Measured optical losses of Sc doped AlN waveguides

Although Sc doped AlN (ScAlN) has been used extensively in micro-electro-mechanical systems (MEMS) devices and more recently in optical devices, there have not been thorough studies of its intrinsic optical losses. Here we explore the optical losses of the Sc0.30Al0.70N waveguide system by observing racetrack resonator waveguide quality factors. Using a partial physical etch, we fabricate waveguides and extract propagation losses as low as 1.6 ± 0.3 dB/cm at wavelengths around 1550 nm, mostly dominated by intrinsic material absorption from the Sc0.30Al0.70N thin film layer. The highest quality factor of the resonators was greater than 87,000. The propagation loss value is lower than any value previously published and shows that this material can be broadly used in optical modulators without significant loss.

Clinical actionability of genetic findings in cerebral palsy

Background and objectives

Single gene mutations are increasingly recognized as causes of cerebral palsy (CP) phenotypes, yet there is currently no standardized framework for measuring their clinical impact. We evaluated Pathogenic/Likely Pathogenic (P/LP) variants identified in individuals with CP to determine how frequently genetic testing results would prompt changes in care.

Methods

We analyzed published P/LP variants in OMIM genes identified in clinical (n = 1,345 individuals) or research (n = 496) cohorts using exome sequencing of CP patients. We established a working group of clinical and research geneticists, developmental pediatricians, genetic counselors, and neurologists and performed a systematic review of existing literature for evidence of clinical management approaches linked to genetic disorders. Scoring rubrics were adapted, and a modified Delphi approach was used to build consensus and establish the anticipated impact on patient care. Overall clinical utility was calculated from metrics assessing outcome severity if left untreated, safety/practicality of the intervention, and anticipated intervention efficacy .

Results

We found 140/1,841 (8%) of individuals in published CP cohorts had a genetic diagnosis classified as actionable , defined as prompting a change in clinical management based on knowledge related to the genetic etiology. 58/243 genes with P/LP variants were classified as actionable; 16 had treatment options targeting the primary disease mechanism , 16 had specific prevention strategies , and 26 had specific symptom management recommendations. The level of evidence was also graded according to ClinGen criteria; 44.6% of interventions had evidence class "D" or below. The potential interventions have clinical utility with 97% of outcomes being moderate-high severity if left untreated and 62% of interventions predicted to be of moderate-high efficacy . Most interventions (71%) were considered moderate-high safety/practicality .

Discussion

Our findings indicate that actionable genetic findings occur in 8% of individuals referred for genetic testing with CP. Evaluation of potential efficacy , outcome severity , and intervention safety / practicality indicates moderate-high clinical utility of these genetic findings. Thus, genetic sequencing to identify these individuals for precision medicine interventions could improve outcomes and provide clinical benefit to individuals with CP. The relatively limited evidence base for most interventions underscores the need for additional research.

HNRNPC haploinsufficiency affects alternative splicing of intellectual disability-associated genes and causes a neurodevelopmental disorder

Heterogeneous nuclear ribonucleoprotein C (HNRNPC) is an essential, ubiquitously abundant protein involved in mRNA processing. Genetic variants in other members of the HNRNP family have been associated with neurodevelopmental disorders. Here, we describe 13 individuals with global developmental delay, intellectual disability, behavioral abnormalities, and subtle facial dysmorphology with heterozygous HNRNPC germline variants. Five of them bear an identical in-frame deletion of nine amino acids in the extreme C terminus. To study the effect of this recurrent variant as well as HNRNPC haploinsufficiency, we used induced pluripotent stem cells (iPSCs) and fibroblasts obtained from affected individuals. While protein localization and oligomerization were unaffected by the recurrent C-terminal deletion variant, total HNRNPC levels were decreased. Previously, reduced HNRNPC levels have been associated with changes in alternative splicing. Therefore, we performed a meta-analysis on published RNA-seq datasets of three different cell lines to identify a ubiquitous HNRNPC-dependent signature of alternative spliced exons. The identified signature was not only confirmed in fibroblasts obtained from an affected individual but also showed a significant enrichment for genes associated with intellectual disability. Hence, we assessed the effect of decreased and increased levels of HNRNPC on neuronal arborization and neuronal migration and found that either condition affects neuronal function. Taken together, our data indicate that HNRNPC haploinsufficiency affects alternative splicing of multiple intellectual disability-associated genes and that the developing brain is sensitive to aberrant levels of HNRNPC. Hence, our data strongly support the inclusion of HNRNPC to the family of HNRNP-related neurodevelopmental disorders.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Inclusion and perception of hand therapy content in occupational therapy programs: A mixed-method study

STUDY DESIGN

Mixed-methods with cross-sectional survey and interviews.

INTRODUCTION

Hand therapy is a specialty area of practice for occupational (OT) and physical therapists (PT), requiring experience and certification beyond entry-level generalist education. Perspectives and inclusion of content related to hand therapy differs among entry-level OT programs and faculty.

PURPOSE

Perception and inclusion of hand therapy content in OT programs was examined in this mixed-method study to better understand the trends in academia regarding integration of content related to hand therapy.

METHODS

A survey was developed, peer-reviewed, and emailed to all accredited entry-level masters and doctorate OT programs via Survey Monkey (SurveyMonkey, Inc., San Mateo, CA). Respondents were also given the opportunity to participate in an interview (n = 2; 5%).

RESULTS

A total of 43 participants responded to the survey, representing a 23% response rate. Quantitative results revealed that 65% of OT programs report including 41+ hours of hand therapy content and 54% report integration of hand therapy content in 2-3 courses. Qualitative trends included the perception of hand content as necessary and beneficial to other areas of practice as well as the perspective that it is too specialized and advanced for generalist curriculum.

DISCUSSION

Educators have a largely positive opinion regarding inclusion and generalizability of hand therapy content within OT curricula with varied content inclusion. While hand therapy related content is valued, increased emphasis on occupation during didactic instruction is recommended for more holistic understanding and occupation-based practice.

CONCLUSION

While trends of hand therapy content inclusion were revealed in the survey, perceptions of hand therapy within the broad spectrum of OT curricula were diverse, indicating a possible lack of unity within the profession regarding this specialty area of practice.

Evaluating the Use of OT Assessments in Individuals With the Ultra-Rare Disease HNRNPH2 Gene Variant

Date Presented 03/27/20

Variants in the HNRNPH2 gene are associated with a neurodevelopmental disorder, including developmental delay, intellectual disability, autism and autistic features, tone abnormalities, and other multisystem problems. A battery of OT assessments to explore OT needs were added to an HNRNPH2 natural history study. Findings indicate further research is necessary in the implementation of OT-based assessments that possess heightened sensitivity to discern disease-specific qualities for this condition.

Primary Author and Speaker: Donnielle Rome-Martin

Additional Authors and Speakers: Olivia Thornburg

Contributing Authors: Jennifer Bain

Graphene-aramid nanocomposite fibres via superacid co-processing

The development of graphene-polymer nanocomposite materials has been hindered by issues such as poor colloidal stability of graphene in liquid media, weak interactions between graphene and the host polymers as well as the lack of scalable and economical graphene synthesis routes. Chlorosulfonic acid (CSA) can spontaneously disperse graphene without the need for mechanical agitation, chemical functionalisation or surfactant stabilisation,1 however is incompatible with most polymers and organic materials. Here, we demonstrate how poly(p-phenylene terephthalamide) (PPTA) - the polymer which constitutes Kevlar - can be co-processed with graphene in CSA and wet-spun into nanocomposite fibres with minimal aggregation of graphene.

Hirsutism in Women

Hirsutism is the excessive growth of terminal hair in a typical male pattern in a female. It is often a sign of excessive androgen levels. Although many conditions can lead to hirsutism, polycystic ovary syndrome and idiopathic hyperandrogenism account for more than 85% of cases. Less common causes include idiopathic hirsutism, nonclassic congenital adrenal hyperplasia, androgen-secreting tumors, medications, hyperprolactinemia, thyroid disorders, and Cushing syndrome. Women with an abnormal hirsutism score based on the Ferriman-Gallwey scoring system should be evaluated for elevated androgen levels. Women with rapid onset of hirsutism over a few months or signs of virilization are at high risk of having an androgen-secreting tumor. Hirsutism may be treated with pharmacologic agents and/or hair removal. Recommended pharmacologic therapies include combined oral contraceptives, finasteride, spironolactone, and topical eflornithine. Because of the length of the hair growth cycle, therapies should be tried for at least six months before switching treatments. Hair removal methods such as shaving, waxing, and plucking may be effective, but their effects are temporary. Photoepilation and electrolysis are somewhat effective for long-term hair removal but are expensive.

A biomimetic magnetosome: formation of iron oxide within carboxylic acid terminated polymersomes

Bioinspired macromolecules can aid nucleation and crystallisation of minerals by mirroring processes observed in nature. Specifically, the iron oxide magnetite (Fe3O4) is produced in a dedicated liposome (called a magnetosome) within magnetic bacteria. This process is controlled by a suite of proteins embedded within the liposome membrane. In this study we look to synthetically mimic both the liposome and nucleation proteins embedded within it using preferential orientation polymer design. Amphiphilic block co-polymers self-assemble into vesicles (polymersomes) and have been used to successfully mimic liposomes. Carboxylic acid residue-rich motifs are common place in biomineralisation nucleating proteins and several magnetosome membrane specific (Mms) proteins (namely Mms6) have a specific carboxylic acid motifs that are found to bind both ferrous and ferric iron ions and nucleate the formation of magnetite. Here we use a combination of 2 diblock co-polymers: Both have the hydrophobic 2-hydroxypropyl methacrylate (PHPMA) block with either a poly(ethylene glycol) (PEG) block or a carboxylic acid terminated poly(2-methacryloyloxyethyl phosphorylcholine) (PMPC) block. These copolymers ((PEG113-PHPMA400) and (PMPC28-PHPMA400) respectively) self-assemble in situ to form polymersomes, with PEG113-PHPMA400 displaying favourably on the outer surface and PMPC28-PHPMA400 on the inner lumen, exposing numerous acidic iron binding carboxylates on the inner membrane. This is a polymersome mimic of a magnetosome (PMM28) containing interior nucleation sites. The resulting PMM28 were found to be 246 ± 137 nm in size. When the PMM28 were subjected to electroporation (5 pulses at 750 V) in an iron solution, iron ions were transported into the PMM28 polymersome core where magnetic iron-oxide was crystallised to fill the core; mimicking a magnetosome. Furthermore it has been shown that PMM28 magnetopolymersomes (PMM28Fe) exhibit a 6 °C temperature increase during in vitro magnetic hyperthermia yielding an intrinsic loss power (ILP) of 3.7 nHm2 kg-1. Such values are comparable to commercially available nanoparticles, but, offer the added potential for further tuning and functionalisation with respect to drug delivery.

Endocrine Conditions in Older Adults: Menopause

Menopause is the cessation of menstruation due to loss of ovarian function and is diagnosed retrospectively after 12 consecutive months of amenorrhea. The average age of onset in the United States is 51 years but symptoms can be present for many years before and after. Vasomotor and genitourinary symptoms are the most common. Hormone replacement therapy (HRT) is the most effective management. Given the possible risks of cardiovascular disease and breast cancer, recommendations for HRT after the Women's Health Initiative study are to limit HRT to the lowest dose and shortest duration to relieve symptoms. Based on more recent data, women younger than 60 years and less than 10 years from menopause onset appear to be at lower risk of these factors when initiating HRT. Dosing, type of HRT, administration route, and duration of use are individualized. Selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, gabapentin, and clonidine are alternative nonhormonal options with high-quality evidence supporting their use for symptom relief. However, these management options are less effective than HRT. Local vaginal therapy is effective and recommended for management of isolated vulvovaginal symptoms. Decisions to discontinue HRT should be based on symptoms and risk factors, not age.

Endocrine Conditions in Older Adults: Anti-Aging Therapies

Interest in slowing or reversing the process of aging continues to grow and has encouraged the growth of an entire anti-aging industry. However, there is a dearth of data based on randomized trials in humans to support proposed therapies to address the various complex processes involved in aging. Hormonal therapies, in particular, have little data to support safe use and are associated with some degree of risk. Experimental data in animal models suggest possible molecular targets but their use in clinical medicine is far in the future. Observational data guide the current recommendations to maintain a healthy lifestyle, including consumption of a healthful diet and achieving adequate sleep, toward the goal of slowing the aging process. Patients may ask their physicians to offer opinions about treatments they hope will increase their health span. To counsel patients effectively, it is important for physicians to understand the basic principles of anti-aging science. Maintenance of supportive, nonjudgmental therapeutic relationships with patients is critical to avoid harmful and costly treatments while trying to present reliable evidence for available anti-aging therapies.

Endocrine Conditions in Older Adults: Osteoporosis

Osteoporosis management has undergone several paradigm shifts over the past 20 years because of emerging technologies and new treatments and decision support tools to guide risk assessment. Practice guidelines in the United States and abroad differ widely on recommendations for screening, prevention, and management. Screening has evolved, with improvements in bone mineral density testing, vertebral fracture assessment, trabecular bone scores, and decision support tools. All of these have improved the identification of patients at high risk of fractures. Prevention of osteoporosis should begin early in life, with adequate dietary calcium and vitamin D intake and exercise in childhood. At older ages, patients should undergo continuous reevaluation to minimize secondary risk factors (eg, comorbid conditions, drugs). Recommended management of osteoporosis includes exercise, bisphosphonates, denosumab, and parathyroid hormone analogs. Choice of optimal management depends on efficacy, potential adverse effects, patient and societal costs, and patient characteristics (eg, severity of disease, underlying etiologies, management preferences). The ideal duration of pharmacotherapy remains unclear. There is potential continued benefit with long-term management but increased risk of some adverse effects. These include atypical fractures and osteonecrosis of the jaw with bisphosphonates and denosumab, and osteosarcoma with parathyroid hormone analogs.

Endocrine Conditions in Older Adults: Adrenal Tumors

Incidentally discovered adrenal masses, referred to as adrenal incidentalomas, are fairly common given the routine use of imaging as part of clinical care in a variety of settings. Adrenal incidentalomas most frequently are benign and hormonally inactive tumors. However, approximately 11% to 15% are hormonally active, which can lead to diagnosis of clinically relevant conditions that affect morbidity and mortality. Thus, all adrenal incidentalomas should be tested for production of hormones at initial diagnosis. A 1-mg dexamethasone suppression test is the initial screening test. Patients then should be referred for appropriate treatment. Among the adrenal mass subtypes, pheochromocytomas are associated with the highest risk of mortality. Every effort should be made to exclude the presence of these tumors. Patients with hypertension and adrenal incidentalomas should be evaluated for aldosterone excess with an aldosterone to renin ratio. Primary malignancy represents a low percentage of adrenal incidentalomas. A minority of adrenal malignancies are primary adrenocortical tumors, which are associated with a poor prognosis and for which management often is palliative.

Phenotype of GABA-transaminase deficiency

OBJECTIVE

We report a case series of 10 patients with γ-aminobutyric acid (GABA)-transaminase deficiency including a novel therapeutic trial and an expanded phenotype.

METHODS

Case ascertainment, literature review, comprehensive evaluations, and long-term treatment with flumazenil.

RESULTS

All patients presented with neonatal or early infantile-onset encephalopathy; other features were hypotonia, hypersomnolence, epilepsy, choreoathetosis, and accelerated linear growth. EEGs showed burst-suppression, modified hypsarrhythmia, multifocal spikes, and generalized spike-wave. Five of the 10 patients are currently alive with age at last follow-up between 18 months and 9.5 years. Treatment with continuous flumazenil was implemented in 2 patients. One patient, with a milder phenotype, began treatment at age 21 months and has continued for 20 months with improved alertness and less excessive adventitious movements. The second patient had a more severe phenotype and was 7 years of age at initiation of flumazenil, which was not continued.

CONCLUSIONS

GABA-transaminase deficiency presents with neonatal or infantile-onset encephalopathy including hypersomnolence and choreoathetosis. A widened phenotypic spectrum is reported as opposed to lethality by 2 years of age. The GABA-A benzodiazepine receptor antagonist flumazenil may represent a therapeutic strategy.

Manufacturing Man-Made Magnetosomes: High-Throughput In Situ Synthesis of Biomimetic Magnetite Loaded Nanovesicles

A new synthetic method for the production of artificial magnetosomes, i.e., lipid-coated vesicles containing magnetic nanoparticles, is demonstrated. Magnetosomes have considerable potential in biomedical and other nanotechnological applications but current production methods rely upon magnetotactic bacteria which limits the range of sizes and shapes that can be generated as well as the obtainable yield. Here, electrohydrodynamic atomization is utilized to form nanoscale liposomes of tunable size followed by electroporation to transport iron into the nanoliposome core resulting in magnetite crystallization. Using a combination of electron and fluorescence microscopy, dynamic light scattering, Raman spectroscopy, and magnetic susceptibility measurements, it is shown that single crystals of single-phase magnetite can be precipitated within each liposome, forming a near-monodisperse population of magnetic nanoparticles. For the specific conditions used in this study the mean particle size is 58 nm (±8 nm) but the system offers a high degree of flexibility in terms of both the size and composition of the final product.

Mitochondrial Encephalomyopathy Lactic Acidosis and Stroke-Like Episodes (MELAS): A Case Report and Critical Reappraisal of Treatment Options

IMPORTANCE

Stroke-like episodes signal progression and significant disability in the mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes syndrome. Arginine is widely used as a treatment for stroke-like episode, although there is little evidence for this intervention. We discuss the management of a patient with mitochondrial encephalomyopathy lactic acidosis and stroke-like episodes who presented with a stroke-like episode.

OBSERVATION

During a seizure, which triggers the stroke-like episode, neurons are forced to utilize glycolysis as a source of adenosine triphosphate. Glycolytic by-products are damaging to the neuron. Breakdown of the blood-brain barrier leads to vasogenic edema.

CONCLUSION

Treatment of stroke-like episode should include anticonvulsants interictally to prevent seizures and dexamethasone ictally to help repair the blood-brain barrier.

Bioinspired nanoreactors for the biomineralisation of metallic-based nanoparticles for nanomedicine

This review explores the synthesis of inorganic metallic-based nanoparticles (MBNPs) (metals, alloys, metal oxides) using biological and biologically inspired nanoreactors for precipitation/crystallisation. Such nanoparticles exhibit a range of nanoscale properties such as surface plasmon resonance (nobel metals e.g. Au), fluorescence (semiconductor quantum dots e.g. CdSe) and nanomagnetism (magnetic alloys e.g. CoPt and iron oxides e.g. magnetite), which are currently the subject of intensive research for their applicability in diagnostic and therapeutic nanomedicine. For such applications, MBNPs are required to be biocompatible, of a precise size and shape for a consistent signal or output and be easily modified with biomolecules for applications. Ideally the MBNPs would be obtained via an environmentally-friendly synthetic route. A biological or biologically inspired nanoreactor synthesis of MBNPs is shown to address these issues. Biological nanoreactors for crystallizing MBNPs within cells (magnetosomes), protein cages (ferritin) and virus capsids (cowpea chlorotic mottle, cowpea mosaic and tobacco mosaic viruses), are discussed along with how these have been modified for applications and for the next generation of new materials. Biomimetic liposome, polymersome and even designed self-assembled proteinosome nanoreactors are also reviewed for MBNP crystallisation and further modification for applications. With the advent of synthetic biology, the research and understanding in this field is growing, with the goal of realising nanoreactor synthesis of MBNPs for biomedical applications within our grasp in the near future.

Free thin anterolateral thigh flap for post-burn neck contractures - a functional and aesthetic solution

Neck contractures after burn injuries produce restrictions in motion and unacceptable aesthetic outcomes. Although different methods of reconstruction have been used in the treatment of this ailment, a limited and unsatisfactory outcome often results. Free thin anterolateral flaps have been found to be a good single stage option for reconstruction of post-burn contractures of the neck. In our study, 11 patients with post flame burn contractures of the neck underwent surgical release and coverage by a free thin anterolateral thigh flap. Patients were followed up for an average of five years and various aspects of functional and aesthetic rehabilitation were assessed. Our findings revealed that the free thin anterolateral flaps covered the defects over anterior and lateral aspects of the neck with good colour match and contour. Furthermore, none of the flaps had any significant early or delayed complications. Two cases had to be reoperated for partial loss of flaps and all patients were satisfied with functional and aesthetic outcomes. We therefore consider free thin anterolateral thigh flaps to provide a good single stage reconstruction for post-burn cervical contractures with good functional and aesthetic outcomes.

Call-Fleming syndrome: headache in a 16-year-old girl

BACKGROUND

Call-Fleming syndrome, also known as reversible cerebral vasoconstriction syndrome, is an important cause of severe headache characterized by segmental constriction of cerebral arteries in multiple vascular distributions. It is commonly described in adults, with a female predominance.

PATIENT

We report a case of a 16-year-old girl with history of anxiety, attention deficit hyperactivity disorder, and migraines on several medications presenting with 2 weeks of worsening headaches.

RESULTS

Cranial computed tomography was normal, but magnetic resonance imaging revealed cortical subarachnoid hemorrhage. Follow-up imaging demonstrated extensive vasoconstriction of small- to medium-sized cerebral arteries. Sertraline and methylphenidate were discontinued, and nifedipine was started. Symptoms rapidly improved, and repeat angiography at 2 months showed no vasoconstriction.

CONCLUSIONS

Call-Fleming syndrome is an important cause of thunderclap headache and should be considered in the pediatric population, especially in the setting of certain medication usage and other known risk factors.

ATP site-directed inhibitors of protein kinase CK2: an update

CK2 denotes a pleiotropic, constitutively active protein kinase whose abnormally high level in many cancer cells is held as an example of "non oncogene addiction". A wide spectrum of cell permeable, fairly specific ATP site-directed CK2 inhibitors are currently available which are proving useful to dissect its biological functions and which share the property of inducing apoptosis of cancer cells with no comparable effect on their "normal" counterparts. One of these, CX-4945, has recently entered clinical trials for the treatment of advanced solid tumors, Castelman's disease and multiple myeloma. The solution of a wide range of 3D structures of inhibitors bound to the catalytic subunits of CK2 reveals that their efficacy substantially relies on hydrophobic interactions within a cavity which is smaller than in other protein kinases. Accordingly the potency of tetra-halogenated benzimidazoles increases upon replacement of chlorine by bromine and, even more, by iodine, and decreases if two unique bulky side chains on CK2 (Val66 and Ile174) are mutated to alanines. Many CK2 inhibitors have been tested on a panel of more than 60 kinases providing Promiscuity Scores useful to evaluate their selectivity, the lowest value (9.47), denoting highest selectivity, being displayed by quinalizarin. The observation that CK2 inhibitors with medium/high promiscuity scores share the ability to inhibit a group of protein kinases as effectively as CK2 discloses the possibility of using their scaffolds for the rational development of selective inhibitors of these kinases, with special reference to PIMs, DYRKs, HIPK2, PKD and ERK8.

Functional testosterone: biochemical assessment of hypogonadism in men--report from a multidisciplinary workshop hosted by the Ontario Society of Clinical Chemists

OBJECTIVES

In 2004, the Ontario Society of Clinical Chemists (OSCC) held an invitational multidisciplinary workshop to establish the most reliable, cost-effective approach to the biochemical assessment of hypogonadism in men.

METHODS

Specialists across Canada in clinical biochemistry, endocrinology, family medicine and urology were invited to participate in this workshop which included individual presentations and a consensus component addressing two challenge statements: 1) 'Determinations for total testosterone (TT) are equivalent to those for bioavailable testosterone (BAT) or calculated BAT (cBAT) or free testosterone (FT) (by analogue radioimmunoassay or equilibrium dialysis) or calculated FT (cFT)'; 2) 'There is no good evidence that borderline low testosterone concentrations in men should be treated'. The main outcomes were to identify what agreement exists in Canada, what issues were still controversial, and what research remains to be addressed.

RESULTS

Six recommendations based on expert opinion addressed these main themes: investigate with morning total testosterone (TT) followed by repetition and reflexive testing of sex hormone binding globulin (SHBG) if testosterone is 8-15 nmol/L with automatic calculation of cBAT; discontinue the use of analogue free testosterone assays; and definitive methods and standards must be available to ensure standardized results.

CONCLUSIONS

Total testosterone is a reliable marker for the initial investigation of men presenting with symptoms of hypogonadism; cBAT is a reasonable follow-up test in patients with equivocal biochemical or consistent symptomatic findings.

Role of sex steroids in modulating tumor necrosis factor alpha-induced changes in vascular function and blood pressure

BACKGROUND

We previously showed that the infusion of tumor necrosis factor alpha (TNF-alpha) induces hypertension and vascular dysfunction in late pregnant but not virgin rats. In the present study, we tested the hypothesis that levels of ovarian hormones to mimic pregnancy are required for TNF-alpha-induced changes in vascular function and blood pressure in rats.

METHODS

Twenty-one-day-release pellets containing 17beta-estradiol, progesterone, or both were implanted in ovariectomized (OVX) rats. Sham OVX rats were used as controls. Twelve days after implantation, TNF-alpha or vehicle was infused via osmotic minipumps (days 12 to 17). On day 18, mean arterial pressure was measured, and animals were sacrificed to assess vascular function.

RESULTS

Average estrogen and progesterone levels across all groups were 106 +/- 6 pg/mL and 88 +/- 5 ng/mL, respectively. The level of TNF-alpha was 41 +/- 7 pg/mL compared with OVX rats infused with vehicle (4 +/- 1 pg/mL). The results show that TNF-alpha did not cause elevated mean arterial pressure in OVX rats with increased estrogen, progesterone, or both. Vascular responses to the endothelium-dependent and independent agonists, acetylcholine and sodium nitroprusside, were also unchanged. Phenylephrine-induced contraction was moderately but significantly increased at the highest concentrations (10(-4) M) only in TNF-alpha-infused rats.

CONCLUSIONS

These data suggest that increased ovarian hormones to the levels observed during pregnancy are not sufficient to promote TNF-alpha-induced increases in blood pressure or vascular dysfunction.

Characterization of a protein kinase B inhibitor in vitro and in insulin-treated liver cells

OBJECTIVE

Abnormal expression of the hepatic gluconeogenic genes (glucose-6-phosphatase [G6Pase] and PEPCK) contributes to hyperglycemia. These genes are repressed by insulin, but this process is defective in diabetic subjects. Protein kinase B (PKB) is implicated in this action of insulin. An inhibitor of PKB, Akt inhibitor (Akti)-1/2, was recently reported; however, the specificity and efficacy against insulin-induced PKB was not reported. Our aim was to characterize the specificity and efficacy of Akti-1/2 in cells exposed to insulin and then establish whether inhibition of PKB is sufficient to prevent regulation of hepatic gene expression by insulin.

RESEARCH DESIGN AND METHODS

Akti-1/2 was assayed against 70 kinases in vitro and its ability to block PKB activation in cells exposed to insulin fully characterized.

RESULTS

Akti-1/2 exhibits high selectivity toward PKBalpha and PKBbeta. Complete inhibition of PKB activity is achieved in liver cells incubated with 1-10 mumol/l Akti-1/2, and this blocks insulin regulation of PEPCK and G6Pase expression. Our data demonstrate that only 5-10% of maximal insulin-induced PKB is required to fully repress PEPCK and G6Pase expression. Finally, we demonstrate reduced insulin sensitivity of these gene promoters in cells exposed to submaximal concentrations of Akti-1/2; however, full repression of the genes can still be achieved by high concentrations of insulin.

CONCLUSIONS

This work establishes the requirement for PKB activity in the insulin regulation of PEPCK, G6Pase, and a third insulin-regulated gene, IGF-binding protein-1 (IGFBP1); suggests a high degree of functional reserve; and identifies Akti-1/2 as a useful tool to delineate PKB function in the liver.

BI-D1870 is a specific inhibitor of the p90 RSK (ribosomal S6 kinase) isoforms in vitro and in vivo

Hormones and growth factors induce the activation of a number of protein kinases that belong to the AGC subfamily, including isoforms of PKA, protein kinase B (also known as Akt), PKC, S6K p70 (ribosomal S6 kinase), RSK (p90 ribosomal S6 kinase) and MSK (mitogen- and stress-activated protein kinase), which then mediate many of the physiological processes that are regulated by these extracellular agonists. It can be difficult to assess the individual functions of each AGC kinase because their substrate specificities are similar. Here we describe the small molecule BI-D1870, which inhibits RSK1, RSK2, RSK3 and RSK4 in vitro with an IC(50) of 10-30 nM, but does not signi-ficantly inhibit ten other AGC kinase members and over 40 other protein kinases tested at 100-fold higher concentrations. BI-D1870 is cell permeant and prevents the RSK-mediated phorbol ester- and EGF (epidermal growth factor)-induced phosphoryl-ation of glycogen synthase kinase-3beta and LKB1 in human embry-onic kidney 293 cells and Rat-2 cells. In contrast, BI-D1870 does not affect the agonist-triggered phosphorylation of substrates for six other AGC kinases. Moreover, BI-D1870 does not suppress the phorbol ester- or EGF-induced phosphorylation of CREB (cAMP-response-element-binding protein), consistent with the genetic evidence indicating that MSK, and not RSK, isoforms mediate the mitogen-induced phosphorylation of this transcription factor.

Enhanced Endothelin Synthesis by Endothelial Cells Exposed to Sera From Pregnant Rats With Decreased Uterine Perfusion

The initiating event in preeclampsia is thought be to reduced uteroplacental perfusion. Although we have reported previously that chronic reductions in uterine perfusion pressure (RUPP) in pregnant rats results in hypertension and enhanced endothelin production, the factors linking placental ischemia and endothelial cell activation remain unclear. The purpose of this study was to determine the role of angiotensin II type-1 (AT1) receptor activation on endothelin production induced by serum from pregnant rats exposed to reductions in uterine perfusion. To achieve this goal, human umbilical vein endothelial cells were exposed to sera collected from RUPP rats or normal pregnant rats. Arterial pressure was significantly higher in RUPP rats (135+/-2 mm Hg) than in pregnant rats (106+/-1 mm Hg). Six hours after exposure to RUPP serum (n=17), cell media endothelin concentration was 18.4+/-2.7 pg/mL as compared with 9.22+/-1.3 pg/mL from cells exposed to serum from normal pregnant rats (n=9). Eighteen hours after exposure to RUPP serum (n=7), endothelin concentration was 30.5+/-3.8 pg/mL as compared with 12.8+/-5.3 pg/mL from cells exposed to normal pregnant rat serum (n=6). In contrast, serum from RUPP rats did not increase endothelin production in human umbilical vein endothelial cells pretreated with an AT1 receptor antagonist, losartan (15 micromol/L). Eighteen hours after exposure to RUPP serum and losartan (n=14), endothelin concentration was 21.3+/-2.2 pg/mL as compared with 16.4+/-3.3 pg/mL from cells exposed to normal pregnant rat serum and losartan (n=10). These data indicate that serum from pregnant rats exposed to reductions in uterine perfusion enhances endothelin production by endothelial cells via by AT1 receptor activation.

Interactions of LY333531 and other bisindolyl maleimide inhibitors with PDK1

LY333531, BIM-1, BIM-2, BIM-3, and BIM-8 are bisindolyl maleimide-based, nanomolar protein kinase C inhibitors. LY333531, a PKCbeta-specific inhibitor, is in clinical trials against diabetes and cardiac ventricular hypertrophy complications. Specificity analysis with a panel of 29 protein kinases reveals that these bisindolyl maleimide inhibitors also inhibit PDK1, a key kinase from the insulin signaling pathway, albeit in the lower microM range. To understand the molecular basis of inhibition, the PDK1 kinase domain was cocrystallized with these bisindolyl maleimide inhibitors. The inhibitor complexes represent the first structural description of this class of compounds, revealing their unusual nonplanar conformation within the ATP binding site and also explaining the higher inhibitory potential of LY33331 compared to the BIM compounds toward PDK1. A combination of site-directed mutagenesis and essential dynamics analysis gives further insight into PDK1 and also PKC inhibition by these compounds, and may aid inhibitor design.

Structural basis for UCN-01 (7-hydroxystaurosporine) specificity and PDK1 (3-phosphoinositide-dependent protein kinase-1) inhibition

PDK1 (3-phosphoinositide-dependent protein kinase-1) is a member of the AGC (cAMP-dependent, cGMP-dependent, protein kinase C) family of protein kinases, and has a key role in insulin and growth-factor signalling through phosphorylation and subsequent activation of a number of other AGC kinase family members, such as protein kinase B. The staurosporine derivative UCN-01 (7-hydroxystaurosporine) has been reported to be a potent inhibitor for PDK1, and is currently undergoing clinical trials for the treatment of cancer. Here, we report the crystal structures of staurosporine and UCN-01 in complex with the kinase domain of PDK1. We show that, although staurosporine and UCN-01 interact with the PDK1 active site in an overall similar manner, the UCN-01 7-hydroxy group, which is not present in staurosporine, generates direct and water-mediated hydrogen bonds with active-site residues. Inhibition data from UCN-01 tested against a panel of 29 different kinases show a different pattern of inhibition compared with staurosporine. We discuss how these differences in inhibition could be attributed to specific interactions with the additional 7-hydroxy group, as well as the size of the 7-hydroxy-group-binding pocket. This information could lead to opportunities for structure-based optimization of PDK1 inhibitors.

Regulation of breast cancer cell chemotaxis by the phosphoinositide 3-kinase p110delta

Class IA phosphoinositide 3'-kinases (PI3Ks) regulate many cellular processes downstream of tyrosine kinases and Ras. Despite a clear implication of PI3K in cancer, little is known about the distribution of the different PI3K isoforms in malignant cells. We screened a large panel of tissues and cell lines for expression of class IA PI3Ks, and document a ubiquitous expression of the p110alpha and p110beta isoforms but a variable and more restricted tissue distribution of the p110delta isoform. Originally found in WBCs, p110delta was also detected in some nonhematopoietic cell types especially those of breast or melanocytic origin, both in the untransformed and transformed state. Isoform-specific neutralization of PI3K isoforms in breast cancer cell lines (by PI3K antibody microinjection or a p110delta-selective pharmacological inhibitor) demonstrated that p110delta is the most important class IA PI3K in the regulation of epidermal growth factor-driven motility in vitro, controlling the directionality and, to a lesser extent, the speed of migration. In contrast, p110beta was required for the direction but not the speed of migration, whereas p110alpha did not impact on either of these parameters. These results show a nonredundant function of PI3K isoforms downstream of the epidermal growth factor receptor and indicate that the presence of p110delta may confer breast cancer cells with selective migratory capacities. The potential clinical implications of p110delta expression in non-WBC-derived tumors are discussed.

A randomised controlled trial of delayed antibiotic prescribing as a strategy for managing uncomplicated respiratory tract infection in primary care

BACKGROUND

Despite evidence that uncomplicated lower respiratory tract infection (cough) does not respond appreciably to antibiotics and that bacterial resistance is increasing, general practitioners (GPs) still prescribe frequently.

AIM

To assess delayed antibiotic prescribing as a strategy for reducing the unnecessary use of antibiotics for cough in primary care.

DESIGN OF STUDY

Open randomised controlled trial of delayed versus immediate prescribing of antibiotics.

SETTING

One hundred and ninety-one adult patients with uncomplicated cough in 22 Scottish practices who would have received antibiotics under the GP's usual practice were randomised to receive either an immediate prescription (92 patients) or a delayed prescription (99 patients).

METHOD

Delayed subjects were asked to wait a week before deciding whether to collect their prescription. Outcome measures included symptom duration, prescription uptake, patient satisfaction, patient enablement, and subsequent consultation rates. The 48 GPs who recruited patients were surveyed six months after the trial to see whether they used delayed prescribing as a part of their normal practice.

RESULTS

Study and control groups were similar at baseline. Of the subjects in the delayed arm, 55% did not pick up their prescription. Although most patients were satisfied, more patients in the immediate arm were very satisfied with the treatment (P = 0.001) and the consultation (P = 0.03). The patients in the immediate arm were also more enabled (3.3 versus 2.4; P = 0.04), although more of them intended to consult for similar complaints in the future (85% versus 69%, P = 0.02). We were unable to detect any difference in actual consulting behaviour in the follow-up period (mean = 15 months [SD = 5 months]). Subsequently, 68% of GPs used delayed prescribing at least monthly; all gave the prescription to the patient.

CONCLUSION

Delayed prescribing is effective at reducing the use of antibiotics for self-limiting cough; however, patients are less satisfied and enabled as a result. Patients may be deterred from consulting rather than becoming enabled.

Treatment of acute otitis media: are children entered into clinical trials representative?

This study involved a meta-analysis of randomised control studies of the treatment of acute otitis media and judged the characteristics of these trials on the basis of methods, age groups, interventions, and outcomes. An investigation of the eight trials reported in the meta-analysis of clinical trials revealed that the number of children entered per doctor in all practices was low and that the recruitment rate was probably lower than 44%. Low recruitment rates indicate that the type of children entered into trials may only relate to those with mild to moderate symptoms and signs, which could explain why the results of these trials show that antibiotics are not essential in treating acute otitis media.

Andropause. Testosterone replacement therapy for aging men

OBJECTIVE

To review the rationale for treating symptomatic aging men whose testosterone levels are mildly reduced or low-normal with testosterone replacement therapy.

QUALITY OF EVIDENCE

Large-scale multicentre prospective studies on the value of treating andropausal men with hormone therapy do not exist because the whole area of hormone therapy is barely 10 years old. Evidence presented is based on physiologic studies, particularly studies in which treatment has been assessed. These were largely uncontrolled open studies. Studies to date report positive responses to testosterone treatment with very few serious side effects.

MAIN MESSAGE

Physicians should consider hypoandrogenism if male patients complain of loss of libido, erectile dysfunction, weakness, fatigue, lethargy, loss of motivation, or mood swings. Less obvious associations with reduced levels of testosterone are anemia and osteoporosis. The main cause of reduced testosterone production is primary gonadal insufficiency, but secondary causes, such as hypothalamic-pituitary disease, should be considered. Evidence shows that most men treated with testosterone will feel better about themselves and their lives.

CONCLUSION

Andropause is a term of convenience describing a complex of symptoms in aging men who have low testosterone levels. Physicians should be aware of its existence, should consider ordering tests for men who have symptoms, and should treat carefully selected patients whose serum testosterone levels are low.

Mothers' ability to identify infants' communicative acts consistently

A mother's ability to identify consistently what she perceives to be communicatively salient behaviours is considered to be fundamental to the process of responding sensitively to prelinguistic infants. The present study investigated the ability of 35 mothers to identify consistently what they perceived to be communicative acts by infants at three ages (0;6, 0;9, and 1;0). Each mother coded the same videotape of her infant's behaviour on two occasions, three months apart, and observed measures of agreement (consistency) between coded records were obtained. A randomization procedure was used to provide distributions of chance levels of agreement between coded records with which observed measures were compared. Comparisons of the mothers' coded records indicated that they were able to identify infants' communicative acts consistently at each age.

A study of clerics who commit sexual offenses: are they different from other sex offenders?

OBJECTIVE

The goal of this study was to determine if cleric-sex offenders differed significantly from other sex offenders when compared to a control group and assessed with standard instruments that examine the major factors important in sexual offenses.

METHOD

Twenty-four male clerics accused of sexual offenses were compared to 24 male sex offender controls, matched on offense type, age, education, and marital status. Both groups were compared to a general sample of sex offenders (n = 2125) matched only for offense type. The three groups were compared on sexual history and preference, substance abuse, mental illness and personality, history of crime and violence, neuropsychological impairment, and endocrine abnormalities, using reliable and valid measures.

RESULTS

The clerics in this study formed a statistically significant highly educated, older, and predominantly single subgroup of sex offenders. The majority of cleric-sex offenders suffered from a sexual disorder (70.8%), predominantly homosexual pedophilia, as measured by phallometric testing, but did not differ from the control groups in this respect. The clerics were comparable to the other two groups in most respects, but tended to show less antisocial personality disorders and somewhat more endocrine disorders. The most noteworthy features differentiating the clerics from highly educated matched controls were that clerics had a longer delay before criminal charges were laid, or lacked criminal charges altogether, and they tended to use force more often in their offenses.

CONCLUSIONS

In spite of differences in age, education, and occupation between cleric-sex offenders and sex offenders in general, the same procedures should be used in the assessment of this group as for the sex offender population in general. Hypotheses about reduced sexual outlet and increased sexual abuse of clerics in childhood were not supported. Assessment and treatment of cleric-sex offenders should focus especially on sexual deviance, substance abuse, and endocrine disorders.

Physicians who commit sexual offences: are they different from other sex offenders?

OBJECTIVE

To determine if physician sex offenders differ significantly from other sex offenders by using a control group and assessing both groups with reliable and valid instruments.

METHOD

Nineteen male physician sex offenders were compared with 19 male sex offender control subjects, matched on offence type, age, education, and marital status. Both groups were compared with a general sample of sex offenders (n = 2125). The 3 groups were compared on sexual history and preference, substance abuse, mental illness, personality, history of crime and violence, neuropsychological impairment, and endocrine abnormalities.

RESULTS

Physicians in this study were highly educated and older, forming a statistically significant subgroup of sex offenders. The majority of physician sex offenders suffered from a sexual disorder (68.4%), as did the other 2 groups. Physicians showed more neuropsychological impairment and endocrine abnormalities and less antisocial behaviour than did the general sample of sex offenders but did not differ from the matched control group. Physician offenders who sexually assaulted their patients did not differ from those who had nonpatient victims.

CONCLUSIONS

Despite differences in age, education, and occupation between physician sex offenders and sex offenders in general, the same assessment procedures can be recommended for examining both groups. Although the sample size is small, results suggest that physicians who commit sexual offences should be scrutinized by phallometric assessment of sexual deviance and especially for neurological and endocrine abnormalities.

Day surgery in Scotland: patient satisfaction and outcomes

OBJECTIVE

To evaluate patients' views on the process and outcome of day surgery in Scotland, and to study patients' satisfaction with care in a range of specific procedures.

DESIGN

Questionnaires completed by a census of day case surgery patients within a band of 25 procedures under the umbrella of five broad groups: (1) general surgery; (2) urology; (3) gynaecology; (4) orthopaedics; (5) ear, nose, and throat; ophthalmology.

SETTING

13 hospitals in six health board areas in Scotland.

SUBJECTS

During the period 1995-6, 5069 day case patients were asked to complete a questionnaire within two weeks of their operation and discharge from hospital.

MAIN OUTCOME MEASURES

Arrangements before admission; immediate postoperative symptoms and complications; problems experienced after discharge; readmission after discharge.

RESULTS

A response rate of 68% was obtained from 13 sites ranging from 43% to 82%. The overall satisfaction score was 85. A total of 894 patients (26%) experienced pain after surgery and 783 (23%) had relatively minor medical problems after discharge. In total, 265 (7.8%) patients were readmitted to hospital after discharge. Few notable differences existed between specialties or hospitals in terms of satisfaction scores, although notable pain was experienced more frequently in gynaecology and general surgery patients. Readmission was more common for urological procedures.

CONCLUSION

Overall, patient satisfaction with day case surgery was high. Dissatisfaction was largely related to waiting times between admission, operation, and discharge. The amount of pain experienced also had a notable impact on the level of patient satisfaction. Day surgery is not without complications, with 26% of patients experiencing notable degrees of pain; 23% having minor medical problems after discharge; and 8% of respondents having to reattend hospital with problems relating to their original operations.

Repeat dispensing by community pharmacists: advantages for patients and practitioners

Repeat prescribing is an appreciable chore for general practitioners (GPs), and often lacks rigorous clinical control. This paper reports on a pilot repeat dispensing system, which employed community pharmacists to streamline the process and provide clinical supervision. The system described operated within the current regulations, was popular, and worked well for patients on stable treatment regimes.

Relationship between new and return consultations and workload in general practice

General practitioners (GPs) in Tayside, with higher weekly surgery workloads, tended to have a greater proportion of return consultations compared with GPs with smaller workloads. By reducing the number of return consultations, GPs could have a notable effect on their workload and alleviate the, oft-quoted, stress induced by the perceived increase in demand for patient care.

Hospital doctors, general practitioners and dentists learning together

The design, implementation and evaluation of an innovative course on education for a group of hospital doctors, general practitioners and dentists is described. It took place over five 2-day modules spread over 21 months. There were 33 participants and several tutors and external resources. The course was designed around group work and used a learner-centred agenda. Evaluation was by use of the nominal group technique during the course and by open questionnaires after 18 months. The course was successful in stimulating a number of activities and in developing the skills and confidence of the participants. Problem areas centred around the tension between the learner-centred agenda and the participants' need for structure. Courses such as this require good administration, as cohesive and supportive tutors' group, a clear statement of aims, even within a learner-centred framework, and the establishment of clear ground rules to allow the participants to feel safe. Without safety it is arguable that less challenging learning will occur.

The Dundee out-of-hours cooperative: preliminary outcomes for the first year of operation

The Dundee out-of-hours cooperative (DDOC) was the first of its kind to be developed in a city in Scotland. In its first year of operation, the key features of the cooperative were that (a) two doctors could deal with the large majority of out-of-hours calls for a population of just under 100,000 patients, (b) only one third of calls required a home visit, (c) most calls were handled within a period of time acceptable to patients, (d) seven out of 10 patients rated the service equal to or better than previous services, and (e) there were extended opportunities for general practitioners (GPs) involved in the scheme to meet with other colleagues during out-of-hours work.

Community hospitals and general practice: extended attachments for medical students

The first year experience of an innovative experiment in undergraduate medical education is described. The study investigated the educational effectiveness of prolonged clinical attachments for medical undergraduates in community hospital-based general practice. It has also assessed the ability of students to take some responsibility for their own learning in a clinically challenging environment. A retrospective evaluation of the experience obtained during the 3 month attachments for a self-selected group of fourth year Dundee medical school undergraduates was made. These undergraduates were placed in 10 mainly rural Scottish general practices with attached community hospitals providing a wide spectrum of inpatient and outpatient medical and surgical care. Students were assessed on the satisfactory completion of a portfolio of learning experiences and a practical clinical skills list. They were also required to submit a clinical project based on some aspect of their work during the attachment. The initial results showed a high degree of student and tutor satisfaction with the attachments. The assessment of all 10 of the students' educational achievements in their attachment were regarded as satisfactory and two were assessed as outstanding. Tutor assessment confirmed the validity of the initiative. Prolonged attachments in community hospital-based general practice for medical undergraduates have proved educationally valid and popular with both students and tutors. The development and dissemination of this model on a wider scale has resource issues which require to be addressed.