Laser therapy for genital lichen sclerosus: A systematic review of the current evidence base

Background

Lichen sclerosus (LS) is a chronic, inflammatory dermatosis. Initial treatment with superpotent topical corticosteroids is the accepted and evidence-based first-line therapy. For those who do not respond after exclusion of other potentiating factors, the best second-line therapy is unclear. Laser therapy is an emerging treatment for genital LS and despite uncertain efficacy its use is gaining popularity in the private sector.

Objectives

We aimed to review the effectiveness of laser therapy for genital LS in men, women and children.

Methods

We conducted a systematic review of all primary studies reporting the use of laser in genital LS. Ovid MEDLINE, PubMed, Ovid Embase, Cochrane CENTRAL, Web of Science, CINAHL and PsycINFO were searched from inception to February 2021. The quality of the studies was assessed using the revised Cochrane risk-of-bias tool for randomized trials, ROBINS-I tool for non-randomized trials and Joanna Briggs Institute checklist for case studies.

Results

A total of 24 studies, involving 616 adults, met inclusion criteria. These were six randomized controlled trials (RCTs), one non-randomized trial, nine single arm trials and eight case series. Where assessed, most studies suggest that laser therapy in patients with LS may improve symptoms, clinical signs, quality of life and sexual function. However, results were highly heterogeneous and methodological quality was very low, therefore meta-analysis was not possible.

Conclusions

There is poor evidence to support the use of laser therapy for genital LS at present. Effectiveness of laser needs to be robustly investigated in well-conducted RCTs.

Interventions for chronic palmoplantar pustulosis: abridged Cochrane systematic review and GRADE assessments

BACKGROUND

Palmoplantar pustulosis (PPP) is a chronic inflammatory disease in which sterile and relapsing pustules appear on the palms and soles.

OBJECTIVES

To assess the effects of interventions for chronic PPP to induce and maintain complete remission.

METHODS

We searched for randomized controlled trials (RCTs), including people with PPP or chronic palmoplantar pustular psoriasis, in the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, LILACS and eight trials registers up to July 2020. Study selection, data extraction and risk-of-bias assessment were carried out independently by two review authors. Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method.

RESULTS

We included 37 RCTs (1663 participants, 76% women, mean age 50 years). Mean treatment duration was 11 weeks. Topical vitamin D derivative may be more effective than placebo in achieving clearance [risk ratio (RR) 7·83, 95% confidence interval (CI) 1·85-33·12; low-certainty evidence from two trials]. Concerning biological therapies, there was little or no difference between etanercept and placebo in achieving clearance (low-certainty evidence from one trial), ustekinumab is less effective than placebo in reducing severity (low-certainty evidence from one trial), and guselkumab (RR 2·88, 95% CI 1·24-6·69) and secukinumab (RR 1·55, 95% CI 1·02-2·35) are probably better in reducing disease severity (moderate-certainty evidence from two and one trial(s), respectively) but may cause more serious adverse events than placebo.

CONCLUSIONS

Evidence is lacking for or against major chronic PPP treatments. Risk of bias and imprecision limit our confidence in the results.

164 Standardised Anticipatory Care Planning in Care Homes Reduces Unscheduled Hospital Admissions

Background

Anticipatory care planning (ACP) is a proactive person-centred approach for “thinking ahead”, exploring and recording a person’s goals and preferred actions when their health deteriorates. As a key part of Comprehensive Geriatric Assessment of frail patients, care home (CH) residents would benefit from ACP.

Introduction

West Lothian has 16 care homes with 853 residents. Between Oct—Dec 2017, 5.21% of CH residents were admitted to hospital each month. Some of these admissions could have been avoided had there been robust ACP in place.

Methods

In 2017 West Lothian Health and Social Care Partnership appointed a GP lead for Care Homes. Through standardising ACP for CH residents, the goal was to improve the pathway for managing medical emergencies and reduce unnecessary unscheduled care calls and admissions. In 2019 this role was taken over by a team of 2WTE Advanced Nurse Practitioners and 1WTE Staff Nurse. Outcome measures include hospital admission rates, number of ACPs in place and uptake of ACP training amongst CH staff.

Interventions

In collaboration with the Medicine of the Elderly Department at St John’s Hospital, a standardised ACP Summary document was developed for use in all CHs. A medical advice and emergency flowchart was created to reduce unnecessary hospital admissions. An continuous education programme was delivered across all CH staff to facilitate and implement this.

Results

Medical admission rates from CHs have decreased by 60% from 6 to 2.2 admissions per week. The largest reduction is in CHs with full ACP use.

Conclusions

Standardised ACP significantly reduces the number of medical admissions. Continuous education and training is crucial in maintaining its implementation, and ensuring its routine use throughout CHs in West Lothian.

Is urinary incontinence associated with lichen sclerosus in females? A systematic review and meta‐analysis

Background

Lichen sclerosus (LS) is a scarring chronic inflammatory disease with a predilection for genital skin in both sexes. The aetiology of LS is controversial, but evidence increasingly suggests that the occluded exposure of susceptible epithelium to urine is involved in the pathogenesis of genital LS in males. This theory has not yet been robustly investigated in females.

Objectives

This review and meta‐analysis examined whether there is an association between urinary incontinence (UI) and genital lichen LS in females.

Methods

We performed a comprehensive search of MEDLINE, Embase and CINAHL to identify observational studies assessing the prevalence of UI in females with LS. DerSimonian and Laird random‐effects models were used to estimate the overall pooled prevalence and risk ratio compared to controls. Heterogeneity was assessed.

Results

In total, eight studies met the inclusion criteria and five studies were included in a meta‐analysis. Three studies were graded as moderate quality and five were poor. The pooled prevalence for UI in LS was 0.35 (95% confidence interval [CI] 0.13–0.58, I² = 98.4%). The risk ratio of UI in LS was 0.97 (95% CI 0.53–1.75, I² = 87.5%).

Conclusion

There appears to be no difference between patients with LS and those without LS in terms of UI. Studies are limited by clinical and methodological quality and heterogeneity is high. Well‐designed prospective studies are needed.

The Coalition Against Major Diseases: developing tools for an integrated drug development process for Alzheimer's and Parkinson's diseases

Aiming to emulate the successful accelerated development of HIV/AIDS drugs, the Critical Path Institute (C-Path), in collaboration with the Engelberg Center for Health Care Reform at the Brookings Institution, has formed the Coalition Against Major Diseases (CAMD). Members include 6 nonprofit groups representing patients' interests, 15 leading pharmaceutical companies, the US Food and Drug Administration (FDA), the European Medicines Agency (EMEA), 2 institutes of the National Institutes of Health (NIH)-the National Institute on Aging (NIA) and the National Institute of Neurological Disorders and Stroke (NINDS)-and representatives from academia. The coalition's purpose is to transform the drug development paradigm for neurodegenerative diseases and serve as a model for other major diseases.

Design and initial performance of SHARP, a polarimeter for the SHARC-II camera at the Caltech Submillimeter Observatory

We have developed a foreoptics module that converts the Submillimeter High Angular Resolution Camera generation II (SHARC-II) camera at the Caltech Submillimeter Observatory into a sensitive imaging polarimeter at wavelengths of 350 and 450 microm. We refer to this module as "SHARP." SHARP splits the incident radiation into two orthogonally polarized beams that are then reimaged onto opposite ends of the 32 x 12 pixel detector array in SHARC-II. A rotating half-wave plate is used just upstream from the polarization-splitting optics. The effect of SHARP is to convert SHARC-II into a dual-beam 12 x 12 pixel polarimeter. A novel feature of SHARP's design is the use of a crossed grid in a submillimeter polarimeter. Here we describe the detailed optical design of SHARP and present results of tests carried out during our first few observing runs. At 350 microm, the beam size (9 arc sec), throughput (75%), and instrumental polarization (<1%) are all very close to our design goals.

Clinical effects of Abeta immunization (AN1792) in patients with AD in an interrupted trial

BACKGROUND

AN1792 (beta-amyloid [Abeta]1-42) immunization reduces Abeta plaque burden and preserves cognitive function in APP transgenic mice. The authors report the results of a phase IIa immunotherapy trial of AN1792(QS-21) in patients with mild to moderate Alzheimer disease (AD) that was interrupted because of meningoencephalitis in 6% of immunized patients.

METHODS

This randomized, multicenter, placebo-controlled, double-blind trial of IM AN1792 225 microg plus the adjuvant QS-21 50 microg (300 patients) and saline (72 patients) included patients aged 50 to 85 years with probable AD, Mini-Mental State Examination (MMSE) 15 to 26. Injections were planned for months 0, 1, 3, 6, 9, and 12. Safety and tolerability were evaluated, and pilot efficacy (AD Assessment Scale-Cognitive Subscale [ADAS-Cog], MRI, neuropsychological test battery [NTB], CSF tau, and Abeta42) was assessed in anti-AN1792 antibody responder patients (immunoglobulin G titer > or = 1:2,200).

RESULTS

Following reports of meningoencephalitis (overall 18/300 [6%]), immunization was stopped after one (2 patients), two (274 patients), or three (24 patients) injections. Of the 300 AN1792(QS-21)-treated patients, 59 (19.7%) developed the predetermined antibody response. Double-blind assessments were maintained for 12 months. No significant differences were found between antibody responder and placebo groups for ADAS-Cog, Disability Assessment for Dementia, Clinical Dementia Rating, MMSE, or Clinical Global Impression of Change, but analyses of the z-score composite across the NTB revealed differences favoring antibody responders (0.03 +/- 0.37 vs -0.20 +/- 0.45; p = 0.020). In the small subset of subjects who had CSF examinations, CSF tau was decreased in antibody responders (n = 11) vs placebo subjects (n = 10; p < 0.001).

CONCLUSION

Although interrupted, this trial provides an indication that Abeta immunotherapy may be useful in Alzheimer disease.

Abeta vaccination effects on plaque pathology in the absence of encephalitis in Alzheimer disease

The authors report a patient with Alzheimer disease (AD) without encephalitis who was immunized with AN-1792 (an adjuvanted formulation of Abeta-42). There were no amyloid plaques in the frontal cortex and abundant Abeta-immunoreactive macrophages, but tangles and amyloid angiopathy were present. The white matter appeared normal and minimal lymphocytic infiltration in the leptomeninges was observed. This case illustrates the effects of an Abeta-based immunization on AD pathogenesis in the absence of overt meningoencephalitis and leukoencephalopathy.

Dialysis for end-stage renal disease. Determining a cost-effective approach

OBJECTIVE

Renal replacement therapy (RRT) is essential for maintenance of life for those with end-stage renal disease. However, there remain many areas of uncertainty about which method of RRT should be chosen. This paper reports an economic model based on a systematic review that attempts to determine which method of dialysis, continuous ambulatory peritoneal dialysis (CAPD) or hemodialysis, a patient should have as the initial method of RRT.

METHODS

A systematic review and a costing exercise carried out in a Scottish hospital were used to populate a Markov model. Scenario analysis was used to model plausible variations in variables included in the model.

RESULTS

In 8 of the 16 scenarios developed hemodialysis dominated CAPD. In a further eight scenarios, the cost per life-year displayed considerable variability, ranging from between 5,000 Pounds to 51,000 Pounds. The higher costs per life-year were associated with minimum estimates of additional survival for a patient starting RRT on hospital hemodialysis.

CONCLUSION

It may be more cost-effective to manage patients starting on RRT with hospital hemodialysis than CAPD. This has particular implications for the United Kingdom, given that up to 50% of new patients receive CAPD.

Selection and integration of a radiology information system

A comprehensive and reliable computer-based RIS can significantly improve patient care. The authors present case studies that illustrate different approaches to selection and implementation of an RIS. Detailed coverage is given to criteria for the RIS, the selection process, integration with hospital information systems and planning for the future.

Geographic variations in conceptions to women aged under 18 in Great Britain during the 1990s

This article examines geographic variations in conceptions to women aged under 18. It presents data on conception rates and the percentage leading to abortion for the three countries of Great Britain, the Government Office Regions of England and local authorities within Great Britain. It provides an overview of variations between areas at each of the three geographic levels and examines whether this variation is associated with the social and demographic characteristics of local authority areas. This article is the first occasion on which conception rates for Scotland have been published on a comparable basis to England and Wales and also the first use of the revised ONS classification to examine conceptions to women aged under 18.

A glider swing intervention for people with dementia

The soothing, repetitive movement of rocking and swinging is well known to anyone who has enjoyed a porch swing or rocking chair. Positive effects of rocking have been reported. However, investigations on its effect in people with dementia are limited. The purposes of this quasi-experimental, repeated-measures design study were to measure the effects of a glider swing on emotions, relaxation, and aggressive behaviors in a group of nursing home residents with dementia (n = 30). Data were obtained during a 5-day baseline phase, a 10-day intervention phase, and a 5-day posttreatment phase. Subjects were placed on the glider for 20 minutes each day during the intervention phase. The results of the study indicate that the glider intervention significantly improved emotions and relaxation. The most noted changes were found after 10 minutes of swinging. However, no differences were found in aggressive behaviors.

Challenges of implementing intervention research in persons with dementia: example of a glider swing intervention

Intervention studies for persons with dementia present many challenges. This article describes challenges encountered in conducting a glider swing intervention study for persons with dementia and the strategies used to manage the problems encountered. The overall purpose of a quasi-experimental study was to explore the effects of a glider swing intervention on emotions, relaxation, and aggressive behaviors in nursing home residents with dementia. Suggestions for investigators conducting intervention studies for persons with dementia are provided.

Extent of misclassification of death from Creutzfeldt-Jakob disease in England 1979-96: retrospective examination of clinical records

OBJECTIVE

To investigate the extent to which deaths from Creutzfeldt-Jakob disease were misclassified during 1979-96.

DESIGN

Structured review of clinical records based on predetermined criteria to determine whether death could have been due to sporadic or variant Creutzfeldt-Jakob disease.

SETTING

100 health authorities and 275 NHS trusts in England.

SUBJECTS

1485 people who died aged 15-44 years from selected neurological disorders in England during 1979-96.

MAIN OUTCOME MEASURE

Cause of death.

RESULTS

The clinical records of 705 (48%) subjects were successfully traced. Tracing of clinical records was highest in subjects who died during 1990-6. There was sufficient information in the records of 640 (91%) of the 705 subjects to exclude Creutzfeldt-Jakob disease as a cause of death. In 61 (9%) subjects, there was insufficient information to reach any conclusion about the validity of the cause of death recorded on the death certificate. The clinical records of four subjects were examined further by the National Creutzfeldt-Jakob Disease Surveillance Unit; none was thought to have died from Creutzfeldt-Jakob disease.

CONCLUSIONS

No new cases of sporadic or variant Creutzfeldt-Jakob disease were detected in a sample of deaths most likely to have included misclassified cases. This suggests that the surveillance system is unlikely to have missed a significant number of cases among people aged 15-44 years. Hence, any rapid increase in the number of cases of variant Creutzfeldt-Jakob disease in this age group is likely to be real not artefactual.

Recanalization of an occluded popliteal artery following posterior knee dislocation

Posterior knee dislocation results in popliteal artery injury in up to one-third of cases. Prompt recognition and treatment of arterial injury is essential for limb salvage. We report a case of complete occlusion of the popliteal artery following posterior knee dislocation treated with saphenous vein bypass without exclusion of the injured arterial segment. Follow-up duplex scanning demonstrated a patent vein graft and a patent ipsilateral popliteal artery. This report suggests that, in some instances, a traumatically occluded popliteal artery may recanalize, and that revascularization with a bypass graft may be the preferred method of repair, particularly in young patients.

Application of a time-resolved fluoroimmunoassay for the analysis of normal prion protein in human blood and its components

BACKGROUND AND OBJECTIVES

To quantify the cellular isoform of prion protein (PrP(c)) in human blood using a new time-resolved dissociation-enhanced fluoroimmunoassay (DELFIA).

MATERIALS AND METHODS

The DELFIA was optimised for human blood samples and applied to isolated cell and plasma fractions from blood donations. The physicochemical properties of PrP(c) were analysed.

RESULTS

26. 5% of blood PrP(c) was associated with the platelet fraction, 0.8% with polymorphonuclear leucocytes, 2.4% with mononuclear leucocytes, 1.8% with red cells and 68.5% with plasma (mean values from 4 processed donations).

CONCLUSION

The majority of blood PrP(c) is found in the platelet and plasma compartments.

Preliminary assessment of whole-blood, red-cell and platelet- leucodepleting filters for possible induction of prion release by leucocyte fragmentation during room temperature processing

Universal leucodepletion is being introduced in the U.K. to reduce a theoretical risk of Creutzfeldt-Jakob disease (CJD) transmission. If CJD infectivity is associated with leucocytes, any cell fragmentation associated with filtration could reduce the potential benefit. Four types each of whole blood, red cell and platelet leucodepletion filters were assessed after holding of blood units for at least 4 h at 22 degrees C. In all cases the mean residual leucocyte content was <1 000 000 per unit, with only two individual filtered whole blood units having a leucocyte content exceeding this. Evidence of leucocyte fragmentation during filtration was sought but not found by assay of soluble elastase, beta-thromboglobulin and normal prion protein, as well as by isotopic labelling of leucocyte external membrane. These preliminary studies indicate that it was possible to prepare leucodepleted blood components by filtration at room temperature, and that this appeared not to be associated with overt cell fragmentation. Definitive demonstration that fragmentation does not occur requires the development of improved general (non-specific) assays for cell membrane fragments.

Development of obstructive hydrocephalus with lumboperitoneal shunting following subarachnoid hemorrhage

Hydrocephalus is a frequent complication of subarachnoid hemorrhage (SAH). The optimum method of treating hydrocephalus in this setting has not been determined. We review our experience with patients developing communicating hydrocephalus secondary to SAH and subsequently treated with lumboperitoneal (LP) shunts. Following hospitalization for the treatment of SAH, patients who developed clinical symptoms and radiologic signs of hydrocephalus were treated with (ventriculoperitoneal) VP or LP shunting. Eighteen patients received an LP shunt, of which seven (28%) developed a non-communicating or obstructive hydrocephalus. These seven patients underwent replacement with a VP shunt and have not had further complications. In the setting of post-SAH communicating hydrocephalus, obstructive hydrocephalus may develop after LP shunt placement. Patients who develop this complication and have their LP shunts converted to VP shunts have a favorable prognosis.

Interleukin-10 inhibits inducible nitric oxide synthase in an animal model of necrotizing enterocolitis

BACKGROUND

Nitric oxide (NO) and its role in surgical inflammation are well documented; demonstrating the role of NO in necrotizing enterocolitis (NEC) and ways in which it may be suppressed may provide avenues for immune modulation in the treatment of NEC.

AIMS

We sought to demonstrate an increase in inducible nitric oxide synthase (iNOS) mRNA and nitric oxide in an experimental model of necrotizing enterocolitis. In addition, we hypothesized that interleukin-10 (IL-10) would attenuate this response.

METHODS

Newborn rats were treated with 25 microliters intraperitoneal IL-10 or vehicle prior to laparotomy, 1 h superior mesenteric artery (SMA) occlusion, 50 micrograms/kg intraluminal platelet activating factor administration, and SMA reperfusion. iNOS mRNA and nitric oxide levels were measured in the liver, small bowel, and serum and compared using Student's t-test.

RESULTS

Small bowel iNOS mRNA increased after NEC induction from 0.058 +/- 0.02 to 0.144 +/- 0.05 relative intensity units (RIU) at 2 h (p < 0.01) and from 0 to 0.09 +/- 0.02 RIU at 6 h (p < 0.03). Liver mRNA increased from 0.026 +/- 0.002 to 0.485 +/- 0.09 RIU (p < 0.002) and from 0 to 0.069 +/- 0.02 RIU (p < 0.0001) at 2 and 6 h, respectively. Serum nitric oxide increased in NEC induced animals at 2 h from 28.04 +/- 10.5 to 45.18 +/- 6.8 microM (p < 0.001). IL-10 suppressed iNOS mRNA and nitric oxide expression at 2 h in small bowel, liver, and serum by 60%, 89%, and 11%, respectively.

CONCLUSIONS

IL-10 decreases iNOS mRNA response in experimental NEC. This down-regulation may be an avenue for anti-inflammatory intervention in NEC.

An enzyme-linked immunosorbent assay for the detection of agents which interfere with the DNA binding activities of transcription factors--exemplified by NF-IL6

Binding of transcription factors to DNA is usually detected by the electrophoretic mobility shift assay also known as gel-shift or band-shift assay. Recently the use of biosensors has allowed factor/DNA interactions to be followed in real time. However, neither of these approaches lends itself easily to high-throughput screening of agents which might interfere with this process. We have therefore developed a 96-well plate-based enzyme-linked immunosorbent assay for this purpose. Biotinylated oligonucleotides bound to streptavidin-coated plates are used to capture recombinant transcription factor proteins which can then be detected using specific antibodies which in turn are recognised by peroxidase-conjugated antisera. The peroxidase catalyzes conversion of a colorless substrate to a colored product which can be quantified by optical densitometry on a plate reader. Agents which interfere with the binding of the transcription factor to DNA reduce the optical density in the well. Using the NF-IL6 transcription factor we show that the assay can detect reductions to 86% at significant levels. The assay may be readily adapted for robotic manipulation, making it ideal for high-throughput screening.

Transposed basilic vein versus polytetrafluorethylene for brachial-axillary arteriovenous fistulas

BACKGROUND

Both transposed basilic vein (BV) and polytetrafluorethylene (PTFE) upper arm arteriovenous fistulas (AVF) are common angioaccess operations. To evaluate the patency and complication rates after AVF, a concurrent series of patients was reviewed.

METHODS

Ninety-eight patients underwent brachial artery to axillary vein AVF: 30 BV and 68 PTFE. The PTFE grafts were performed in the standard fashion, whereas the basilic veins were translocated subcutaneously to the brachial artery.

RESULTS

Risk factors were similar between the two groups. Basilic vein AVF had better patency at 24 months (70% BV versus 46% PTFE, P = 0.023). The dialysis access complications were higher in the BV group (20%) versus PTFE (5%), but the PTFE group had a higher infection rate (10%) than BV (0%).

CONCLUSIONS

The primary and secondary patency rates were superior in the BV AVFs. The BV AVF preserves the venous outflow tract after AVF thrombosis for a future PTFE AVF operation.

Dementia in people aged 65 years and older: a growing problem?

This study examines trends in death rates from dementias and neurodegenerative disorders in people aged 65 and over in England and Wales between 1979 and 1996. In total, there were 171,590 deaths from dementias and neurodegenerative disorders, with the number of deaths per year increasing from 3,021 in 1979 to 10,415 in 1996. Age-standardised death rates for all diagnoses combined increased from 39 to 96 per 100,000 for men and from 45 to 101 for women between 1979 and 1996. The most dramatic increase was seen in death rates from Alzheimer's disease which increased from less than 1 per 100,000 in 1979 to 19 for men and 21 for women in 1996.

Activated keratinocytes in the epidermis of hypertrophic scars

The etiology of hypertrophic scarring, a pathological end point of wound healing, is unknown. The scars most commonly occur when epithelialization has been delayed during, for example, the healing of deep dermal burn wounds. Hypertrophic scars are conventionally described as a dermal pathology in which the epidermis has only a passive role. In this study, the expression of keratin intermediate filament proteins and filaggrin has been investigated in the epidermis of hypertrophic scars and site-matched controls from the same patients. Hypertrophic scar epidermis was found to express the hyperproliferative keratins K6 and K16 in interfollicular epidermis in association with K17 and precocious expression of filaggrin. K16 mRNA was localized by in situ hybridization using a highly specific cRNA probe. In contrast to the immunohistochemical location of K16 protein, the K16 mRNA was found to be expressed in the basal cell layer of normal skin. In hypertrophic scars the mRNA distribution corroborated the abnormal K16 protein distribution. These results suggest the keratinocytes in hypertrophic scar epidermis have entered an alternative differentiation pathway and are expressing an activated phenotype. Activated keratinocytes are a feature of the early stages of wound healing producing growth factors that influence fibroblasts, endothelial cells, and the inflammatory response. We propose that cellular mechanisms in the pathogenesis of hypertrophic scarring are more complex than isolated dermal phenomena. The persistence of activated keratinocytes in hypertrophic scar epidermis implicates abnormal epidermal-mesenchymal interactions.

Reversible ischemia determined by xenon-enhanced CT after 90 minutes of complete basilar artery occlusion

Intraarterial thrombolytic therapy decreases mortality in the treatment of acute basilar artery occlusion. An acute decrease in cerebral blood flow (CBF) (<12 mL/100 g per minute) has been reported to invariably result in infarction. We report a case of acute basilar artery occlusion, recanalized within 90 minutes, with reversal of CBF of less than 6 mL/100 g per minute. After reperfusion, areas with persistent CBF of 6 mL/100 g per minute resulted in infarctions on subsequent CT studies. Parenchymal viability is possible after 90 minutes of posterior CBF of 6 mL/100 g per minute.

Non-acute casemix in the Illawarra

There are problems associated with the use of acute care diagnosis-related groups for prospective payment for rehabilitation medicine services. As a preliminary effort to assist in the development of the National Non-Acute Inpatient Casemix Project, a modified costing study was done in the rehabilitation and geriatrics ward of the Illawarra Regional Hospital; its aim was to assess the validity of the functional independence measure (FIM) and the resource utilization group (RUG) system as predictors of staff time involvement in inpatient rehabilitation services. Data collected on 51 patients over 3 months showed that in a standard Australian rehabilitation unit the costs of staff involvement varied depending on the type of functional impairment and severity of carer burden. The FIM alone was not predictive of rehabilitation costs and the RUG 2 instrument was not comprehensively predictive of cost. The RUG 3 instrument developed in the USA did not allocated weightings appropriate to Australian costs. If, however, functional impairment groups were combined with one of these measures of carer burden, then costs did fall into categories reflective of staff time involvement. An Australian system which incorporates an instrument measuring functional capacity may be useful for resource allocation in rehabilitation care.

Activation of a cryptic streptomycin-resistance gene in the Bacteroides erm transposon, Tn4551

Bacteroides compound transposons encoding erm resistance are highly homologous but previous studies have shown some divergence of Tn4551. Results presented here describe a novel Tn4551 streptomycin-resistance gene, aadS, that was phenotypically silent in wild-type Bacteroides. However, aadS expression could be activated by a trans-acting chromosomal mutation. The aadS-encoded peptide displayed significant homology to Gram-positive streptomycin-dependent adenyltransferases, and enzymatic analysis confirmed the production of this activity. Examination of the nucleotide sequence showed that 200 bp upstream of aadS, the DNA base composition changed abruptly from 31% G+C to 48% G+C. These two regions were demarcated by a DNA sequence with homology to the recombination hot spots reported for Tn21 and the Bacteroides ermFU gene and to sequences at the ends of the chromosomal Bacteroides conjugal element, XBU4422.

Regulation of ketone formation and phosphoenolpyruvate carboxykinase activity in the small intestinal mucosa of infant rats

We studied the effect of different hormones added in vivo or in vitro on ketogenesis and phosphoenolpyruvate carboxykinase (PEPCK) activity in the small intestinal mucosa of suckling rats. Injection of insulin or dexamethasone in vivo or of an antiglucagon antiserum decreased the rate of ketone formation in the mucosa whereas injection of anti-insulin antiserum led to increased mucosal ketogenesis. PEPCK activity in the mucosa was decreased by the antiglucagon serum but was not affected by insulin or anti-insulin serum injections. Both liver and brown fat PEPCK responded as expected with the activity being elevated by anti-insulin serum and depressed by both insulin and antiglucagon serum. In the in vitro experiments, no effect of any of the agents on PEPCK was found. Ketone formation was suppressed in vitro by insulin or dexamethasone addition to the medium.

Partial deletion of the beta-globin gene: a common beta-thalassaemia allele in Asian Indians

We have examined 11 families of Asian Indian origin, who are segregating beta-thalassaemia alleles, for coupled restriction enzyme site markers. A beta-thalassaemia deletion allele, which removes over 600 base pairs, is a common cause of thalassaemia in this population. This deletion can be conveniently detected in AvaII restriction enzyme digests. Consequently AvaII digests are particularly informative in this population because both the deletion and a coupled restriction site polymorphism may be simultaneously observed.

Regulation of phosphoenolpyruvate carboxykinase and fatty acid synthetase in brown fat of suckling rats

Infant rats were injected with prednisolone (0.5-5 mg/100 g wt). This caused phosphoenolpyruvate carboxykinase (PEPCK) activity to rise in liver and to decrease in brown fat. Fatty acid synthetase (FAS) activity remained unchanged in liver but increased in brown fat. A single injection of prednisolone caused hepatic PEPCK activity to remain elevated for at least 7 days. Brown fat FAS also remained high for that period. However, brown fat PEPK activity returned to normal on the third day after the injection. A single injection of prednisolone or cortisone to 5-day-old rats caused a transient elevation of the blood level of insulin and a prolonged decrease in that of growth hormone. No effect on the level of glucagon was noted. Injections of insulin had effects similar to those of prednisolone, i.e. a rise in hepatic and a fall in brown fat PEPCK. Using antibodies prepared to hepatic PEPCK it was shown that the observed changes were due to changes in the rate of synthesis of the enzyme. Using actinomycin D indirect evidence was obtained that changes in FAS activity of brown fat were also due to changes in the synthetic rate.

Changes in tyrosine transaminase and phosphoenolpyruvate kinase activities during short term incubation of fetal liver

Incubation of fetal rat liver homogenates at 37 degrees for 2-3 hr increased PEPK activity in the 100,000 X g supernatant 5-fold and TTA activity 10-fold. At the same time, activity in the 100,000 X g pellet decreaed and no change was observed in the whole homogenate. It is concluded that during incubation of fetal liver pieces or homogenates in vitro, a redistribution of enzymes occurs between cell particles and cell sap. It is suggested that release of enzyme into the cell sap may be the first stimulus for subsequent enzyme synthesis which occurs after birth.

High glucose concentration and phosphoenolpyruvate carboxykinase activity in human and rat fetal liver cultures

In cultures of human and rat fetal liver, phosphoenolpyruvate carboxykinase activity increases during the first 24 hr of culturing. This increase can be suppressed by adding cycloheximide to the culture medium or by adding a high glucose concentration. This, however, applies only to human fetal liver and to fetal liver from rats obtained just before term. In younger rat fetal liver, glucose, on the contrary, increases the activity of phosphoenolpyruvate carboxykinase. A high glucose concentration in the medium also leads to higher citrate cleavage enzyme activity and to lower alpha-glycerolphosphate dehydrogenase (cytoplasmic) activity in rat fetal liver cultures.

Enzyme activities during culturing of fetal rat liver

Liver from fetal rats was cultured in a simple medium. In such cultures tyrosine transaminase (TTA) activity had increased after 20 min and reached twice the initial value within 2 h. Phosphoenolpyruvate earboxykinase (PEPCK) activity decreased during culturing. Incubation of microsomes from fresh fetal liver with dibutyryl cyclic AMP (DcAMP), oleic acid, or acetyl-CoA led to an increase in their TTA activity. It is suggested that the early rise in TTA during culturing is due to release of the enzyme from the microsomal fraction. In contrast to human fetal liver, oleic acid did not induce PEPCK in rat fetal liver cultures. In neither species was there an effect of DcAMP on the amount of fatty acids in the culture medium or on the activities of carnitine acetyl- and carnitine palmitoyltransferases.

Metabolism of subcutaneous adipose tissue in the immediate postnatal period of human newborns. Developmental changes in some cytoplasmic enzymes

The activities of citrate cleavage enzyme (CCE; EC 4.1.3.8), malic enzyme (ME; EC 1.1.1.40), phosphoenol pyruvate carboxykinase (PEPK; EC 2.7.1.40), α-glycerophosphate dehydrogenase (GPD EC 1.1.1.8) and glucose-6-phosphate dehydrogenase (G-6-PD; EC 1.1.1.49) was measured in cytosol of subcutaneous adipose (white) tissue in human new borns and adults. ME activity was highest during the first day of life and then decreased. CCE was higher in the newborn adipose tissue than in adults. G-6-PD and GPD activities were higher in the neonate. No changes were noted with PEPK. Our results obtained on activities of enzymes involved in citrate breakdown (CCE) providing acetylCoA and furnishing ‘reduction potential’ for fatiy acid synthesis (ME, G-6-PD) suggest that fatty acid synthesis decreases rapidly after birth. This decrease in enzymes involved in fatty acid synthesis is faster than the decrease in enzymes involved in glycerol production