the professional literature and existing ethics guidelines and policies addressing relationships between staff members and service recipients and made recommendations for a new policy.

RESULTS AND CONCLUSIONS

The work group formulated five guiding principles: prevention of the exploitation of recipients of services by staff; the right of recipients to be treated as competent autonomous human beings; recognition that certain developmental stages, treatment settings, and pre-existing relationships increase a service recipient's vulnerability to exploitation and call for more stringent regulation of staff actions; acceptance of a spectrum of permissible relationships for staff and recipients outside of the relationship dictated by the staff member's job description; and recognition of the difference between a relationship focused on treatment or service provision and other professional relationships between providers and current or former recipients. The principles were used to develop a model policy on relationships between staff and recipients that addresses both the organizational complexity and the recipient-centered rehabilitation model of a large state-operated mental health system.

A constitutively active and nuclear form of the MAP kinase ERK2 is sufficient for neurite outgrowth and cell transformation

BACKGROUND

Mitogen-activated protein (MAP) kinases are ubiquitous components of many signal transduction pathways. Constitutively active variants have been isolated for every component of the extracellular-signal-regulated kinase 1 (ERK1) and ERK2 MAP kinase pathway except for the ERK itself.

RESULTS

To create an activated ERK2 variant, we fused ERK2 to the low activity form of its upstream regulator, the MAP kinase kinase MEK1. The ERK2 in this fusion protein was active in the absence of extracellular signals. Expression of the fusion protein in mammalian cells did not activate endogenous ERK1 or ERK2. It was sufficient, however, to induce activation of the transcription factors Elk-1 and AP-1, neurite extension in PC12 cells in the absence of nerve growth factor, and foci of morphologically and growth-transformed NIH3T3 cells, if the fusion protein was localized to the nucleus. A cytoplasmic fusion protein was without effect.

CONCLUSIONS

Activation of ERK2 is sufficient to cause several transcriptional and phenotypic responses in mammalian cells. Nuclear localization of activated ERK2 is required to induce these events.

Phosphorylation of the MAP kinase ERK2 promotes its homodimerization and nuclear translocation

The MAP kinase ERK2 is widely involved in eukaryotic signal transduction. Upon activation it translocates to the nucleus of the stimulated cell, where it phosphorylates nuclear targets. We find that nuclear accumulation of microinjected ERK2 depends on its phosphorylation state rather than on its activity or on upstream components of its signaling pathway. Phosphorylated ERK2 forms dimers with phosphorylated and unphosphorylated ERK2 partners. Disruption of dimerization by mutagenesis of ERK2 reduces its ability to accumulate in the nucleus, suggesting that dimerization is essential for its normal ligand-dependent relocalization. The crystal structure of phosphorylated ERK2 reveals the basis for dimerization. Other MAP kinase family members also form dimers. The generality of this behavior suggests that dimerization is part of the mechanism of action of the MAP kinase family.

Contributions of the mitogen-activated protein (MAP) kinase backbone and phosphorylation loop to MEK specificity

To examine the specificity of MEKs for MAP kinase family members, we determined the abilities of several MEK isoforms to phosphorylate mutants of the MAP kinase ERK2 and the related kinase ERK3 which are modified in the phosphorylation loop. The ERK2 mutants included mutations of the two phosphorylation sites, mutations of the acidic residue between these two sites, and mutations that shorten the length of this loop. All mutants were tested for phosphorylation by six mammalian MEKs and compared with several wild type MAP kinases. MEK1 and MEK2 phosphorylate a majority of the ERK2 mutants. MEK2 but not MEK1 will phosphorylate ERK3. Alteration of the residue between the two phosphorylation sites neither dramatically affected the activity of MEK1 and MEK2 toward ERK2 nor conferred recognition by other MEKs. Likewise, reduction of the length of the phosphorylation loop only partially reduces recognition by MEK1 and MEK2 but does not promote recognition by other MEKs. Thus other yet to be identified factors must contribute to the specificity of MEK recognition of MAP kinases.

Characterization of a protein kinase that phosphorylates serine 189 of the mitogen-activated protein kinase homolog ERK3

A novel protein kinase activity present in nuclear and cytosolic extracts has been identified and partially purified as a consequence of its tight binding to and phosphorylation of the extracellular signal-regulated protein kinase (ERK) 3. This novel protein kinase is inactivated by treatment with phosphoprotein phosphatase 2A. The ERK3 protein kinase was immunologically distinct from mitogen-activated protein (MAP) kinase/ERK kinases (MEK) 1 and 2 which phosphorylate the ERK3-related MAP kinases ERK1 and ERK2. This ERK3 kinase phosphorylated a single site on ERK3, Ser189, comparable to Thr183, one of the two activating phosphorylation sites of ERK2. To test the specificity of the ERK3 kinase, mutants of ERK3 and ERK2 were made in which the phosphorylated residues were exchanged. The double mutant S189T,G191Y ERK3, in which the phosphorylated residues from ERK2 replaced the comparable residues in ERK3, was phosphorylated by the ERK3 kinase but only on threonine. The ERK3 kinase did not phosphorylate ERK2 or ERK2 mutants. These findings indicate that although the ERK3 kinase is highly specific for ERK3, it does not recognize tyrosine, a feature that distinguishes it from MEKs that phosphorylate other ERK/MAP kinase family members.

Autophosphorylation activates the soluble cytoplasmic domain of the insulin receptor in an intermolecular reaction

The cytoplasmic protein-tyrosine kinase domain of the insulin receptor (residues 959-1355) has been expressed as a soluble protein in Sf9 insect cells via a Baculovirus expression vector (Ellis, L., Levitan, A., Cobb, M.H., and Ramos, P. (1988) J. Virol. 62, 1634-1639). The purified protein is a monomer as judged by its behavior in sucrose gradients and on gel filtration in the presence or absence of protamine. The initial rate of autophosphorylation using 3 mM MgCl2 is increased 20-30-fold by protamine. A maximum of 4-5 mol of phosphate are incorporated per mol of enzyme. The activity of the enzyme as a function of phosphorylation state was studied for three substrates: a synthetic dodecapeptide derived from the sequence of the major autophosphorylation site in the insulin receptor, poly(Glu, Tyr), 4:1, and histone 2B. Autophosphorylation of the protein to a stoichiometry of 4-5 mol of phosphate/mol increases its enzymatic activity as much as 200-fold; a 30-fold increase in activity occurs upon addition of 1 mol of phosphate/mol. The activities of unphosphorylated enzyme with the three substrates are 3.4, 2.3, and 0.44 nmol/min/mg, respectively. The activities of the autophosphorylated enzyme with the three substrates are 175, 274, and 45 nmol/min/mg, respectively. Exposure of the autophosphorylated enzyme to ADP results in a loss of phosphate from the enzyme which is associated with a decrease in enzymatic activity. Autophosphorylation of the kinase in the presence or absence of protamine displays a marked dependence on enzyme concentration. Furthermore, the rate of autophosphorylation decreases as the viscosity of the solution increases. Taken together, these data suggest that phosphorylation occurs via an intermolecular reaction.

Structure of the nucleotide activation switch in glycogen phosphorylase a

Adenosine monophosphate is required for the activation of glycogen phosphorylase b and for release of the inhibition of phosphorylase a by glucose. Two molecules of adenosine monophosphate (AMP) bind to symmetry related sites at the subunit interface of the phosphorylase dimer. Adenosine triphosphate (ATP) binds to the same site, but does not promote catalytic activity. The structure of glucose-inhibited phosphorylase a bound to AMP and also of the complex formed with glucose and ATP is described. Crystallographic refinement of these complexes reveals that structural changes are associated with AMP but not ATP binding. The origin of these effects can be traced to different effector binding modes exhibited by AMP and ATP, respectively. The conformational changes associated with AMP binding traverse multiple paths in the enzyme and link the effector and catalytic sites.

Crystallization of the gene 45 protein from the DNA replication fork of bacteriophage T4

The gene 45 protein from bacteriophage T4 has been purified and is crystallized. This protein is part of the T4 DNA replication complex. The crystallized protein is active in complementation assays. X-ray diffraction analysis is in progress; data are measured for the native and several heavy atom derivatives. The crystals diffract to about 3.5-A resolution.

My heart stood still. The personal case history of an anaesthetist

The author--an anaesthetist--describes his experience as a patient undergoing open-heart surgery. He reports excellent professional management and a very satisfactory result but offers some constructive criticisms.

Carcinoma arising in pilonidal sinuses

Pilonidal carcinoma is an infrequent complication of pilonidal disease. The surgeon's suspicion should be raised in cases of longstanding pilonidal inflammation. The disease occurs most frequently in men. The lesion is often a well-differentiated squamous carcinoma. Wide excisions at the initial procedure following a brief period of local wound care, is the optimum treatment and increases the chances for a five-year survival. Definitive closure of the defect is delayed and accomplished by rotational flaps or skin grafts. It palpable nodes are present in the inguinal region they should be biopsied even though this does not necessarily connote metastasis. When inguinal node metastasis is present, this is associated with a poor prognosis. The incidence of occult node metastasis is not known because no prophylactic groin dissections were performed. Staged groin dissections were not associated with any long-term survivals. The series was too small to determine its palliative potential. Radiation therapy may palliate local bone or soft tissue recurrences. Re-excisions of local soft tissue recurrences can provide, in some instances, long disease-free intervals. Both topical and systemic chemotherapy were administered in more recent cases with poor results, but this series is not large enough to form conclusions for this modality of treatment.

Dreadnought Seamen's Hospital

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