A comparison of the carbon footprint of alternative sampling approaches for cervical screening in the UK: A descriptive study

OBJECTIVE

To understand whether self-sampling can reduce carbon emissions (CO2 e) from the NHS cervical screening programme (NHSCSP) by comparing the carbon footprint of three sampling strategies: routine cervical sampling, vaginal self-sampling and first-void (FV) urine collection.

DESIGN

Descriptive study.

SETTING

National Health Service (NHS), United Kingdom (UK).

POPULATION OR SAMPLE

Patients aged 25-64 years eligible for cervical screening in the UK.

METHODS

A carbon footprint analysis was undertaken for three cervical screening sampling approaches, from point of invitation to screening through to preparation for transport to the laboratory for HPV testing. A combination of primary and secondary data were used, with a bottom-up approach applied to collection of primary data.

MAIN OUTCOME MEASURES

We report CO2 e per sampling approach, which is the unit used to express carbon footprint and harmonise the contributions of greenhouse gases with different global warming potentials.

RESULTS

The total carbon footprint of routine cervical sampling is 3670 g CO2 e. By comparison, vaginal self-sampling had a total carbon footprint of 423 g CO2 e, and FV urine sampling 570 g CO2 e. The largest share of emissions for routine sampling was attributable to the carbon footprint associated with an appointment in a primary care setting, which totalled 2768 g CO2 e.

CONCLUSIONS

Routine cervical sampling is up to 8.7-fold more carbon-intensive than self-sampling approaches with equivalent effectiveness. We found negligible differences in the carbon footprint of alternative self-sampling methods, supporting the need for an informed choice of screening options for participants, which includes sharing information on their environmental impacts.

Risk factors for adverse outcomes in twin pregnancies: a narrative review

PURPOSE

Globally, the incidence of twin pregnancies is rising owing to the use of assisted reproductive technologies (ART), emigration and deferment of pregnancy until advanced maternal age (AMA). While twin pregnancies have higher absolute risks of adverse outcomes, including miscarriage, stillbirth, neonatal death and preterm delivery, the impact of specific exposures and risk factors related to these outcomes may differ between twin pregnancies and singleton pregnancies. Regarding modifiable factors, data are sometimes based on evidence extrapolated from singleton or whole obstetric populations. Therefore, targeted evidence is required to provide care tailored to twin pregnancies to prevent adverse outcomes. We aimed to comprehensively review the association between different risk factors and adverse outcomes in twin pregnancies, including data on chorionicity, and to compare these to singletons.

MATERIALS AND METHODS

This review examines the risks associated with chorionicity, AMA, body mass index (BMI), socioeconomic and ethnic inequalities, maternal smoking, use of ART, maternal perception of fetal movement, and maternal comorbidities, including hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM). Adverse outcomes reported were preterm birth, admission to the neonatal intensive care unit (NICU), stillbirth and neonatal mortality. As such, fetal mortality and morbidity will be under-represented, as pregnancy loss before 22-24 weeks is omitted.

RESULTS

Monochorionicity increases the risk of stillbirth, NICU admission, and preterm delivery in twin pregnancy. AMA predisposes twin pregnancies to higher risks of mortality, admission to the NICU, and preterm birth than singleton pregnancies do. Conversely, the impact of BMI, socioeconomic inequalities, smoking, ART, and HDP on adverse outcomes appears to be lower in twin pregnancies than in singleton pregnancies. This attenuation might be explained by the higher baseline risk of adverse outcomes such as preterm birth in twin pregnancies. Some exposures, such as ART use and GDM, appear to be "protective" against perinatal mortality in twin pregnancies, despite being established risk factors for adverse outcomes in singleton pregnancies, potentially related to access to specialist care. There is a paucity of evidence available to counsel mothers of twin pregnancies regarding reduced fetal movement.

CONCLUSIONS

Overall, the risk factors for adverse pregnancy outcomes differ between twin and singleton pregnancies. This highlights the need for further studies to examine the association between risk factors and adverse outcomes in twin pregnancies. The resulting data would facilitate tailored guidance for twin pregnancies, contribute to improved antenatal care, and inform wider public health strategies.

Quality improvement in the undergraduate medical curriculum: the need for clinical exposure

This correspondence article aims to outline the importance of an integrated clinical component within Quality Improvement education in response to the recently published article by Shah et al.. The Quality Improvement and Patient Safety workshops described in the above study were compared with the Quality Improvement module experienced by medical students at King's College London. The key difference between the two methods of teaching Quality Improvement was the clinical project undertaken by King's College Students, which helped students gain an appreciation of the pitfalls of instigating change in a clinical environment. The authors feel that this arguably more authentic experience could have benefited the students in the study in making them feel better equipped to use the skills learned in the theoretical workshops in their later careers.

Research capacity training for surveillance and response in the Indo-Pacific: a case study of implementation

SETTING

Surveillance and response workforce in the Indo-Pacific region, including Papua New Guinea (PNG), Solomon Islands, Fiji, Eastern Indonesia and Timor-Leste.

OBJECTIVE

To evaluate the implementation of a modified WHO SORT IT research training programme which included a workplace-based research project. The training was designed for surveillance and response frontline workforce in the Indo-Pacific region.

DESIGN

This was a programme evaluation using mixed methods. Fifty-three health and biosecurity workers from Fiji, Indonesia, PNG, Solomon Islands and Timor-Leste participated in the research training programme.

RESULTS

Implementation of the programme was modified to reflect the context of participant countries. Work-place research projects focused on priority issues identified by local policy makers and in-country stakeholders. Self-reported research skills showed a significant increase (P < 0.01) after the completion of training. Participants reported high scores for satisfaction with training.

CONCLUSIONS

This case study provides lessons learnt for future research training, and demonstrates that the SORT IT model can be modified to reflect the context of implementation without compromising purpose or outcomes.

Pleomorphic dermal sarcoma: a clinical and histological review of 49 cases

Pleomorphic dermal sarcoma (PDS) is a rare mesenchymal neoplasm that shares histopathological features with atypical fibroxanthoma (AFX), but has additional features of deep invasion of the superficial subcutis, tumour necrosis, and vascular and perineural invasion, which confers a risk of local recurrence and metastases. To study the clinical and pathological spectrum more comprehensively, we retrieved 49 cases of pleomorphic dermal sarcoma from our departmental files. There was a strong male predominance (n=45). The mean (range) age at presentation was 80 (47-97) years. The tumours had a median (range) maximum dimension of 23.5 (5-75) mm. There was a strong predilection for the head and face (n=47), with the scalp (n=32) being the most common site. Ulceration was observed in 21 patients, tumour necrosis in seven, perineural infiltration in six, and lymphovascular invasion in two. CD10 was expressed in all cases. Smooth muscle actin was expressed in 15 and CD68 in 14. Follow up was available in 41 cases (mean (range) 22.4 (2-90) months). Six patients had local recurrences, despite all having originally undergone primary surgical resections and having reports of clear margins. Progressive metastatic disease was observed in one patient who died from their disease. Based on the Kaplan Meier method, median overall survival was 70.8 (8.4-133.1) months. Although AFX and PDS may be part of a spectrum, distinction is important to emphasise the potential for malignant behaviour in PDS.

WP1-23 Vascular collagen 4A1 in subcortical white matter of older people and primates

Objectives

To test whether collagen 4A1 in cerebral small arteries associated with age, hypertension or small vessel disease (SVD).

Design

Neuropathology cohort study.

Subjects

Older people age >65 years with minimal Alzheimer’s Disease.

Methods

We examined subcortical white matter in archived brain tissue from older people (n=34, 15F/19M, median age 84, range 65–99 y) and from experimental non-human primates (NHP, Macaca mulatta) that were young adults (n=9, age 6.2–8.3 y) or older adults (n=8, age 17.0–22.7 y). Some of the primates (5 young, 3 older) were chronically hypertensive. Vascular collagen 4A1 immunohistochemical labelling was examined qualitatively and quantified as percent area fraction.

Results

Collagen 4A1 labelling was common in arterial myocytes and in the adventitial layer in human and primate brain arteries, as well as in basement membrane, which frequently exhibited replication. Among older people, collagen 4A1 associated with neuropathological SVD severity (sclerotic index; r=−0.461, p=0.0409, least squares) and with radiological SVD severity (leukoaraiosis; p=0.0455, 1-way ANOVA) but not with age or clinical history of hypertension. In NHP, age but not hypertension was significantly associated with collagen-4A1 labelling (p=0.0396, 0.232 respectively, 2-way ANOVA).

Conclusions

In this small cohort, vascular collagen 4A1 was related to SVD severity in older humans, in accord with genetic associations of COL4A1 with SVD phenotypes.

Transgressive women don't deserve protection: young men's narratives of sexual violence against women in rural Papua New Guinea

Sexual violence against women and girls is commonplace in Papua New Guinea (PNG). While the experiences of women are rightly given central place in institutional responses to sexual violence, the men who perpetrate violence are often overlooked, an oversight that undermines the effectiveness of prevention efforts. This paper draws on interviews conducted with young men as part of a qualitative longitudinal study of masculinity and male sexuality in a rural highland area of PNG. It explores one aspect of male sexuality: men's narratives of sexual violence. Most striking from the data is that the collective enactment of sexual violence against women and girls is reported as an everyday and accepted practice amongst young men. However, not all women and girls were described as equally at risk, with those who transgress gender roles and roles inscribed and reinforced by patriarchal structures, at greater risk. To address this situation, efforts to reduce sexual violence against women and girls require an increased focus on male-centred intervention to critically engage with the forms of patriarchal authority that give license to sexual violence. Understanding the perceptions and experiences of men as perpetrators of sexual violence is a critical first step in the process of changing normative perceptions of gender, a task crucial to reducing sexual violence in countries such as PNG.

Marking sutures to orientate specimens of basal cell carcinoma: do they really make a difference?

Traditionally, marking sutures have been used to orientate specimens of non-melanomatous skin cancers, and they provide an identifiable point as a reference for monitoring and further treatment. For histopathological purposes, the orientated specimen is marked with different inks, which enables measurement to the nearest lateral and deep margins, and if invaded, guides further excision. We retrospectively analysed 688 specimens of basal cell carcinoma (BCC) from the head and neck from two separate years: 2010 and 2012. Marking sutures were used in 663 (96%) cases. There were 21 invaded margins (3%), 17 (81%) at the lateral margin and 4 (19%) at the deep margin. Of the 17 with invaded lateral margins, 10 were from the nose, and the remaining 7 from other sites including the ear (n=2), and neck, forehead, temple, eyelid, and cheek (n=1 each). Of the 663 marked specimens, the marking stitch was useful in only one patient who needed another operation (0.2%). We suggest that routine orientation of BCC, even from high risk areas, is not necessary. If the operating surgeon questions the size of the margin when a lesion is ill-defined or of a high-risk histological subtype, then excision with monitored en-face margins should be considered with traditional Mohs surgery or a reliable modified version.

Hydrophobically-associating cationic polymers as micro-bubble surface modifiers in dissolved air flotation for cyanobacteria cell separation

Dissolved air flotation (DAF), an effective treatment method for clarifying algae/cyanobacteria-laden water, is highly dependent on coagulation-flocculation. Treatment of algae can be problematic due to unpredictable coagulant demand during blooms. To eliminate the need for coagulation-flocculation, the use of commercial polymers or surfactants to alter bubble charge in DAF has shown potential, termed the PosiDAF process. When using surfactants, poor removal was obtained but good bubble adherence was observed. Conversely, when using polymers, effective cell removal was obtained, attributed to polymer bridging, but polymers did not adhere well to the bubble surface, resulting in a cationic clarified effluent that was indicative of high polymer concentrations. In order to combine the attributes of both polymers (bridging ability) and surfactants (hydrophobicity), in this study, a commercially-available cationic polymer, poly(dimethylaminoethyl methacrylate) (polyDMAEMA), was functionalised with hydrophobic pendant groups of various carbon chain lengths to improve adherence of polymer to a bubble surface. Its performance in PosiDAF was contrasted against commercially-available poly(diallyl dimethyl ammonium chloride) (polyDADMAC). All synthesised polymers used for bubble surface modification were found to produce positively charged bubbles. When applying these cationic micro-bubbles in PosiDAF, in the absence of coagulation-flocculation, cell removals in excess of 90% were obtained, reaching a maximum of 99% cell removal and thus demonstrating process viability. Of the synthesised polymers, the polymer containing the largest hydrophobic functionality resulted in highly anionic treated effluent, suggesting stronger adherence of polymers to bubble surfaces and reduced residual polymer concentrations.

Hearing outcomes following primary malleostapedial rotation ossiculoplasty in patients undergoing modified radical mastoidectomy

INTRODUCTION

Treatment of cholesteatoma consists of either excision or exteriorisation of disease. Approaches have traditionally included a radical or modified radical mastoidectomy and combined approach tympanoplasty. Hearing thresholds following a modified radical mastoidectomy alone have been reported as poor. We assessed hearing outcomes in patients undergoing a primary malleostapedial reconstruction combined with their open cavity surgery.

METHODS

All patients undergoing open cavity mastoidectomy with primary malleostapedial rotation ossiculoplasty between 2009 and 2013 were identified. Case notes were reviewed, and demographic data, recurrence rate and audiometry were recorded.

RESULTS

Twenty-one patients were identified. The age range was 10-65 years. There was no evidence of recurrence of cholesteatoma. The mean postoperative air-bone gap was 20dBHL, 23dBHL, 10dBHL and 27dBHL at 0.5kHz, 1kHz, 2kHz and 4kHz respectively. Excluding cases consistent with a postoperative ossicular discontinuity (n=3), the mean postoperative air-bone gap was 15dBHL, 19dBHL, 8dBHL and 26dBHL at 0.5kHz, 1kHz, 2kHz and 4kHz respectively.

CONCLUSIONS

The improvement in hearing thresholds demonstrated in this cohort of patients supports the use of this form of ossiculoplasty in those undergoing open cavity procedures. This would also suggest that the subsequent use of hearing aids in these patients would require less amplification and therefore provide superior hearing outcomes. As hearing loss remains a significant concern following modified radical mastoidectomy, we suggest an open cavity with primary malleostapedial rotation ossiculoplasty as a viable alternative to modified radical mastoidectomy alone, in selected cases.

Micron-size metal-binding hydrogel particles improve germination and radicle elongation of Australian metallophyte grasses in mine waste rock and tailings

Metal contamination of landscapes as a result of mining and other industrial activities is a pervasive problem worldwide. Metal contaminated soils often lack effective vegetation cover and are prone to contaminant leaching and dispersion through erosion, leading to contamination of the environment. Metal-binding hydrogel particle amendments could ameliorate mine wastes prior to planting and enhance seedling emergence. In this study, micron-size thiol functional cross-linked acrylamide polymer hydrogel particles (X3) were synthesised and tested in laboratory-scale experiments on phytotoxic mine wastes to determine their capacity to: (i) increase substrate water holding capacity (WHC); (ii) reduce metal availability to plants to below the phytotoxicity threshold; and (iii) enhance germination characteristics and early radicle development of two Australian metallophyte grasses under limiting and non-limiting water conditions. Addition of X3 to mine wastes significantly increased their WHC and lowered toxic soluble metal concentrations in mine waste leachates. Germination percentages and radicle elongation of both grasses in wastes were significantly increased. Highest germination percentages and greater radicle development recorded in X3 amended wastes under water limited conditions suggests that X3 was able to ameliorate metal toxicity to radicles, and provide moisture, which improved the imbibition and consequent germination of the seeds.

Metal-binding hydrogel particles alleviate soil toxicity and facilitate healthy plant establishment of the native metallophyte grass Astrebla lappacea in mine waste rock and tailings

Soil contaminants are potentially a major threat to human and ecosystem health and sustainable production of food and energy where mineral processing wastes are discharged into the environment. In extreme conditions, metal concentrations in wastes often exceed even the metal tolerance thresholds of metallophytes (metal-tolerant plants) and sites remain barren with high risks of contaminant leaching and dispersion into the environment via erosion. A novel soil amendment based on micron-size thiol functional cross-linked acrylamide polymer hydrogel particles (X3) binds toxic soluble metals irreversibly and significantly reduces their concentrations in the soil solution to below the phytotoxicity thresholds. X3 mixed into the top 50mm of phytotoxic mine waste materials in pots in glasshouse conditions reduced total soluble concentrations of toxic contaminants by 90.3-98.7% in waste rock, and 88.6-96.4% in tailings immediately after application. After 61 days, quality of unamended bottom layer of X3-treated pots was also significantly improved in both wastes. Combination of X3 and metallophytes was more efficient at improving soil solution quality than X3 alone. Addition of X3 to substrates increased substrate water retention and water availability to plants by up to 108% and 98% for waste rock and tailings respectively. Soil quality improvement by X3 allowed successful early establishment of the native metallophyte grass Astrebla lappacea on both wastes where plants failed to establish otherwise.

Metal-binding particles alleviate lead and zinc toxicity during seed germination of metallophyte grass Astrebla lappacea

Combining metal-binding particles and metal-tolerant plants (metallophytes) offers a promising new approach for rehabilitation of heavy metal contaminated sites. Three types of hydrogel metal-binding polymer particles were synthesized and their effects on metal concentrations tested in vitro using metal ion solutions. The most effective of the tested polymers was a micron-sized thiol functional cross-linked acrylamide polymer which reduced the available solution concentrations of Pb(2+) (9.65 mM), Cu(2+) (4mM) and Zn(2+) (10mM) by 86.5%, 75.5% and 63.8%, respectively, and was able to store water up to 608% of its dry mass. This polymer was not toxic to seed germination. In deionised water, it enhanced seed germination, and at otherwise phytotoxic Pb(2+) (9.65 mM) and Zn(2+) (10mM) concentrations, it allowed normal germination and root elongation of the metallophyte grass Astrebla lappacea. We conclude that the polymer has the potential to facilitate restoration of heavy metal contaminated lands by reducing the concentration of metal cations in the soil solution and improving germination rates through reduced toxicity and enhanced plant water relations.

Nupafant, a PAF-antagonist prototype for suppression of ventricular fibrillation without liability for QT prolongation?

BACKGROUND AND PURPOSE

PAF antagonists inhibit ischaemia-induced ventricular fibrillation (VF) in animals. However, unfavourable ancillary actions (on QT interval and coronary flow) have been reported with the PAF antagonist, BN-50739. If these are class actions, they would preclude development of PAF antagonists as novel anti-VF drugs. Our purpose was to examine this proposition using the hitherto untested PAF antagonist, nupafant.

EXPERIMENTAL APPROACH

Two rat heart preparations (Langendorff and 'dual coronary' perfusion) were used to assay nupafant's effects on ischaemia-induced VF, coronary flow and QT interval, and to test for the site-selectivity necessary if any effects on VF are caused by PAF antagonism.

KEY RESULTS

Global (whole-heart) delivery of 10 microM nupafant, reduced the incidence of ischaemia-induced VF and widened QT interval without affecting coronary flow. Importantly, lower concentrations (0.1 and 1 microM) had no effect on VF, yet widened QT almost identically to 10 microM nupafant. When nupafant was delivered selectively to (and entrapped within) the involved region it partially protected against VF (P<0.05). This occurred without change in QT interval. Selective nupafant delivery to the uninvolved region was without effect.

CONCLUSIONS AND IMPLICATIONS

Nupafant protects against ischaemia-induced VF primarily by site-selective actions in the ischaemic region but, unlike BN-50739, the effect is unrelated to its QT widening action, and is not compromised by any effect on coronary flow. This establishes proof of concept that VF suppression by PAF antagonism need not invariably be associated with QT prolongation or vasodilatation, justifying further development of this drug class.

Saving clinicians' time by delegating routine aspects of therapy to a computer: a randomized controlled trial in phobia/panic disorder

BACKGROUND

The demand for time-consuming psychotherapy of phobia/panic exceeds the supply of trained therapists. Delegating routine therapy aspects to a computer might ease this problem.

METHOD

Ninety-three out-patients with phobia or panic disorder were randomized in a 2: 2 : 1 ratio to have self-exposure therapy guided either mainly by a stand-alone computer system (FearFighter) or entirely face-to-face by a clinician, or to have mainly computer-guided self-relaxation as a placebo. Both computer groups (FearFighter and relaxation) had brief back-up advice from a clinician. Primary outcome measures were self- and blind-assessor ratings of Main Problem and Goals, and Global Phobia.

RESULTS

Drop-outs occurred significantly more often in the two self-exposure groups (43% if mainly computer-guided, 24% if entirely clinician-guided) than with self-relaxation (6%); the difference between the two self-exposure groups was not significant. Even with all drop-outs included, the mainly computer-guided exposure group and the relaxation group had 73% less clinician time per patient than did the entirely clinician-guided exposure group. The two self-exposure groups had comparable improvement and satisfaction at post-treatment and at 1-month follow-up, while relaxation was ineffective. Mean improvement on the primary outcome measures (self- and assessor-rated) was 46% computer, 49% clinician, 9% relaxation at post-treatment (week 10) and 58% computer, 53% clinician and -4% relaxation at 1-month follow-up (week 14). Mean effect sizes on the primary outcome measures were 2.9 computer, 3.5 clinician and 0.5 relaxation at post-treatment; and 3.7 computer, 3.5 clinician and 0.5 relaxation at 1-month follow-up. The assessor did not rate patients at follow-up.

CONCLUSIONS

Despite its (non-significantly) higher dropout rate, self-exposure therapy for panic/ phobia cut clinician time per patient by 73% without losing efficacy when guided mainly by a computer rather than entirely by a clinician. The finding needs confirmation at a follow-up that is longer and includes a blind assessor. Self-relaxation had the highest rate of completers but was ineffective.

Asymmetric synthesis of BB-3497--a potent peptide deformylase inhibitor

By screening a library of metalloenzyme inhibitors, the N-formyl-hydroxylamine derivative BB-3497 was identified as a potent inhibitor of Escherichia coli peptide deformylase with antibacterial activity both in vitro and in vivo. The homochiral synthesis of BB-3497, involving a novel asymmetric Michael addition reaction is described.

Antibiotic activity and characterization of BB-3497, a novel peptide deformylase inhibitor

Peptide deformylase (PDF) is an essential bacterial metalloenzyme which deformylates the N-formylmethionine of newly synthesized polypeptides and as such represents a novel target for antibacterial chemotherapy. To identify novel PDF inhibitors, we screened a metalloenzyme inhibitor library and identified an N-formyl-hydroxylamine derivative, BB-3497, and a related natural hydroxamic acid antibiotic, actinonin, as potent and selective inhibitors of PDF. To elucidate the interactions that contribute to the binding affinity of these inhibitors, we determined the crystal structures of BB-3497 and actinonin bound to Escherichia coli PDF at resolutions of 2.1 and 1.75 A, respectively. In both complexes, the active-site metal atom was pentacoordinated by the side chains of Cys 90, His 132, and His 136 and the two oxygen atoms of N-formyl-hydroxylamine or hydroxamate. BB-3497 had activity against gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus faecalis, and activity against some gram-negative bacteria. Time-kill analysis showed that the mode of action of BB-3497 was primarily bacteriostatic. The mechanism of resistance was via mutations within the formyltransferase gene, as previously described for actinonin. While actinonin and its derivatives have not been used clinically because of their poor pharmacokinetic properties, BB-3497 was shown to be orally bioavailable. A single oral dose of BB-3497 given 1 h after intraperitoneal injection of S. aureus Smith or methicillin-resistant S. aureus protected mice from infection with median effective doses of 8 and 14 mg/kg of body weight, respectively. These data validate PDF as a novel target for the design of a new generation of antibacterial agents.

Electron transfer during the oxidation of ammonia by the chemolithotrophic bacterium Nitrosomonas europaea

The combined action of ammonia monooxygenase, AMO, (NH(3)+2e(-)+O(2)-->NH(2)OH) and hydroxylamine oxidoreductase, HAO, (NH(2)OH+H(2)O-->HNO(2)+4e(-)+4H(+)) accounts for ammonia oxidation in Nitrosomonas europaea. Pathways for electrons from HAO to O(2), nitrite, NO, H(2)O(2) or AMO are reviewed and some recent advances described. The membrane cytochrome c(M)552 is proposed to participate in the path between HAO and ubiquinone. A bc(1) complex is shown to mediate between ubiquinol and the terminal oxidase and is shown to be downstream of HAO. A novel, red, low-potential, periplasmic copper protein, nitrosocyanin, is introduced. Possible mechanisms for the inhibition of ammonia oxidation in cells by protonophores are summarized. Genes for nitrite- and NO-reductase but not N(2)O or nitrate reductase are present in the genome of Nitrosomonas. Nitrite reductase is not repressed by growth on O(2); the flux of nitrite reduction is controlled at the substrate level.

How is gout managed in primary care? A review of current practice and proposed guidelines

Twelve practices with a total list of 74,111 patients were audited; 429 patients were identified with a diagnosis of gout. A wide variation in various clinical and laboratory assessments was detected. Similar variations were also noted regarding dietary advice and medical treatment. Monitoring of patients was infrequent. As a result of this audit, guidelines are proposed to improve the diagnosis and management of gout in the community.

Combinatorial chemistry as a tool for drug discovery

The question 'will combinatorial chemistry deliver real medicines' has been posed [96]. First it is important to realise that the chemical part of the drug discovery process cannot stand alone; the integration of synthesis and biological assays is fundamental to the combinatorial approach. The results presented in Tables 3.1 to 3.8 suggest that so far smaller directed combinatorial libraries have obtained equivalent results to those obtained previously from traditional medicinal chemistry analogue programs. Unfortunately, because of the long time it takes to develop pharmaceutical drugs there are no examples yet of marketed drugs discovered by combinatorial methods. There are interesting examples where active leads have been discovered from the screening of the same library against multiple targets (e.g. libraries 13, 39, 43, 66, 71 and 76). It is now possible to handle much larger libraries of non-oligomeric structures and the chemistry required for such applications is becoming available. Whether combinatorial approaches can also be adapted to deal with all the other requirements of a successful pharmaceutical (lack of toxicity, bioavailability etc.) is open to question but there are already examples such as cassette dosing [235-237]. However we can still be optimistic about the possibility of larger libraries producing avenues of investigation for the medicinal chemist to develop into real drugs. Combinatorial chemistry is an important tool for the medicinal chemist.

A structural change in the kinesin motor protein that drives motility

Kinesin motors power many motile processes by converting ATP energy into unidirectional motion along microtubules. The force-generating and enzymatic properties of conventional kinesin have been extensively studied; however, the structural basis of movement is unknown. Here we have detected and visualized a large conformational change of an approximately 15-amino-acid region (the neck linker) in kinesin using electron paramagnetic resonance, fluorescence resonance energy transfer, pre-steady state kinetics and cryo-electron microscopy. This region becomes immobilized and extended towards the microtubule 'plus' end when kinesin binds microtubules and ATP, and reverts to a more mobile conformation when gamma-phosphate is released after nucleotide hydrolysis. This conformational change explains both the direction of kinesin motion and processive movement by the kinesin dimer.

The synthesis and biological evaluation of non-peptidic matrix metalloproteinase inhibitors

Novel sulfonamide matrix metalloproteinase inhibitors of general formula (9) were synthesised by a route involving a stereoselective conjugate addition reaction. Enzyme selectivity was found to be dependant on the nature of the sulfonamide substituents. Compounds (9f, 9q) are potent selective collagenase inhibitors with good oral bioavailability.

Laparoscopic-assisted Doderlein hysterectomy: retrospective analysis of 300 consecutive cases

OBJECTIVE

To assess the clinical outcomes of the Doderlein laparoscopic-assisted hysterectomy.

DESIGN

A retrospective study.

SETTING

Women's Endoscopic Laser Foundation at South Cleveland Hospital, Middlesbrough and St James's University Hospital, Leeds.

POPULATION

Three hundred consecutive women who had a laparoscopic-assisted Doderlein hysterectomy.

METHODS

Patients were identified from the laparoscopic hysterectomy theatre log at both sites. Case notes were requested and examined.

MAIN OUTCOME MEASURES

Operative time, uterine weight, associated pelvic pathology, blood loss, hospital stay, intra-operative and post-operative complications.

RESULTS

The operations were performed by eight different surgeons, seven of whom were laparoscopic trainees. The mean operating time was 102 minutes (SD 30). Additional surgery including unilateral or bilateral salpingo-oophorectomy, was carried out in 247 patients (82%). The mean uterine weight was 140 g (SD 74). One hundred and thirty-two women (44%) had a normal pelvis at hysterectomy. The mean drop in haemoglobin and haematocrit was 1.46 g (SD 0.95) and 4.4% (SD 2.8), respectively. The overall complication rate was 18%, of which 6.2% were classed as major. The major complications included four cystotomies, five unscheduled laparotomies, seven post-operative blood transfusions, one pulmonary embolus and two re-operations (within six weeks). The mean hospital stay was three days.

CONCLUSIONS

Laparoscopic-assisted Doderlein hysterectomy is an alternative to standard laparoscopic hysterectomy techniques. It has the advantage of being easy to learn and is associated with low complication rates, compared with other laparoscopic and traditional techniques for hysterectomy.

Preclinical and clinical studies of MMP inhibitors in cancer

The role of matrix metalloproteinases in tumor angiogenesis and growth is now well recognized for models of both human and animal cancer. Clinical studies currently under way with the prototype matrix metalloproteinase inhibitor, marimastat, will establish whether inhibitors of these enzymes are of benefit in the treatment of different types of human cancer. On chronic therapy in humans, marimastat induces a reversible tendinitis that can also be detected in certain animal species. This paper compares the ability of broad-spectrum and various types of selective matrix metalloproteinase inhibitors to induce tendinitis and to exhibit anticancer effects in an animal cancer model. Under conditions in which both systemic exposure and inhibitor potency are controlled, selective inhibitors are less pro-tendinitic, but are weaker anticancer agents than broad-spectrum agents such as marimastat. The clinical relevance of these findings is discussed.

Multicenter evaluation of electrical stimulation systems for walking

OBJECTIVE

To test the long-term benefits of several noninvasive systems for functional electrical stimulation (FES) during walking.

DESIGN

Forty subjects (average years since injury, 5.4) were studied in four centers for an average time of 1 year. Gait parameters were tested for all subjects with and without FES. Thus, subjects served as their own controls, since the specific effect of using FES could be separated from improvements resulting from other factors (e.g., training).

SETTING

Subjects used the devices in the community, but were tested in a university or hospital setting.

PATIENTS

Subjects with spinal cord injury (n = 31) were compared to subjects with cerebral damage (n = 9).

MAIN OUTCOME MEASURES

Gait parameters (speed, cycle time, stride length). Acceptance was studied by means of a questionnaire.

RESULTS

Some initial improvement in walking speed (average increase of >20%) occurred, and continuing gains were seen (average total improvement, 45%). The largest relative gains were seen in the slowest walkers (speeds of <0.3 m/sec). Acceptance of the FES systems was good and improved systems have been developed using feedback from the subjects.

CONCLUSIONS

Based on the improvements in speed and the acceptance of these FES systems, a greatly increased role for FES in treating gait disorders is suggested.

The fate of heavy oil wastes in soil microcosms. I: A performance assessment of biotransformation indices

A controlled soil microcosm study was used to evaluate the performance of selected oil biotransformation indices using samples of Nigerian crude, a blended ballast oil and No. 6 fuel oil. Biotic losses were demonstrated through loss of solvent extractable matter (SEM) and changes in class fraction distribution in weathered soil extracts relative to sterilised controls. GC-EI MS peak identification and quantification was achieved for selected (sigma) n-alkanes, the isoprenoid alkanes norpristane (iC18), pristane (iC19) and phytane (iC20), combined mono-substituted (1-, 2-, 3- and 9-) methylphenanthrenes (sigma methylphenanthrenes), combined dimethylphenanthrenes (sigma dimethylphenanthrenes) and the hopane isomers 17 alpha(H)21 beta(H)-hopane and 17 alpha(H)21 beta(H)-30-norhopane. The [sigma n-alkanes:17 alpha(H)21 beta(H)-hopane] index was most sensitive to oil biotransformation and most accurately reflected depletion of oil from contaminated soils in this study. This index was found to be the most reliable for the No. 6 fuel oil saturates, dropping from 81.9 to 18.1 over the course of the 256-day microcosm study. In terms of sensitivity, and taking into account the results of an ANOVA analysis, the biotransformation indices most sensitive to oil biotransformation were (in order of decreasing sensitivity): [sigma C14-28:17 alpha(H)21 beta(H)-hopane] >> [sigma C14-28:sigma dimethylphenanthrenes] > [C18:phytane].

The fate of heavy oil wastes in soil microcosms. II: A performance assessment of source correlation indices

Chemical fingerprinting is commonly undertaken to assist in the resolution of multi-party liability disputes, particularly when contaminants have migrated beyond property boundaries, in litigation-driven environmental assessments related to oil spills, and in assessing potential environmental impacts following releases of petroleum products into the environment. In this paper, we present data relating to the performance of source correlation indices for selected heavy oils over the course of a 9-month microcosm study. The results obtained in this study demonstrated that hopane pair indices varied little in magnitude, and may therefore be considered reliable source correlation indices. Over the course of the 9-month microcosm study [17 alpha(H)21 beta(H)-norhopane: 17 alpha(H)21 beta(H)-hopane] exhibited mean values of 0.7 +/- 0.1 for a heavy ballast oil, and mean values that varied between 0.6 and 0.7 (+/- 0.05) for a crude oil. Similarly [(17 alpha(H)21 beta(H)-homohopane (22S): 17 alpha(H)21 beta(H)-homohopane (22R)] gave a mean value of 1.3 (precisions less than 0.05) and [17 alpha(H)21 beta(H)-bishomohopane: 17 alpha(H)21 beta(H)-methylhopane] varied between 1.3 and 1.6 (precision up to 0.1) for the same crude oil. These source correlation indices may be used to support a correlation between fresh and weathered oil samples for source identification purposes involving heavy and crude oil contamination of the terrestrial environment.

High-resolution model of the microtubule

A high-resolution model of the microtubule has been obtained by docking the crystal structure of tubulin into a 20 A map of the microtubule. The excellent fit indicates the similarity of the tubulin conformation in both polymers and defines the orientation of the tubulin structure within the microtubule. Long C-terminal helices form the crest on the outside of the protofilament, while long loops define the microtubule lumen. The exchangeable nucleotide in beta-tubulin is exposed at the plus end of the microtubule, while the proposed catalytic residue in alpha-tubulin is exposed at the minus end. Extensive longitudinal interfaces between monomers have polar and hydrophobic components. At the lateral contacts, a nucleotide-sensitive helix interacts with a loop that contributes to the binding site of taxol in beta-tubulin.

Ultrasound-guided unilateral neck exploration for sporadic primary hyperparathyroidism: is it worthwhile?

The role of preoperative localisation tests before initial neck exploration for primary hyperparathyroidism (PHP) remains controversial, as does the optimal surgical approach. We report our experience with preoperative ultrasound (US) and the operative management of sporadic PHP between 1990 and 1995. Preoperative US was carried out by an experienced radiologist. Three surgeons adopted a policy of 'selective' US-guided unilateral neck exploration (UNE); the fourth surgeon performed routine bilateral neck exploration (BNE). There were 72 patients: 26 men and 46 women, with a mean age of 57.4 +/- 12.5 years (range 21-80 years). All patients underwent initial neck exploration for 'sporadic' PHP, of whom 63 had preoperative US. This was positive in 52 patients; 27 of whom underwent a UNE, 23 had a BNE, and two patients had a UNE converted to a BNE. Patients with 'negative' US (n = 11), and those receiving no preoperative localisation test (n = 90) underwent a BNE. The sensitivity, specificity and accuracy of US were 80% (52/65), 100% (61/61), and 90% (113/126), respectively. Comparable success rates were achieved (BNE: 97% (33/34) vs UNE: 93% (27/29), P < 0.05), with very low morbidity. Failures with the scan-guided UNE were caused by missed contralateral adenomas. An experienced radiologist and a low incidence of multiglandular disease (MGD) are essential prerequisites for the scan-guided unilateral approach. An experienced surgeon, on the other hand, is the only prerequisite for the 'gold standard' bilateral approach.

The synthesis of novel matrix metalloproteinase inhibitors employing the Ireland-Claisen rearrangement

Matrix metalloproteinase inhibitors of general formula (1) were synthesised by a route involving an Ireland-Claisen rearrangement which enables systematic modification of the substituent alpha to the hydroxamic acid. An analogue (12c) possessing an alpha-cyclopentyl group is a potent broad spectrum inhibitor that displays high and sustained blood levels following oral dosing in both the rat and marmoset ex-vivo bioassays. This compound and analogues are also potent inhibitors of TNF alpha release.

Discovery of protease inhibitors using targeted libraries

There continues to be considerable effort towards the construction of compound libraries targeted for the inhibition of protease enzymes. New tag-encoding methods for library deconvolution have been applied to this problem and there has been particular interest in novel solid-phase linkers for the introduction of key pharmacophore groups required for protease inhibition. Recent reports have tended to focus on nonpeptidic libraries, and, notably, structure-based design methods are now being applied to direct library design.

Self-mutilation: culture, contexts and nursing responses

Few papers address the issue of deliberate self-mutilation other than from clinical perspectives. This paper advocates a user-perspective and discusses some of the issues which might attend such a change. The occurrence of self-mutilation is placed within a cultural framework so as to enlarge the debate beyond the confines of medical/nursing responses. It is suggested that nurses abrogate their attachment to such responses and embrace more collaborative approaches to care. In particular, nurses are asked to review their (moral) responses to self-mutilation, an activity which, too often, has been responded to with scorn and derision.

The influence of quality of care upon contraceptive use in rural Bangladesh

Efforts to develop quantitative indicators of quality of care for family planning services, and to evaluate its role in contraceptive behavior, remain at an early stage. The present study, based upon an analysis of prospective data from a sample of 7,800 reproductive-aged rural Bangladeshi women, provides empirical evidence on the importance of quality of care for contraceptive practice. The results demonstrate that the perceptions of women regarding the quality of field-worker care were significantly related to the probability of subsequent adoption of a family planning method. Women who were not using a method and who scored high on an index of perceived quality of care were 27 percent more likely to adopt a method subsequently, compared with women with a low score. Effects were even more pronounced for contraceptive continuation; high quality of care was associated with a 72 percent greater likelihood of continued use of any method of contraception.

emScope: A Tool Kit for Control and Automation of a Remote Electron Microscope

We have developed a portable and extensible set of tools and applications for control of a remote transmission electron microscope (TEM). These tools will be used to develop a system for automatically acquiring large numbers of high quality images from a TEM in a routine, robust, and efficient manner. In particular we plan to develop applications that allow for data collection from specimens preserved in vitreous ice. Copyright 1997 Academic Press. Copyright 1997 Academic Press

A model for the microtubule-Ncd motor protein complex obtained by cryo-electron microscopy and image analysis

Kinesin motors convert chemical energy from ATP hydrolysis into unidirectional movement. To understand how kinesin motors bind to and move along microtubules, we fit the atomic structure of the motor domain of Ncd (a kinesin motor involved in meiosis and mitosis) into three-dimensional density maps of Ncd-microtubule complexes calculated by cryo-electron microscopy and image analysis. The model reveals that Ncd shares an extensive interaction surface with the microtubule, and that a portion of the binding site involves loops that contain conserved residues. In the Ncd dimer, the microtubule-bound motor domain makes intimate contact with its partner head, which is dissociated from the microtubule. This head-head interaction may be important in positioning the dissociated head to take a step to the next binding site on the microtubule protofilament.

Conformational changes due to calcium-induced calmodulin dissociation in brush border myosin I-decorated F-actin revealed by cryoelectron microscopy and image analysis

Brush border myosin I (BBMI) is a single-headed molecular motor. Its catalytic domain exhibits extensive sequence homology to the catalytic domain of myosin II, while its tail lacks the coiled-coil nature of myosin II. The BBMI tail domain contains at least three IQ motifs and binds calmodulin. Addition of calcium removes one of these calmodulin light chains, with effects on ATPase activity and motility in in vitro assays. Using the techniques of cryoelectron microscopy and helical image analysis we have calculated three-dimensional (3D) maps of BBMI-decorated actin filaments prepared in the presence and absence of calcium. The 3D maps describe a BBMI catalytic domain that is strikingly similar to the catalytic domain of myosin II subfragment 1 (S1), with the exception of a short amino-terminal region of the heavy chain, which is absent from BBMI. The tail domains of BBMI and S1 are highly divergent in structure, continuing on from their respective motor domains with very different geometries. Addition of calcium to BBMI, and the concomitant loss of a calmodulin light chain, results in an extensive reorganization of mass in the tail domain.

Two-dimensional crystallization of brush border myosin I

Brush border myosin-I (BBMI) is a single-headed unconventional myosin found in the microvilli of intestinal epithelial cells, where it links the core bundle of actin filaments to the plasma membrane. An association of BBMI with anionic phospholipids has been shown to be mediated by a carboxy-terminal domain which is rich in basic amino acids. We have exploited this natural affinity of BBMI for negatively charged lipids to form two-dimensional (2D) crystals of this protein which are suitable for structural analysis by electron crystallographic techniques. The 2D crystals which we have obtained belong to one of two space groups, p22121 or p2. We present here projection maps calculated from images of negatively stained crystals for each of these crystal types to a resolution of 20 A and show that the asymmetric unit is the same in both crystal types.