Global Globin Network Consensus Paper: Classification and Stratified Roadmaps for Improved Thalassaemia Care and Prevention in 32 Countries

The Global Globin Network (GGN) is a project-wide initiative of the Human Variome/Global Variome Project (HVP) focusing on haemoglobinopathies to build the capacity for genomic diagnosis, clinical services, and research in low- and middle-income countries. At present, there is no framework to evaluate the improvement of care, treatment, and prevention of thalassaemia and other haemoglobinopathies globally, despite thalassaemia being one of the most common monogenic diseases worldwide. Here, we propose a universally applicable system for evaluating and grouping countries based on qualitative indicators according to the quality of care, treatment, and prevention of haemoglobinopathies. We also apply this system to GGN countries as proof of principle. To this end, qualitative indicators were extracted from the IthaMaps database of the ITHANET portal, which allowed four groups of countries (A, B, C, and D) to be defined based on major qualitative indicators, supported by minor qualitative indicators for countries with limited resource settings and by the overall haemoglobinopathy carrier frequency for the target countries of immigration. The proposed rubrics and accumulative scores will help analyse the performance and improvement of care, treatment, and prevention of haemoglobinopathies in the GGN and beyond. Our proposed criteria complement future data collection from GGN countries to help monitor the quality of services for haemoglobinopathies, provide ongoing estimates for services and epidemiology in GGN countries, and note the contribution of the GGN to a local and global reduction of disease burden.

Total and unicondylar knee arthroplasty are equivalent treatment options in end-stage spontaneous osteonecrosis of the knee, and the size of the lesion has no influence on the results

PURPOSE

The purpose of the present study was to compare total (TKA) and unicondylar (UKA) knee arthroplasty for spontaneous osteonecrosis of the knee (SONK), and to investigate potential correlations to radiographic parameters.

METHODS

All consecutive patients with a magnetic resonance imaging (MRI) proven SONK treated with either TKA or UKA between 2002 and 2018 were analysed. The primary outcomes were postoperative complications and failure rates. Functional assessment included Knee Society Score (KSS), WOMAC Score, and range of motion. A novel three-dimensional measurement method was established to determine the size of the osteonecrotic lesion. All outcome parameters were correlated to the size of the necrotic lesion using Spearman's rank correlation.

RESULTS

The two treatment groups (34 TKAs, 37 UKAs) did not differ regarding age, body mass index, and ratio of the volume of the necrotic lesion to the volume of the femoral condyle (n.s.). At a mean follow-up of 6.6 years, patients with UKA had better functional outcomes compared to patients with a TKA (WOMAC Score 1.0 vs. 1.6, p = 0.04; KSS pain 86 vs. 83, n.s), with a similar complication rate. No correlation was found between necrotic lesion size and failure rate (n.s.).

CONCLUSION

UKA is a valuable treatment option for SONK leading to good functional results and a low failure rate. In case of a surgeon's concern regarding implant anchorage, TKA represents an equivalent solution. The MR-tomographic size of the osteonecrotic lesions seems to have no influence on the results.

LEVEL OF EVIDENCE

III.

Choroid plexus-derived miR-204 regulates the number of quiescent neural stem cells in the adult brain

Regulation of adult neural stem cell (NSC) number is critical for lifelong neurogenesis. Here, we identified a post-transcriptional control mechanism, centered around the microRNA 204 (miR-204), to control the maintenance of quiescent (q)NSCs. miR-204 regulates a spectrum of transcripts involved in cell cycle regulation, neuronal migration, and differentiation in qNSCs. Importantly, inhibition of miR-204 function reduced the number of qNSCs in the subependymal zone (SEZ) by inducing pre-mature activation and differentiation of NSCs without changing their neurogenic potential. Strikingly, we identified the choroid plexus of the mouse lateral ventricle as the major source of miR-204 that is released into the cerebrospinal fluid to control number of NSCs within the SEZ. Taken together, our results describe a novel mechanism to maintain adult somatic stem cells by a niche-specific miRNA repressing activation and differentiation of stem cells.

Protease-mediated Inflammation: An In Vitro Human Keratinocyte-based Screening Tool for Anti-inflammatory Drug Nanocarrier Systems

Background:

Refined encapsulation approaches in dermatotherapy gain increased interest. There is need of reproducible in vitro systems representing disease features to screen drug delivery systems for preclinical assessment. Inflammatory human skin diseases are commonly accompanied by abnormal epidermal differentiation and barrier impairment. Serine proteases (SPs) and their inhibitors play a critical role in such dysfunctional differentiation. SPs also initiate cellular pathways via activation of protease-activated receptors, which contribute to inflammation. Thus, function and activity of SPs should be considered for the design of new therapies of such disorders.

Objectives:

Herein, we established a novel simplified cell culture model, based on SP-mediated inflammation suitable to assess nanocarriers loaded with anti-inflammatory drugs.

Methods:

SP-mediated inflammation and the regulatory effect of free or encapsulated dexamethasone were determined by measuring interleukin-6 and interleukin-8 in culture medium of HaCaT (human adult low calcium temperature)-keratinocytes. Additionally, radical formation was analyzed by electron paramagnetic resonance spectroscopy. Cellular uptake of core-multishell nanocarriers was investigated by fluorescence microscopy. Cytotoxicity of all additives was determined by a viability assay.

Results:

SP-Stimulation of keratinocytes resulted in increased radical production and release of inflammatory cytokines without affecting cell viability. Induced inflammation was successfully downregulated by addition of free or encapsulated dexamethasone.

Conclusion:

SP-addition can be used as inflammatory stimulus in cell culture to mimic effects of aberrant enzymatic activities found in skin of atopic dermatitis patients. The set-up is appropriate as a preliminary test to examine the effectiveness of new molecules or delivery-systems to counteract serine protease-mediated inflammatory processes prior to skin studies.

Human Variome Project country nodes: documenting genetic information within a country

The Human Variome Project (http://www.humanvariomeproject.org) is an international effort aiming to systematically collect and share information on all human genetic variation. The two main pillars of this effort are gene/disease-specific databases and a network of Human Variome Project Country Nodes. The latter are nationwide efforts to document the genomic variation reported within a specific population. The development and successful operation of the Human Variome Project Country Nodes are of utmost importance to the success of Human Variome Project's aims and goals because they not only allow the genetic burden of disease to be quantified in different countries, but also provide diagnosticians and researchers access to an up-to-date resource that will assist them in their daily clinical practice and biomedical research, respectively. Here, we report the discussions and recommendations that resulted from the inaugural meeting of the International Confederation of Countries Advisory Council, held on 12th December 2011, during the 2011 Human Variome Project Beijing Meeting. We discuss the steps necessary to maximize the impact of the Country Node effort for developing regional and country-specific clinical genetics resources and summarize a few well-coordinated genetic data collection initiatives that would serve as paradigms for similar projects.

[Conclusions and recommendations of a WHO expert consultation meeting on iron supplementation for infants and young children in malaria endemic areas]

This article presents the results of an expert consultation meeting aimed at evaluating the safety and public health implications of administering supplemental iron to infants and young children in malaria-endemic areas. Participants at this meeting that took place in Lyon, France on June 12-14, 2006 reached consensus on several important issues related to iron supplementation for infants and young children in malaria-endemic areas. The conclusions in this report apply specifically to regions where malaria is endemic.

Recommendations of the 2006 Human Variome Project meeting

Lists of variations in genomic DNA and their effects have been kept for some time and have been used in diagnostics and research. Although these lists have been carefully gathered and curated, there has been little standardization and coordination, complicating their use. Given the myriad possible variations in the estimated 24,000 genes in the human genome, it would be useful to have standard criteria for databases of variation. Incomplete collection and ascertainment of variants demonstrates a need for a universally accessible system. These and other problems led to the World Heath Organization-cosponsored meeting on June 20-23, 2006 in Melbourne, Australia, which launched the Human Variome Project. This meeting addressed all areas of human genetics relevant to collection of information on variation and its effects. Members of each of eight sessions (the clinic and phenotype, the diagnostic laboratory, the research laboratory, curation and collection, informatics, relevance to the emerging world, integration and federation and funding and sustainability) developed a number of recommendations that were then organized into a total of 96 recommendations to act as a foundation for future work worldwide. Here we summarize the background of the project, the meeting and its recommendations.

UNESCO?s perspective on biological resource centres

The initiative of the Organisation for Economic Co-operation and Development (OECD) to establish biological resources centres (BRCs) and eventually a Global Biological Resources Centres Network (GBRCN) is a welcome one at a time when loss of biodiversity is becoming a critical concern to scientists and many governments.

The interaction of selected natural products with human recombinant glutathione transferases

The interaction of geshoidin, diospyrin and ergothioneine, with heterologously expressed human glutathione transferases (GSTs) was investigated in vitro. Diospyrin and geshoidin inhibited the three GST isoforms tested, with IC50 values in the range 0.1-0.5 microm, whereas ergothioneine had no effect on the GSTs. The predominant mode of inhibition was noncompetitive with respect to both glutathione (GSH) and 1-chloro-2,4-dinitrobenzene (CDNB). Diospyrin, however, competitively inhibited A1-1 and M1-1 with respect to GSH and geshoidin displayed mixed inhibition toward A1-1 with respect to GSH. The Ki values for diospyrin with respect to both GSH and CDNB were in the range 0.08-0.6 microM and those for geshoidin were in the range 16-173 microM. These results indicate that diospyrin is a potent inhibitor of heterologously expressed human GSTs A1-1, M1-1 and P1-1. Diospyrin and geshoidin were also found to inactivate P1-1 with diospyrin being a potent inactivator. Given these inhibitory properties, diospyrin may be a potential GST chemomodulator. Ergothioneine inactivated P1-1 only after preincubation and it enhanced ethacrynic acid inactivation of P1-1. Inactivation of P1-1 by ergothioneine may have implications for the antioxidant roles of P1-1 and ergothioneine in vivo.

The African-specific CYP2D617 allele encodes an enzyme with changed substrate specificity

OBJECTIVE

The effects of the CYP2D6*17 and *29 alleles on substrate specificity and enzyme activity were studied by correlating CYP2D6 genotype to phenotype with 4 probe drugs (codeine, debrisoquine, dextromethorphan, metoprolol) in black Tanzanians and white Swedes.

METHODS

The black Tanzanian subjects represented the following 6 genotypic groups: A, (CYP2D6*1 or *2)/(*1 or *2) (n = 13); B, CYP2D6*17 /*17 (n = 5); C, CYP2D6*29 /*29 (n = 4); D, CYP2D6*1 /*17 (n = 5); E, CYP2D6*5/*17 (n = 4); and F, various genotypes (n = 4). The white subjects were from 4 groups, as follows: A, (CYP2D6*1 or *2)/(*1 or *2) (n = 7); B, (CYP2D6*1 or *2)/(*3, *4, or *5) (n = 7); C, homozygous for defect alleles (n = 7); and D, duplicated CYP2D6 gene (n = 2).

RESULTS

The metabolic ratios of the 4 probe drugs correlated significantly (r (s) = 0.69-0.92; P <.001) in both populations. Tanzanian subjects homozygous for the CYP2D6*17 allele were slower metabolizers when debrisoquine or dextromethorphan was used as the probe drug than when codeine or metoprolol was used, showing a different substrate specificity of CYP2D6.17 than of CYP2D6.1 and CYP2D6.2. This was confirmed with analysis of covariance of the different metabolic ratios for a subgroup of subjects carrying only the CYP2D6*17 mutated allele (n = 9) compared with all other subjects (n = 44). The metabolic ratios of dextromethorphan and metoprolol differed significantly among Tanzanian subjects homozygous for the CYP2D6*29 allele compared with those with CYP2D6*1 or *2 alleles.

CONCLUSION

We found differences in the disposition of 4 CYP2D6 probe drugs in black Tanzanians compared with Swedes. The differences were caused by the presence of CYP2D6.17 and CYP2D6.29. The results show that CYP2D6.17 exhibits altered substrate specificity compared with CYP2D6.1 and CYP2D6.2.

The implementation of evidence-based medicine in general practice prescribing

BACKGROUND

Research on the implementation of evidence-based medicine has focused on how best to influence doctors through information and education strategies. In order to understand the barriers and facilitators to implementation, it may also be important to study the characteristics of those doctors and practices that successfully implement evidence-based changes.

AIM

To determine the relationship between practice and doctor characteristics and the implementation of recommended evidence-based changes in the area of prescribing.

METHOD

Visits were made to 39 practices in southern England. Audits of three key prescribing changes were carried out and amalgamated to produce an 'implementation score' for each practice. These scores were related to a wide range of practice and doctor variables obtained from a questionnaire survey of doctors and practice managers.

RESULTS

There was wide variation between the practices' implementation scores (mean 67%, range 45% to 88%). The only factors that had a significant relationship with implementation of these important prescribing changes were an innovative approach among the doctors (most practitioners were cautious of change), and fundholding status. Use of clinical protocols, disease registers, or computers was not associated with overall implementation score, nor was the doctor's age. Doctors complained of information overload.

CONCLUSIONS

The emphasis on the need for evidence in medicine, and better transmission of information, needs to be balanced by a recognition that most general practitioners are pragmatic, averse to innovation, and already feel overwhelmed with information. Important advances in therapy may be crowded out. More attention should be given to the facilitation of priority changes in practices.

The career outcomes for doctors completing general practice vocational training 1990-1995

BACKGROUND

While much has been published about the career outcomes of doctors who completed general practice vocational training prior to 1990, no evidence is currently available about those who have qualified since that time.

AIM

To obtain information about the career paths of doctors who had completed general practice vocational training since 1990, and to compare the results with previously published data.

METHOD

Postal questionnaire survey of all doctors completing vocational training during the period 1990-1995 in three regions of the United Kingdom. The study examined current work status, career path since completion of training, desire for and experience of part-time training, degree of difficulty in choosing and following a career, and the degree to which certain factors impeded career choice.

RESULTS

The overall response rate was 64.8%, although there was a significant difference between the response rates for men and women. While virtually all responders were employed, with the majority working in general practice, women were significantly less likely than men to be working as principals in general practice, for all cohorts. These results were very similar to those cohorts described in earlier studies. The career paths of doctors only became stable after about four years. Of those working in general practice, about 20% found it difficult to choose their career, and about 10% found it difficult to follow their career. Out-of-hours work was the major factor impeding career choice.

CONCLUSION

Although they are taking longer to reach, the final career destinations of doctors completing vocational training since 1990 are no different from those of earlier cohorts.

Content validity of a trainer's report: summative assessment in general practice

A structured trainer's report for use in summative assessment in general practice has been designed, and it is important that the content validity of this report is tested before it is widely adopted. The aim of this paper was to assess the content validity of a proposed report from the perspective of doctors who have recently completed vocational training. A postal questionnaire survey was sent out seeking the views of 220 doctors who had completed vocational training in 1994 as to whether or not the proposed contents were items that are needed in general practice, and whether or not the items were suitable for assessment by means of a trainer's report. The response rate was 73.3%. More than 85% of respondents agreed that the 31 items proposed for inclusion in the trainer's report were needed in general practice. While the proportions agreeing that the items were suitable for assessment by a trainer's report were considerably lower, for 26 items significantly more agreed that they were suitable than disagreed. Analysis of the freetext comments made by respondents illustrated their concerns. The results provide support for the content validity of this proposed trainer's report; however it is important that the concerns expressed are addressed.

A novel mutant variant of the CYP2D6 gene (CYP2D6*17) common in a black African population: association with diminished debrisoquine hydroxylase activity

1. The debrisoquine hydroxylase (CYP2D6) is polymorphically distributed. Not only are there differences in the proportions of extensive metabolisers to poor metabolisers in various ethnic groups, but there are also pronounced variations in the metabolic capacity among those classified as extensive metabolisers. 2. The mean debrisoquine metabolic ratio of Caucasian extensive metabolisers is lower than that for a number of African populations. In the present study, we have searched for novel CYP2D6 mutations to explain the diminished enzyme activity in African populations. 3. Three Zimbabwean Shona subjects with EM phenotypes (metabolic ratios for debrisoquine of 0.4, 1.5 and 10.5 respectively) were selected and the open reading frame of the CYP2D6 gene of each was sequenced. 4. The subject with metabolic ratio of 10.5 was found to be homozygous for an allele with a nucleotide exchange in exon 2, 1111C-->T causing a 107Thr-->Ile amino acid exchange in a conserved region of the enzyme. In addition, he was homozygous for the 2938C-->T and 4268G-->C mutations causing 296Arg-->Ser and 486Ser-->Thr amino acid substitution found in the CYP2D6*2 allele. 5. Seventy-six Zimbabwean Shona subjects were subsequently genotyped for the 1111C-->T mutation and for the intron 1 gene conversion present in the CYP2D6*2 gene. The 1111C-->T mutation was found at an allele frequency of 34% and was only present in alleles carrying the gene conversion in intron 1 indicative for the CYP2D6*2 gene. 6. This allele (CYP2D6*17), containing the 1111C-->T, 2938C-->T and 4268G-->C mutations, was found to be strongly associated with lower capacity for debrisoquine hydroxylation. We therefore postulate that the CYP2D6*17 allele might contribute to the molecular basis of the previously established diminished debrisoquine hydroxylase activity in African Bantu populations.

Phenotype and genotype analysis of debrisoquine hydroxylase (CYP2D6) in a black Zimbabwean population. Reduced enzyme activity and evaluation of metabolic correlation of CYP2D6 probe drugs

OBJECTIVE

Debrisoquine hydroxylase (CYP2D6) is responsble for the oxidative metabolism of many clinically used drugs. Since this enzyme has been poorly studied in the southern part of Africa, we examined the CYP2D6 phenotypes and genotypes in 103 unrelated black Zimbabweans.

METHODS

Phenotyping for CYP2D6 activity was done using debrisoquine and metoprolol as probe drugs by measuring the urinary metabolic ratio (MR) of parent drug to metabolite concentration ratios. Genotyping was done using polymerase chain reaction (PCR), restriction fragment length polymorphism (RFLP), single-strand conformation polymorphism (SSCP) and sequencing analyses with respect to CYP2D6 variants of interest.

RESULTS AND CONCLUSION

Phenotyping with debrisoquine revealed two poor metabolisers (PMs), whereas 5 subjects out of 94 were PMs using metoprolol as probe drug. Genotypes predictive of the poor metaboliser status were observed for the two subjects who were PMs with both probe drugs, whereas no mutations could explain the PM phenotype for metoprolol among the three remaining subjects, a fact possibly explained by lack of compliance in metoprolol intake. There was a moderate correlation of 0.67 between the debrisoquine and metoprolol metabolic ratios in the 89 subjects who were extensive metabolisers for both probe drugs. The median values for the metabolic ratios for debrisoquine and metoprolol as probe drugs were 1.00 and 1.35, respectively, which are higher than those observed in Caucasian populations. This is indicative of a decreased capacity for metabolism of CYP2D6 substrates by Zimbabweans compared to Caucasians. Evaluation of the DNA samples for the known allelic variants CYP2D6A, CYP2D6B, CYP2D6C, CYP2D6D or CYP2D6Ch1 yielded no explanation for these results.

Content of a trainer's report for summative assessment in general practice: views of trainers

BACKGROUND

Summative assessment of doctors completing general practice vocational training will become compulsory for those completing training after 1 September 1996. One component of the assessment will be a trainer's report.

AIM

A study set out to consider the content of the trainer's report. It aimed to determine which elements of general practice general practitioner trainers believe are the most important for independent general practice; to seek the views of trainers as to the most appropriate methods for assessing these elements in summative assessment of general practitioner registrars; and to determine how frequently trainers have been sufficiently concerned about the performance of registrars to consider not signing the form denoting satisfactory completion of the training year.

METHOD

A questionnaire was sent to 1296 general practitioner trainers in the United Kingdom. The main outcome measures used were: the percentage of respondents indicating that an element was very important/crucial for independent general practice; the percentage of respondents indicating a favoured method of assessment that did not include a trainer's report at all; and the proportion of trainers who had ever considered not signing the form denoting satisfactory completion of the training year.

RESULTS

The response rate was 78%. Of 75 elements examined, 31 were considered important for independent general practice by 70% or more of respondents. For 29 of these 31 elements, fewer than 30% of respondents would choose a method of assessment that did not include a trainer's report at all. Twenty-six per cent of respondents had considered not signing the form denoting satisfactory completion of the training year, which represents a trainer considering not signing this form once every 29 years.

CONCLUSION

These results provide a basis for the content of a structured trainer's report for summative assessment in general practice; such a report is likely to contain about 30 items. Data from the Joint Committee on Postgraduate Training for General Practice and the present study suggest that, for every form not signed, trainers considered not signing the forms of another 13 general practitioner registrars. This highlights the need for a report that will help trainers to make the difficult decision as to whether or not a registrar is ready for independent practice.

Consensus minimum standards for use in a trainer's report for summative assessment in general practice

BACKGROUND

Summative assessment of general practitioner registrars is to be introduced in September 1996, one component of which will be a report by the trainer. Standards must be set and guidance provided as to the most appropriate ways of obtaining evidence for the trainer's assessment.

AIM

The first aim of this study was to set consensus minimum standards for 30 items that are likely to form the content of a trainer's report; the second aim was to provide a consensus view on the most appropriate methods of assessment to be used by trainers.

METHOD

A consensus conference was held in March 1995 during which the 30 items were discussed by a group of 30 general practitioners, of whom 27 were experienced trainers. This resulted in a draft document that was circulated to the conference attenders and other experts for consultation.

RESULTS

Draft minimum standards were produced for all 30 items after the consensus conference with a mean of 2.5 standards for each item. Of those involved in the consultation exercise, 82% replied. Most of the revisions suggested at this stage were of a minor nature; the only major revision was to divide one item into two, resulting in a final total of 31 items. All but one of the 80 standards could be assessed by direct observation; 41 (51%) could be assessed by tutorial-based discussion and 61 (76%) by methods specific to that standard. Trainers or their practice partners were viewed as acceptable sources of evidence for all items and hospital consultants and primary health care team members were viewed as acceptable for just over half of the items.

CONCLUSION

Standards for use by trainers when providing a general practitioner report for the summative assessment of registrars have been developed by consensus conference and have been subjected to review by consultation. Acceptable methods by which registrars could be assessed against these standards, and suitable personnel who could provide evidence, have also been suggested.

General practice careers: changing experience of men and women vocational trainees between 1974 and 1989

The aim of this study was to consider the careers pursued by men and women general practitioner trainees following the completion of their training, and to assess changes since 1974. It was based on a postal questionnaire survey involving 995 doctors who had completed general practice vocational training in the Oxford region between 1974 and 1989. A total of 796 doctors replied to the questionnaire (498 men and 298 women, overall response rate 80%). The vast majority of ex-trainees were working in general practice at the time of the survey (men 87%, women 71%). Women were less likely to have become principals than men (75% versus 97%). Most women (71% of those completing training before 1988) reported at least one period of non-employment. While the duration of maternity leave dropped only slightly during the 15 years studied, the length of voluntary and involuntary unemployment experienced by women fell markedly. Men experienced little unemployment with no change in length of unemployment over time. Considerably fewer women than men (6% versus 13%) had become involved in teaching or training. The degree of difficulty in choosing and following a general practice career remained constant over time for women. In contrast there was a significant increase in the difficulties experienced by men. The proportion of men and women completing training in 1984-89 who found following a general practice career 'difficult or very difficult' was similar (10% of men, 13% of women). The possibility of improving these experiences, particularly by encouraging flexibility in the early years after completion of training, is discussed.

Molecular epidemiology of aflatoxin exposures: validation of aflatoxin-N7-guanine levels in urine as a biomarker in experimental rat models and humans

Human epidemiology and experimental animal data have provided the statistical association and biological information necessary to propose that aflatoxins are risk factors for human liver cancer. As liver cancer causes at least 200,000 deaths per year, prevention measures must be developed to ameliorate this nearly always fatal disease. Preventive strategies will be facilitated by the identification of individuals at high risk. It is the goal of the molecular dosimetry field to provide facile and accurate biomarkers to identify people at high risk for carcinogen exposure and consequent adverse health effects. We have developed methods to defect the major aflatoxin DNA adduct, aflatoxin N7-guanine (AFB-N7-guanine), in urine, examined the dose-response characteristics in people living in China and The Gambia, and have found an excellent association of this biomarker with exposure. In addition to exposure studies in people, our laboratories have monitored AFB-N7-guanine excretion in the urine of rats whose risk for developing cancer has been modulated with dietary chemoprotective agents such that independent groups of animals receiving the same dosage of aflatoxin B1 were at either high or low risk for tumorigenesis. The production of DNA damage by aflatoxins is not the exclusive mechanism for liver cancer. Many other factors, including hepatitis B virus, cell proliferation, and nutritional status, can exert strong modification effects in human disease. Thus, molecular epidemiological investigations that examine only one biomarker may greatly underestimate or overestimate the risk for an individual.(ABSTRACT TRUNCATED AT 250 WORDS)

The primary health care team: history and contractual farces

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Training for minor surgery in general practice during preregistration surgical posts

OBJECTIVE

To study the teaching of minor surgery to preregistration house officers in surgery and their confidence in their skills.

DESIGN

Questionnaire survey of consultants and vocational trainees.

SETTING

Trent, Oxford, and East Anglian Regional Health Authorities.

SUBJECTS

All consultant surgeons (n = 148) with preregistration house officers on their firm and all first year vocational trainees in general practice (n = 165).

MAIN OUTCOME MEASURES

Time spent teaching minor surgery to preregistration house officers; source of teaching; trainees' confidence in their skills in 15 minor surgical procedures and degree of confidence that consultants expected their junior house officers to achieve.

RESULTS

137 (93%) consultants and 139 (84%) vocational trainees replied; 131 of the consultants' replies and all the trainees' replies were analysable. Only 14 consultants had a curriculum for teaching junior house officers, and 90 offered less than four hours' teaching a week. Only 11 trainees thought that their firm had had a curriculum, and 102 reported having received under two hours' teaching a week. The consultants indicated that they did most of the teaching, but the trainees reported having received most of their teaching from junior registrars. Seventy nine consultants attempted to teach minor surgery. They expected their junior house officers to acquire greater confidence in their skills in minor surgery than did the other consultants, but overall the confidence expected was low. The trainees were more confident than the consultants expected them to be, but overall confidence was still low. Those who had received more teaching were significantly more confident.

CONCLUSIONS

The educational potential of the post of preregistration house officer in surgery seems underexploited, particularly with regard to teaching skills in minor surgery.

Effect of dietary crude-protein type on fertilization and embryo quality in dairy cattle

An experiment was conducted to determine whether balancing dietary crude protein for optimal rumen degradability would improve fertilization rate and quality of ova in lactating dairy cows. Thirty-eight Holstein cows in early lactation were fed 1 of 2 diets formulated to be isocaloric and isonitrogenous, containing 16% crude protein. Diet 1 contained 73% rumen degradable intake protein, whereas diet 2 contained 64% rumen degradable intake protein. The cows were induced to superovulate and were inseminated, and ova were recovered nonsurgically on postbreeding day 7. Ova were counted and classified as fertilized or unfertilized. Fertilized ova were scored as excellent, good, fair, poor, or degenerate. Unfertilized ova and poor and degenerate embryos were considered to be nontransferable ova and excellent, good, and fair embryos were considered to be transferable ova. There were no differences for mean number of fertilized, unfertilized, transferable, or nontransferable ova recovered from cows fed the 2 diets (P greater than 0.10). Mean percentage of fertilized ova recovered from cows was greater (P less than 0.05) in those fed diet 2, compared with diet 1. Mean percentage of transferable ova recovered from cows tended to be greater (P = 0.06) in those fed diet 2, compared with diet 1. More cows failed to yield transferable ova (P less than 0.05) when fed diet 1, compared with diet 2. Fertilization failure or early degeneration of embryos may occur in cows fed excess rumen degradable protein.

Changes of the surface proteolytic activity in synchronized Ehrlich ascites tumor cells grown in vivo

Changes of the cell surface proteolytic activity during the cell cycle in vitro were reported. Using an easy assay, with casein as a substrate, the proteolytic activity on the surface of Ehrlich ascites tumor (EAT) cells grown in vivo was determined. The cleavage of casein incubated with EAT cells increased linearly for 20 min and permitted reproducible enzyme activity determinations. If the proliferation of exponentially growing EAT cells was partially synchronized by an intraperitoneal bleomycin injection, a significant increase of the surface enzymatic activity was observed in cells with an increased DNA content. This finding supports the results obtained with transformed cells in vitro, indicating that elevated proteolytic surface activity occurs in the late synthesis phase and prior to mitosis. However, the observed effect may also be due to changes of gene expression caused by bleomycin.