The new Foundation Programme Mental Health Curriculum: foundation doctors' perceptions of its importance and their competency: pre-post psychiatric placement evaluation study

AIMS AND METHOD

The new 2021 UK Foundation Programme Curriculum mandates foundation doctors to acquire mental health competencies. This study aimed to evaluate the effectiveness of psychiatry placements in facilitating competency attainment, foundation doctors' perceived importance of acquiring these and their preferred teaching methods. Utilising Kirkpatrick's evaluation framework, the study employed a pre-post intervention design assessing the impact of psychiatry placements on 135 foundation doctors across three cohorts from August 2021 to March 2022.

RESULTS

Initially, foundation doctors assigned high importance to mental health competencies. Post-placements, this perceived importance improved slightly, whereas that of clinical skills scenarios slightly decreased. Significant confidence increases were observed in recognising and assessing specific psychiatric disorders. Foundation doctors favoured small seminar groups and on-the-job ad hoc teaching. Qualitative insights underscored the need for context-specific teaching.

CLINICAL IMPLICATIONS

Psychiatry placements enhance foundation doctors' confidence and perceived importance of mental health competencies as specified by the curriculum. Addressing clinical scenario gaps through context-specific teaching and transferable skills development is essential. Customised teaching approaches, especially small seminars and ad hoc teaching, hold promise for effective mental health training.

Penn Healthy Diet survey: pilot validation and scoring

Though diet quality is widely recognised as linked to risk of chronic disease, health systems have been challenged to find a user-friendly, efficient way to obtain information about diet. The Penn Healthy Diet (PHD) survey was designed to fill this void. The purposes of this pilot project were to assess the patient experience with the PHD, to validate the accuracy of the PHD against related items in a diet recall and to explore scoring algorithms with relationship to the Healthy Eating Index (HEI)-2015 computed from the recall data. A convenience sample of participants in the Penn Health BioBank was surveyed with the PHD, the Automated Self-Administered 24-hour recall (ASA24) and experience questions. Kappa scores and Spearman correlations were used to compare related questions in the PHD to the ASA24. Numerical scoring, regression tree and weighted regressions were computed for scoring. Participants assessed the PHD as easy to use and were willing to repeat the survey at least annually. The three scoring algorithms were strongly associated with HEI-2015 scores using National Health and Nutrition Examination Survey 2017-2018 data from which the PHD was developed and moderately associated with the pilot replication data. The PHD is acceptable to participants and at least moderately correlated with the HEI-2015. Further validation in a larger sample will enable the selection of the strongest scoring approach.

Acetylcholinesterase inhibitors for autistic spectrum disorders

BACKGROUND

Autism spectrum disorder (autism) is a neurodevelopmental condition characterised by impairments in social communication and interaction, plus restricted, repetitive patterns of behaviour and interests. Whilst some people embrace autism as part of their identity, others struggle with their difficulties, and some seek treatment. There are no current interventions that result in complete reduction of autism features. Acetylcholine is a neurotransmitter for the cholinergic system and has a role in attention, novelty seeking, and memory. Low levels of acetylcholine have been investigated as a potential contributor to autism symptomatology. Donepezil, galantamine, and rivastigmine (commonly referred to as acetylcholinesterase inhibitors) all inhibit acetylcholinesterase, and have slightly different modes of action and biological availability, so their effectiveness and side-effect profiles may vary. The effect of various acetylcholinesterase inhibitor on core autism features across the lifespan, and possible adverse effects, have not been thoroughly investigated.

OBJECTIVES

To evaluate the efficacy and harms of acetylcholinesterase inhibitors for people with the core features (social interaction, communication, and restrictive and repetitive behaviours) of autism. To assess the effects of acetylcholinesterase inhibitors on non-core features of autism.

SEARCH METHODS

In November 2022, we searched CENTRAL, MEDLINE, Embase, eight other databases, and two trials registers. We also searched the reference lists of included studies and relevant reviews, and contacted authors of relevant studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs), comparing acetylcholinesterase inhibitors (e.g. galantamine, donepezil, or rivastigmine) of varying doses, delivered orally or via transdermal patch, either as monotherapy or adjunct therapy, with placebo. People of any age, with a clinical diagnosis of autism were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were core features of autism and adverse effects. Secondary outcomes were language, irritability, hyperactivity, and general health and function. We used GRADE to assess certainty of evidence.

MAIN RESULTS

We included two RCTs (74 participants). One study was conducted in Iran, the second in the USA, although exact location in the USA is unclear. Galantamine plus risperidone versus placebo plus risperidone One study compared the effects of galantamine plus risperidone to placebo plus risperidone (40 participants, aged 4 years to 12 years). Primary and secondary outcomes of interest were measured postintervention, using subscales of the Aberrant Behavior Checklist (score 0 to 3; higher scores = greater impairment). Very low-certainty evidence showed there was little to no difference between the two groups postintervention for social communication (mean difference (MD) -2.75, 95% confidence interval (CI) -5.88 to 0.38), and restricted and repetitive behaviour (MD -0.55, 95% CI -3.47 to 2.37). Overall autism features were not assessed. Adverse events may be higher in the galantamine plus risperidone group (75%) compared with the placebo plus risperidone group (35%): odds ratio 5.57, 95% CI 1.42 to 21.86, low-certainty evidence. No serious adverse events were reported. Low-certainty evidence showed a small difference in irritability (MD -3.50, 95% CI -6.39 to -0.61), with the galantamine plus risperidone group showing a greater decline on the irritability subscale than the placebo group postintervention. There was no evidence of a difference between the groups in hyperactivity postintervention (MD -5.20, 95% CI -10.51 to 0.11). General health and function were not assessed. Donepezil versus placebo One study compared donepezil to placebo (34 participants aged 8 years to 17 years). Primary outcomes of interest were measured postintervention, using subscales of the Modified Version of The Real Life Rating Scale (scored 0 to 3; higher scores = greater impairment). Very low-certainty evidence showed no evidence of group differences immediately postintervention in overall autism features (MD 0.07, 95% CI -0.19 to 0.33), or in the autism symptom domains of social communication (MD -0.02, 95% CI -0.34 to 0.30), and restricted and repetitive behaviours (MD 0.04, 95% CI -0.27 to 0.35). Significant adverse events leading to study withdrawal in at least one participant was implied in the data analysis section, but not explicitly reported. The evidence is very uncertain about the effect of donepezil, compared to placebo, on the secondary outcomes of interest, including irritability (MD 1.08, 95% CI -0.41 to 2.57), hyperactivity (MD 2.60, 95% CI 0.50 to 4.70), and general health and function (MD 0.03, 95% CI -0.48 to 0.54) postintervention. Across all analyses within this comparison, we judged the evidence to be very low-certainty due to high risk of bias, and very serious imprecision (results based on one small study with wide confidence intervals). The study narratively reported adverse events for the study as a whole, rather than by treatment group.

AUTHORS' CONCLUSIONS

Evidence about the effectiveness of acetylcholinesterase inhibitors as a medication to improve outcomes for autistic adults is lacking, and for autistic children is very uncertain. There is a need for more evidence of improvement in outcomes of relevance to clinical care, autistic people, and their families. There are a number of ongoing studies involving acetylcholinesterase inhibitors, and future updates of this review may add to the current evidence.

Accumulation and deposition of triacylglycerols in the starchy endosperm of wheat grain

A combination of lipidomics, transcriptomics and bioimaging has been used to study triacylglycerol synthesis and deposition in the developing starchy endosperm of wheat. The content of TAG increased between 14 and 34 days after anthesis, from 50 to 115 mg/100 g dry wt and from about 35 to 175 mg/100 g dry wt in two experiments. The major fatty acids were C16 (palmitic C16:0 and palmitoleic C16:1) and C18 (stearic C18:0, oleic C18:1, linoleic C18:2 and linolenic C18:3), with unsaturated fatty acids accounting for about 75-80% of the total throughout development. Linoleic acid (C18:2) was the major component at all stages and the proportion increased during development. Transcript profiling indicated that predominant route to TAG synthesis and oil accumulation is via the Kennedy pathway and diacylglycerol acyltransferase (DGAT) activity. Confocal microscopy of stained tissue sections showed that TAG accumulated in droplets which are associated with protein and concentrated in the starchy endosperm cells below the sub-aleurone cells. Transcripts encoding 16kd oleosins were also expressed, indicating that the oil droplets are in part stabilised by oleosin proteins.

Genetic variation in wheat grain quality is associated with differences in the galactolipid content of flour and the gas bubble properties of dough liquor

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A QTL for breadmaking quality is associated with more galactolipids in flours.

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Dough liquor fractions from the same flours also have higher galactolipid contents.

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The dough liquor fractions with higher galactolipids exhibit increased elasticity.

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These increases indicate a mechanism of action for the quality QTL.

Lipids affect the quality of wheat flour for breadmaking. One possible mechanism is stabilization of the gas cells which are formed during dough mixing and expanded during fermentation, leading to a greater loaf volume and evenness of texture. We therefore compared the lipidomic profiles of flour and dough liquor fractions (which contain surface-active components present at the gas bubble interface) from two sets of wheat lines differing in allelic variation at a QTL for loaf volume. Analyses of fractions from three field trials showed consistent increases in the contents of galactolipids (monogalactosyl diglyceride and digalactosyl diglyceride) in flour and dough liquor of the lines with the increasing (good quality) allele. Biophysical analysis showed that this was associated with greater elasticity of the dough liquor fraction. This is consistent with published studies reporting a relationship between galactolipids and breadmaking quality and suggests a mechanism of action for the QTL.

Simulated patients and objective structured clinical examinations: review of their use in medical education

Simulated or standardised patients have been used in medical education and other medical settings for some 30 years (Box 1). Their use encompasses undergraduate and postgraduate learning, the monitoring of doctors' performance and standardisation of clinical examinations. Simulation has been used for instruction in industry and the military for much longer (Jason et al, 1971) but the first known effective use of simulated patients was by Barrows & Abrahamson (1964), who used them to appraise students' performance in clinical neurology examinations.

Cyclic Nucleotides and Phosphodiesterases in Platelets

It is now almost 30 years since the discovery that prostaglandin E1 (PGE1) inhibits platelet responses to aggregating agents, together with finding that the effects of this compound are mediated by adenosine 3′, 5′-cyclic monophosphate (cAMP) initiated interest in the physiological and pharmacological regulation of platelet function by other agents that increase platelet cAMP, as reviewed elsewhere.1 The most important agonists that stimulate cAMP formation in platelets have now been identified as prostacyclin (PGI2), prostaglandin D2 (PGD2), and adenosine, which exert their effects through receptors of the serpentine or seven transmembrane segment class (IP, DP and A2 receptors, respectively).2 The latter then stimulate cAMP formation by adenylyl cyclase via the GTP-dependent activation of the G-protein, Gs (Fig. 1). In the classical view, cAMP exerts its effects solely by binding to the RI and RII regulatory subunits of type I and type II cAMP-dependent protein kinases (PKA). The catalytic subunits of the kinases then dissociate and phosphorylate selected serine and threonine residues on target proteins that prevent or reverse platelet activation.2 A crucial role is played by cAMP phosphodiesterases, which degrade cAMP to 5′-AMP, thereby diminishing and terminating the effects of agonists that stimulate cAMP formation (Fig. 1). In early studies, this was demonstrated by the ability of first-generation inhibitors of cAMP phosphodiesterases, particularly the methylxanthines, to inhibit platelet aggregation and potentiate the inhibitory effects of activators of platelet adenylyl cyclase.1 Such studies provided the rationale for the subsequent development of more potent and selective phosphodiesterase inhibitors as potential antithrombotic agents.

Interest in the role of guanosine 3′,5′-cyclic monophosphate (cGMP) in platelets closely followed the discovery of the inhibitory action of cAMP. An early hypothesis that cGMP might potentiate platelet aggregation was abandoned by 1978, after it was shown that some inhibitors of platelet aggregation, such as nitroprusside (NP), also increased platelet cGMP.1 It soon emerged that all nitrovasodilators release nitric oxide and activate soluble guanylyl cyclase (GC) and that the cGMP formed stimulates cGMP-dependent protein kinases (PKG) in many cells and tissues (Fig. 1), including vascular smooth muscle and platelets.3 The crucial physiological importance of this pathway was established with the identification of endothelium-derived relaxing factor (EDRF) as nitric oxide.4 cGMP phosphodiesterases play an essential role by limiting increases in cellular cGMP, and inhibition of these enzymes was found to potentiate the effects of nitric oxide and nitric oxide donors on platelets and other cells.5

The ability of cAMP and cGMP to activate distinct protein kinases led to a persistent view that these two cyclic nucleotides operate in parallel and independent ways to inhibit platelet function, cAMP mediating the effects of agonists such as PGI2, and cGMP mediating the effects of nitric oxide.2,3 However, over the last 10 years, considerable evidence has accumulated to indicate that this is not the case in platelets (or in many other cells) and that cross-talk between the cAMP and cGMP systems may occur on at least two levels, affecting both cyclic nucleotide phosphodiesterase (PDE) and protein kinase activities (Fig. 1). One of the most significant of these interactions is through the effects of cGMP on the hydrolysis of cAMP by PDEs. It is the purpose of this chapter to describe platelet PDEs and to discuss how their individual characteristics and regulation may impact platelet function and the design of useful antithrombotic agents. In addition, evidence that both cGMP and cAMP may activate PKG and that these cyclic nucleotides may exert effects in platelets that do not involve either PKA or PKG will be discussed briefly.

Neuroleptic malignant syndrome following catatonia: Vigilance is the price of antipsychotic prescription

Objectives:

To describe a case of neuroleptic malignant syndrome following antipsychotic treatment of catatonia, highlighting the potentially serious complications of this rare adverse drug reaction.

Methods:

We present a case report of a patient who developed this syndrome with various sequelae.

Results:

The patient developed neuroleptic after being treated with lorazepam and olanzapine for catatonia. He subsequently developed the complications of rhabdomyolysis, acute kidney injury, pulmonary embolism, urinary retention and ileus. He received high-dose lorazepam, anticoagulation and intravenous fluids. Antipsychotic medication in the form of haloperidol was reinstated with no adverse effect, and he went on to make a full recovery.

Conclusions:

This case illustrates the potential life-threatening complications of neuroleptic malignant syndrome and the need for a low index of clinical suspicion. It also highlights the lack of evidence for treatment of catatonia, including the use of antipsychotics.

Glycerolipid Characterization and Nutrient Deprivation-Associated Changes in the Green Picoalga Ostreococcus tauri

The picoalga Ostreococcus tauri is a minimal photosynthetic eukaryote that has been used as a model system. O. tauri is known to efficiently produce docosahexaenoic acid (DHA). We provide a comprehensive study of the glycerolipidome of O. tauri and validate this species as model for related picoeukaryotes. O. tauri lipids displayed unique features that combined traits from the green and the chromalveolate lineages. The betaine lipid diacylglyceryl-hydroxymethyl-trimethyl-β-alanine and phosphatidyldimethylpropanethiol, both hallmarks of chromalveolates, were identified as presumed extraplastidial lipids. DHA was confined to these lipids, while plastidial lipids of prokaryotic type were characterized by the overwhelming presence of ω-3 C18 polyunsaturated fatty acids (FAs), 18:5 being restricted to galactolipids. C16:4, an FA typical of green microalgae galactolipids, also was a major component of O. tauri extraplastidial lipids, while the 16:4-coenzyme A (CoA) species was not detected. Triacylglycerols (TAGs) displayed the complete panel of FAs, and many species exhibited combinations of FAs diagnostic for plastidial and extraplastidial lipids. Importantly, under nutrient deprivation, 16:4 and ω-3 C18 polyunsaturated FAs accumulated into de novo synthesized TAGs while DHA-TAG species remained rather stable, indicating an increased contribution of FAs of plastidial origin to TAG synthesis. Nutrient deprivation further severely down-regulated the conversion of 18:3 to 18:4, resulting in obvious inversion of the 18:3/18:4 ratio in plastidial lipids, TAGs, as well as acyl-CoAs. The fine-tuned and dynamic regulation of the 18:3/18:4 ratio suggested an important physiological role of these FAs in photosynthetic membranes. Acyl position in structural and storage lipids together with acyl-CoA analysis further help to determine mechanisms possibly involved in glycerolipid synthesis.

Metabolome Analysis Reveals Betaine Lipids as Major Source for Triglyceride Formation, and the Accumulation of Sedoheptulose during Nitrogen-Starvation of Phaeodactylum tricornutum

Oleaginous microalgae are considered as a promising resource for the production of biofuels. Especially diatoms arouse interest as biofuel producers since they are most productive in carbon fixation and very flexible to environmental changes in the nature. Naturally, triacylglycerol (TAG) accumulation in algae only occurs under stress conditions like nitrogen-limitation. We focused on Phaeodactylum strain Pt4 (UTEX 646), because of its ability to grow in medium with low salinity and therefore being suited when saline water is less available or for wastewater cultivation strategies. Our data show an increase in neutral lipids during nitrogen-depletion and predominantly 16:0 and 16:1(n-7) accumulated in the TAG fraction. The molecular species composition of TAG suggests a remodeling primarily from the betaine lipid diacylglyceroltrimethylhomoserine (DGTS), but a contribution of the chloroplast galactolipid monogalactosyldiacylglycerol (MGDG) cannot be excluded. Interestingly, the acyl-CoA pool is rich in 20:5(n-3) and 22:6(n-3) in all analyzed conditions, but these fatty acids are almost excluded from TAG. Other metabolites most obviously depleted under nitrogen-starvation were amino acids, lyso-phospholipids and tricarboxylic acid (TCA) cycle intermediates, whereas sulfur-containing metabolites as dimethylsulfoniopropionate, dimethylsulfoniobutyrate and methylsulfate as well as short acyl chain carnitines, propanoyl-carnitine and butanoyl-carnitine increased upon nitrogen-starvation. Moreover, the Calvin cycle may be de-regulated since sedoheptulose accumulated after nitrogen-depletion. Together the data provide now the basis for new strategies to improve lipid production and storage in Phaeodactylum strain Pt4.

Dual Fatty Acid Elongase Complex Interactions in Arabidopsis

Very long chain fatty acids (VLCFAs) are involved in plant development and particularly in several cellular processes such as membrane trafficking, cell division and cell differentiation. However, the precise role of VLCFAs in these different cellular processes is still poorly understood in plants. In order to identify new factors associated with the biosynthesis or function of VLCFAs, a yeast multicopy suppressor screen was carried out in a yeast mutant strain defective for fatty acid elongation. Loss of function of the elongase 3 hydroxyacyl-CoA dehydratase PHS1 in yeast and PASTICCINO2 in plants prevents growth and induces cytokinesis defects. PROTEIN TYROSIN PHOSPHATASE-LIKE (PTPLA) previously characterized as an inactive dehydratase was able to restore yeast phs1 growth and VLCFAs elongation but not the plant pas2-1 defects. PTPLA interacted with elongase subunits in the Endoplasmic Reticulum (ER) and its absence induced the accumulation of 3-hydroxyacyl-CoA as expected from a dehydratase involved in fatty acid (FA) elongation. However, loss of PTPLA function increased VLCFA levels, an effect that was dependent on the presence of PAS2 indicating that PTPLA activity repressed FA elongation. The two dehydratases have specific expression profiles in the root with PAS2, mostly restricted to the endodermis, while PTPLA was confined in the vascular tissue and pericycle cells. Comparative ectopic expression of PTPLA and PAS2 in their respective domains confirmed the existence of two independent elongase complexes based on PAS2 or PTPLA dehydratase that are functionally interacting.

ECERIFERUM2-LIKE proteins have unique biochemical and physiological functions in very-long-chain fatty acid elongation

The extension of very-long-chain fatty acids (VLCFAs) for the synthesis of specialized apoplastic lipids requires unique biochemical machinery. Condensing enzymes catalyze the first reaction in fatty acid elongation and determine the chain length of fatty acids accepted and produced by the fatty acid elongation complex. Although necessary for the elongation of all VLCFAs, known condensing enzymes cannot efficiently synthesize VLCFAs longer than 28 carbons, despite the prevalence of C28 to C34 acyl lipids in cuticular wax and the pollen coat. The eceriferum2 (cer2) mutant of Arabidopsis (Arabidopsis thaliana) was previously shown to have a specific deficiency in cuticular waxes longer than 28 carbons, and heterologous expression of CER2 in yeast (Saccharomyces cerevisiae) demonstrated that it can modify the acyl chain length produced by a condensing enzyme from 28 to 30 carbon atoms. Here, we report the physiological functions and biochemical specificities of the CER2 homologs CER2-LIKE1 and CER2-LIKE2 by mutant analysis and heterologous expression in yeast. We demonstrate that all three CER2-LIKEs function with the same small subset of condensing enzymes, and that they have different effects on the substrate specificity of the same condensing enzyme. Finally, we show that the changes in acyl chain length caused by each CER2-LIKE protein are of substantial importance for cuticle formation and pollen coat function.

Development of pharyngo-esophageal physiology during swallowing in the preterm infant

BACKGROUND

Poor feeding is a common cause of prolonged hospitalization of preterm infants. Pharyngeal and upper esophageal sphincter (UES) function of preterm infants has been technically difficult to assess and is therefore poorly characterized. The aim of this study was to assess the development of pharyngeal motility, UES function, and their coordination during nutritive swallowing in preterm infants.

METHODS

Development of swallowing was assessed in 18 preterm infants. High resolution manometry was performed at first oral feeding attempt (31-32 week) and then weekly for 4 weeks. Pharyngeal and UES pressure changes were characterized in 980 swallows.

KEY RESULTS

During swallowing, we observed an age-related increase in peak pharyngeal pressure at the laryngeal inlet (1 cm above UES) but an age-related decrease in the time required for the UES to fully relax to nadir. Analysis of the timing of proximal pharyngeal contractile peak and UES nadir showed that the UES was not fully relaxed when bolus propulsive forces were at their peak in the youngest infants.

CONCLUSIONS & INFERENCES

Results show developmental changes in infant swallow physiology that can be clearly linked to the effectiveness of nutritive swallowing. Most preterm infants demonstrated poor pharyngeal pressures at the laryngeal inlet coupled with poor coordination of pharyngeal propulsion with UES relaxation. These pressure patterns were less efficient than those demonstrated by older infants who were more adept at feeding. These observations may explain why infants under 34 weeks are physiologically unable to feed effectively and experience frequent choking and fatigue during feeding.

ELOVL2 controls the level of n-6 28:5 and 30:5 fatty acids in testis, a prerequisite for male fertility and sperm maturation in mice

ELOVL2 is a member of the mammalian microsomal ELOVL fatty acid enzyme family, involved in the elongation of very long-chain fatty acids including PUFAs required for various cellular functions in mammals. Here, we used ELOVL2-ablated (Elovl2(-/-)) mice to show that the PUFAs with 24-30 carbon atoms of the ω-6 family in testis are indispensable for normal sperm formation and fertility in male mice. The lack of Elovl2 was associated with a complete arrest of spermatogenesis, with seminiferous tubules displaying only spermatogonia and primary spermatocytes without further germinal cells. Furthermore, based on acyl-CoA profiling, heterozygous Elovl2(+/-) male mice exhibited haploinsufficiency, with reduced levels of C28:5 and C30:5n-6 PUFAs, which gave rise to impaired formation and function of haploid spermatides. These new insights reveal a novel mechanism involving ELOVL2-derived PUFAs in mammals and previously unrecognized roles for C28 and C30 n-6 PUFAs in male fertility. In accordance with the function suggested for ELOVL2, the Elovl2(-/-) mice show distorted levels of serum C20 and C22 PUFAs from both the n-3 and the n-6 series. However, dietary supplementation with C22:6n-3 could not restore male fertility to Elovl2(+/-) mice, suggesting that the changes in n-6 fatty acid composition seen in the testis of the Elovl2(+/-) mice, cannot be compensated by increased C22:6n-3 content.

Perceptions of occupational injury and illness costs by size of organization

BACKGROUND

Little is known about how organizations perceive and monitor occupational injury and illness costs.

AIMS

To explore perceptions of injury and illness costs, the extent to which organizations monitor their impact, attitudes towards this practice and views on using cost information in health and safety campaigns.

METHODS

Interviews were conducted with 212 representatives from 49 small- and medium-sized enterprises (SMEs) and 80 large organizations from a range of industry sectors.

RESULTS

Health and safety investments were driven by a range of factors, of which cost reduction was only one. Human costs were also considered important. Injuries were perceived to represent a substantial business cost by 10% of respondents from SMEs and 56% of those from large organizations. Most were uncertain about the financial impact of work-related illness. No organizations had attempted to monitor occupational illness costs. Injury costs had been assessed within 3 SMEs and 30 large organizations. Only 12% of SME representatives recognized the benefits of costing health and safety failures and around half were unreceptive to the use of cost information in health and safety promotions. Two-thirds of those from large organizations recognized some benefit in measuring costs, and over three-quarters welcomed the provision of industry-specific information.

CONCLUSIONS

Provision of information that focuses solely on the economic implications of occupational injury and illness may be of limited value and agencies involved in the promotion of health and safety should incorporate a range of information, taking into account the needs and concerns of different sectors.

Very-long-chain fatty acids are involved in polar auxin transport and developmental patterning in Arabidopsis

Very-long-chain fatty acids (VLCFAs) are essential for many aspects of plant development and necessary for the synthesis of seed storage triacylglycerols, epicuticular waxes, and sphingolipids. Identification of the acetyl-CoA carboxylase PASTICCINO3 and the 3-hydroxy acyl-CoA dehydratase PASTICCINO2 revealed that VLCFAs are important for cell proliferation and tissue patterning. Here, we show that the immunophilin PASTICCINO1 (PAS1) is also required for VLCFA synthesis. Impairment of PAS1 function results in reduction of VLCFA levels that particularly affects the composition of sphingolipids, known to be important for cell polarity in animals. Moreover, PAS1 associates with several enzymes of the VLCFA elongase complex in the endoplasmic reticulum. The pas1 mutants are deficient in lateral root formation and are characterized by an abnormal patterning of the embryo apex, which leads to defective cotyledon organogenesis. Our data indicate that in both tissues, defective organogenesis is associated with the mistargeting of the auxin efflux carrier PIN FORMED1 in specific cells, resulting in local alteration of polar auxin distribution. Furthermore, we show that exogenous VLCFAs rescue lateral root organogenesis and polar auxin distribution, indicating their direct involvement in these processes. Based on these data, we propose that PAS1 acts as a molecular scaffold for the fatty acid elongase complex in the endoplasmic reticulum and that the resulting VLCFAs are required for polar auxin transport and tissue patterning during plant development.

Very-long-chain fatty acids are involved in polar auxin transport and developmental patterning in Arabidopsis

Very-long-chain fatty acids (VLCFAs) are essential for many aspects of plant development and necessary for the synthesis of seed storage triacylglycerols, epicuticular waxes, and sphingolipids. Identification of the acetyl-CoA carboxylase PASTICCINO3 and the 3-hydroxy acyl-CoA dehydratase PASTICCINO2 revealed that VLCFAs are important for cell proliferation and tissue patterning. Here, we show that the immunophilin PASTICCINO1 (PAS1) is also required for VLCFA synthesis. Impairment of PAS1 function results in reduction of VLCFA levels that particularly affects the composition of sphingolipids, known to be important for cell polarity in animals. Moreover, PAS1 associates with several enzymes of the VLCFA elongase complex in the endoplasmic reticulum. The pas1 mutants are deficient in lateral root formation and are characterized by an abnormal patterning of the embryo apex, which leads to defective cotyledon organogenesis. Our data indicate that in both tissues, defective organogenesis is associated with the mistargeting of the auxin efflux carrier PIN FORMED1 in specific cells, resulting in local alteration of polar auxin distribution. Furthermore, we show that exogenous VLCFAs rescue lateral root organogenesis and polar auxin distribution, indicating their direct involvement in these processes. Based on these data, we propose that PAS1 acts as a molecular scaffold for the fatty acid elongase complex in the endoplasmic reticulum and that the resulting VLCFAs are required for polar auxin transport and tissue patterning during plant development.

Interventions for preventing injuries in the construction industry

BACKGROUND

Construction workers are frequently exposed to various types of injury-inducing hazards. A number of injury prevention interventions have been proposed, yet the effectiveness of these is uncertain.

OBJECTIVES

To assess the effects of interventions for preventing injuries among workers at construction sites.

SEARCH STRATEGY

We searched the Cochrane Injuries Group's specialised register, CENTRAL, MEDLINE, EMBASE, PsycINFO, OSH-ROM (including NIOSHTIC and HSELINE), EI Compendex. The reference lists of relevant papers, reviews and websites were also searched. The searches were not restricted by language or publication status. All databases were searched up to June 2006.

SELECTION CRITERIA

Randomized controlled trials, controlled before-after studies and interrupted time series of all types of interventions for preventing fatal and non-fatal injuries among workers at construction sites.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study quality. For interrupted time series, we reanalysed the studies and used an initial effect, measured as the change in injury-rate in the year after the intervention, as well as a sustained effect, measured as the change in time trend before and after the intervention.

MAIN RESULTS

Five interrupted time series studies met the inclusion criteria. Three studies evaluated the effect of regulations, one evaluated a safety campaign, and one a drug-free workplace program on fatal or non-fatal injuries compared to no drug-free workplace program. The overall methodological quality was low. The regulatory interventions did not show either an initial or sustained effect on fatal or non-fatal injuries, with effect sizes of 0.69 (95% confidence interval (CI) -1.70 to 3.09) and 0.28 (95% CI 0.05 to 0.51). The safety campaign did have an initial and sustained effect, reducing non-fatal injuries with effect sizes of -1.82 (95% CI -2.90 to -0.75) and -1.30 (95% CI -1.79 to -0.80) respectively. The drug-free workplace program did have an initial and sustained effect, reducing non-fatal injuries compared to no intervention, with effect sizes of -6.74 (95% CI -10.02 to -3.54) and -1.76 (95% CI -3.11 to -0.41) respectively.

AUTHORS' CONCLUSIONS

The vast majority of technical, human factors and organisational interventions which are recommended by standard texts of safety, consultants and safety courses, have not been adequately evaluated. There is no evidence that regulations for reducing fatal and non-fatal injuries are effective. There is limited evidence that a multifaceted safety campaign and a multifaceted drug program can reduce non-fatal injuries in the construction industry.

Cloning and characterization of unusual fatty acid desaturases from Anemone leveillei: identification of an acyl-coenzyme A C20 Delta5-desaturase responsible for the synthesis of sciadonic acid

The seed oil of Anemone leveillei contains significant amounts of sciadonic acid (20:3Delta(5,11,14); SA), an unusual non-methylene-interrupted fatty acid with pharmaceutical potential similar to arachidonic acid. Two candidate cDNAs (AL10 and AL21) for the C(20) Delta(5cis)-desaturase from developing seeds of A. leveillei were functionally characterized in transgenic Arabidopsis (Arabidopsis thaliana) plants. The open reading frames of both Delta(5)-desaturases showed some similarity to presumptive acyl-coenzyme A (CoA) desaturases found in animals and plants. When expressed in transgenic Arabidopsis, AL21 showed a broad range of substrate specificity, utilizing both saturated (16:0 and 18:0) and unsaturated (18:2, n-6 and 18:3, n-3) substrates. In contrast, AL10 did not show any activity in wild-type Arabidopsis. Coexpression of AL10 or AL21 with a C(18) Delta(9)-elongase in transgenic Arabidopsis plants resulted in the production of SA and juniperonic fatty acid (20:4Delta(5,11,14,17)). Thus, AL10 acted only on C(20) polyunsaturated fatty acids in a manner analogous to "front-end" desaturases. However, neither AL10 nor AL21 contain the cytochrome b(5) domain normally present in this class of enzymes. Acyl-CoA profiling of transgenic Arabidopsis plants and developing A. leveillei seeds revealed significant accumulation of Delta(5)-unsaturated fatty acids as acyl-CoAs compared to the accumulation of these fatty acids in total lipids. Positional analysis of triacylglycerols of A. leveillei seeds showed that Delta(5)-desaturated fatty acids were present in both sn-2 and sn-1 + sn-3 positions, although the majority of 16:1Delta(5), 18:1Delta(5), and SA was present at the sn-2 position. Our data provide biochemical evidence for the A. leveillei Delta(5)-desaturases using acyl-CoA substrates.

A Bifunctional Δ12,Δ15-Desaturase from Acanthamoeba castellanii Directs the Synthesis of Highly Unusual n-1 Series Unsaturated Fatty Acids

The free-living soil protozoon Acanthamoeba castellanii synthesizes a range of polyunsaturated fatty acids, the balance of which can be altered by environmental changes. We have isolated and functionally characterized in yeast a microsomal desaturase from A. castellanii, which catalyzes the sequential conversion of C(16) and C(18) Delta9-monounsaturated fatty acids to di- and tri-unsaturated forms. In the case of C(16) substrates, this bifunctional A. castellanii Delta12,Delta15-desaturase generated a highly unusual fatty acid, hexadecatrienoic acid (16:3Delta(9,12,15)(n-1)). The identification of a desaturase, which can catalyze the insertion of a double bond between the terminal two carbons of a fatty acid represents a new addition to desaturase functionality and plasticity. We have also co-expressed in yeast the A. castellanii bifunctional Delta12,Delta15-desaturase with a microsomal Delta6-desaturase, resulting in the synthesis of the highly unsaturated C(16) fatty acid hexadecatetraenoic acid (16:4Delta(6,9,12,15)(n-1)), previously only reported in marine microorganisms. Our work therefore demonstrates the feasibility of the heterologous synthesis of polyunsaturated fatty acids of the n-1 series. The presence of a bifunctional Delta12,Delta15-desaturase in A. castellanii is also considered with reference to the evolution of desaturases and the lineage of this protist.

A stage of change approach to reducing occupational ill health

OBJECTIVE

Interventions targeted by stage of change have been shown to improve the efficacy of public health promotion initiatives in areas such as smoking cessation, alcohol reduction, and mammography screening. Targeted interventions are designed to tackle the key attitudes, beliefs, and intentions that underpin an individual's health-related behavior. Work-related ill health is an increasingly serious issue, the most common cause of which in both the UK and the US is musculoskeletal disorders. This study examined whether the stage approach could be applied to workplace interventions aimed at improving occupational health.

METHOD

A total of 24 multi-component occupational interventions aimed at reducing musculoskeletal disorders were monitored over a period of 4-6 months. In half of these cases, approaches were targeted according to workers' stage of change.

RESULTS

Targeted interventions were found to be significantly more effective in promoting risk awareness and desired behavior change among workers. Significant reductions were also found in self-reported musculoskeletal discomfort among workers having received targeted interventions. No significant differences were found in self-reported musculoskeletal discomfort among workers following standard interventions.

CONCLUSION

Stage-matched approaches may offer scope for substantially improving the efficacy of occupational health and safety interventions by increasing the uptake, implementation, and maintenance of risk-reducing measures.

Identification of Primula "front-end" desaturases with distinct n-6 or n-3 substrate preferences

cDNA clones encoding cytochrome b(5) fusion desaturases were isolated from Primula cortusoides L. and Primula luteola Ruprecht, species previously shown to preferentially accumulate either n-6 or n-3 Delta6-desaturated fatty acids, respectively. Functional characterisation of these desaturases in yeast revealed that the recombinant Primula enzymes displayed substrate preferences, resulting in the predominant synthesis of either gamma-linolenic acid (n-6) or stearidonic acid (n-3). Independent expression of the two Primula desaturases in transgenic Arabidopsis thaliana confirmed these results, with gamma-linolenic acid and stearidonic acid accumulating in both leaf and seed tissues to different levels, depending on the substrate specificity of the desaturase. Targeted lipid analysis of transgenic Arabidopsis lines revealed the presence of Delta6-desaturated fatty acids in the acyl-CoA pools of leaf but not seed tissue. The implications for the transgenic synthesis of C(20) polyunsaturated fatty acids via the elongation of Delta6-desaturated fatty acids are discussed, as is the potential of using Primula desaturases in the synthesis of C(18) n-3 polyunsaturated fatty acids such as stearidonic acid.

The alternative pathway C20 Delta8-desaturase from the non-photosynthetic organism Acanthamoeba castellanii is an atypical cytochrome b5-fusion desaturase

A cDNA encoding a C20 Delta8-desaturase was isolated from the free-living soil amoeba, Acanthamoeba castellanii and functionally characterised by heterologous expression. The open reading frame of the A. castellanii C20 Delta8-desaturase showed similarity to other microsomal front-end desaturases, but the N-terminal domain contained a variant form of the conserved heme-binding motif in which H-P-G-G is replaced by H-P-A-G. Co-expression of the A. castellani Delta8-desaturase with the Isochrysis galbana Delta9-elongase in transgenic Arabidopsis plants confirmed the activity observed in yeast and its role in the alternative pathway for C20 polyunsaturated fatty acid synthesis. Acyl-CoA profiles of these transgenic plants revealed an unexpected accumulation of C20 fatty acids in the acyl-CoA pool. This is the first report of an alternative pathway C20 Delta8-desaturase from a non-photosynthetic organism, and also the first report of a front-end desaturase lacking the canonical cytochrome b5 domain.

Antioxidants for preventing pre-eclampsia

BACKGROUND

Oxidative stress has been proposed as a key factor involved in the development of pre-eclampsia. Supplementing women with antioxidants during pregnancy may help to counteract oxidative stress and thereby prevent or delay the onset of pre-eclampsia.

OBJECTIVES

To determine the effectiveness and safety of any antioxidant supplementation during pregnancy and the risk of developing pre-eclampsia and its related complications.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (June 2004) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2004).

SELECTION CRITERIA

All randomised and quasi-randomised trials comparing one or more antioxidants with either placebo or no antioxidants during pregnancy for the prevention of pre-eclampsia, and trials comparing one or more antioxidants with another, or with other interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, data extraction and trial quality. Data were double-entered into the Review Manager software.

MAIN RESULTS

Seven trials involving 6082 women are included in this review. The largest trial (5021 women) was quasi-random and only three of the seven included trials were rated high quality. Supplementing women with any antioxidants during pregnancy compared with control or placebo was associated with a 39% reduction in the risk of pre-eclampsia (relative risk (RR) 0.61, 95% confidence intervals (CI) 0.50 to 0.75, seven trials, 6082 women). Women receiving antioxidants compared with control or placebo also had a reduced risk of having a small-for-gestational-age infant (RR 0.64, 95% CI 0.47 to 0.87, three trials, 634 women), their infants had a greater mean birthweight (weighted mean difference 91.83 g, 95% CI 11.55 to 172.11, three trials, 451 women), but they were more likely to give birth preterm (RR 1.38, 95% CI 1.04 to 1.82, three trials, 583 women). There were insufficient data for reliable conclusions about possible effects on any other outcomes.

AUTHORS' CONCLUSIONS

These results should be interpreted with caution, as most of the data come from poor quality studies. Nevertheless, antioxidant supplementation seems to reduce the risk of pre-eclampsia. There also appears to be a reduction in the risk of having a small-for-gestational-age baby associated with antioxidants, although there is an increase in the risk of preterm birth. Several large trials are ongoing, and the results of these are needed before antioxidants can be recommended for clinical practice.

Rapid simultaneous measurement of multiple cytokines using 100 microl sample volumes--association with neonatal sepsis

Early diagnosis of neonatal infection has proved problematic due to the inadequacy of currently available laboratory tests. Neonatal sepsis is associated with an increase in plasma-derived cytokine levels, but an increase of a single cytokine cannot identify neonatal sepsis specifically and multiple cytokine levels are required. The time constraints and relatively large volume of plasma required to measure multiple cytokines from newborn infants by conventional enzyme-linked immunosorbent assay (ELISA) techniques is prohibitive. We therefore applied cytometric bead array (CBA) technology for simultaneous measurement of multiple cytokines from a group of 18 term neonates with infection confirmed by culture and a control group. 'Normal' ranges were established for each cytokine from 1-7-, 8-14- and 15-21-day-old newborns. There was no significant change in the levels of cytokines from infants in different control age groups, suggesting that basal cytokine levels are unchanged in the first 3 weeks of life. In the patient groups, however, there was a significant difference in several cytokines between the different age groups. Interleukin (IL)-6, IL-10 and IL-12 were increased significantly in the 1-7-day-old patient group compared to either the 8-14 and 15-21 age group, suggesting that infection in utero is associated with increased levels of these cytokines compared to infection acquired following birth. When individual patient cytokine levels were compared to normal control reference ranges, two patients failed to show significant elevation of any cytokine tested. All other patients showed elevated levels of between one and nine cytokines tested (mean of 4.6). There was no correlation between elevated cytokine levels and types of infective organism or patient age. In conclusion, neonatal sepsis is associated with the elevation of multiple plasma cytokines. The use of CBA kits is a rapid, easy, low sample volume and sensitive method to measure multiple plasma cytokines.

Expression profiling of the response of Arabidopsis thaliana to methanol stimulation

In order to obtain information about the metabolism of methanol in plants, gene expression in response to methanol stimulation was analysed in leaves of Arabidopsis thaliana through the use of a 26,090 element oligonucleotide microarray. Following confirmation of data and the application of selection criteria, a total of 484 (1.9%) transcripts were shown to be regulated in response to a 10% methanol application. Samples were taken at 1, 24 and 72 h. Of the total identified transcripts, only 20 were shared between all three time points of which only two were down-regulated. Based on functional category analysis of these genes, at 1 h, the largest categories were metabolism, cell communication/signal transduction processes, defence genes associated with transcription and aspects of RNA processing; a few related to cell division and growth; but none were associated with photosynthesis. At 24 and 72 h, the number and overall proportion of regulated transcripts associated with metabolism increased further. Direct measurement of anthocyanin and flavonoid content confirmed that methanol-regulated transcripts corresponded to flavonoid pathways. Within the functional class metabolism, genes encoding detoxification proteins represented by far the most strongly regulated group. These included, cytochrome P450's, glucosyl transferases and members of the ABC transporter family. It is concluded that exposure to methanol affects the expression of hundreds of genes and that multiple detoxification and signalling pathways are activated.

Multiple leucocyte activation markers to detect neonatal infection

Diagnosis of congenital or neonatal infection is often based on clinical signs. However, clinical symptoms of infections may not be specific, and for this reason early diagnosis is often determined on results of laboratory tests, which may not currently be adequate. A more reliable method of detection of infection may be the demonstration of activated lymphocytes, which can be conducted rapidly and before the isolation of the infected organism. We have shown that detection of up-regulation of CD45RO, an activated/memory isoform of CD45 present on T cells, provides a reasonably sensitive screening test for neonatal infection. We also showed that dual expression of CD45RA/CD45RO was up-regulated early during the infective process in neonates with documented infection. However, other leucocytes are also activated during the infective process. To improve the sensitivity of the neonatal infection screening test and to identify the types of leucocytes involved in the immune response to the infective organism, we studied further the up-regulation of a comprehensive range of surface activation markers on T cells, monocytes and natural killer (NK) cells from a group of 17 newborn patients with positive culture, a group of 40 possibly infected patients based on clinical signs and a control group. 'Normal' ranges were established for each activation marker for each leucocyte subset from 1 to 7 and 7-14-day-old newborns <35 weeks' gestation and 35-40 weeks' gestation. There was a significant increase in the percentage of T cells expressing CD25 in the peripheral blood from infants at 2 weeks of age. Expression of HLA-DR on T cells, CD25 and CD69 on monocytes and HLA-DR on NK cells was also increased significantly in the peripheral blood from infants at 2 weeks of age and may reflect a maturation of these functional surface molecules. Up-regulation of CD69 on NK cells was the most sensitive marker for neonatal sepsis (positive in 13/16 patients). CD69 and CD25 expression was increased significantly on T cells in 11/17 and 10/17 patients, respectively. A combination of CD45RA/CD45RO and CD45RO identified 11/16 infected patients. Measurement of CD69 expression on NK cells with CD45RA, CD45RO, CD25 and CD69 expression on T cells resulted in a significant increase in at least two leucocyte activation markers from infected patients. In conclusion, this is the first report of the up-regulation of CD69 on NK cells as a sensitive marker of neonatal infection. A combination of this marker with CD45RA, CD45RO, CD25 and CD69 expression on peripheral blood derived T cells is the most sensitive and specific for neonatal infection.

Physiological responses of the CAM epiphyte Tillandsia usneoides L. (Bromeliaceae) to variations in light and water supply

In an effort to understand the mechanisms that sustain rootless atmospheric plants, the modulation of Crassulacean acid metabolism (CAM) in response to variations in irradiance and water supply was investigated in the epiphyte Tillandsia usneoides. Plants were acclimated to three light regimes, i.e. high, intermediate and low, with integrated photon flux densities (PFD) of 14.40, 8.64 and 4.32 mol m-2 d-1 equivalent to an instantaneous PFD of 200, 100, and 50 mumol m-2 s-1, respectively. Daily watering was then withdrawn from half of the plants at each PFD for 7 d prior to sampling. In response to the three PFD treatments, chlorophyll content increased in plants acclimated to lower irradiances. Light response curves using non-invasive measurements of chlorophyll fluorescence demonstrated that photosystem II efficiency (phi PSII) was maintained in high PFD acclimated plants, as they exhibited a larger capacity for non-photochemical dissipation (NPQ) of excess light energy than low PFD acclimated plants. Net CO2 uptake increased in response to higher PFD, reflecting enhanced carboxylation capacity in terms of phosphoenolpyruvate carboxylase (PEPc) and ribulose 1,5-bisphosphate carboxylase/oxygenase (Rubisco) activities. After water was withdrawn, nocturnal net CO2 uptake and accumulated levels of acidity declined in all PFD treatments, concomitant with increased respiratory recycling of malate. Examining the strategies employed by epiphytes such as T. usneodies to tolerate extreme light and water regimes has demonstrated the importance of physiological mechanisms that allow flexible carboxylation capacity and continued carbon cycling to maintain photosynthetic integrity.

Congenital bowel perforation in twin-to-twin transfusion syndrome

Two unrelated survivors of twin-to-twin transfusion syndrome (TTTS) presented with intestinal perforation at birth. Both were localised perforations without any suggestion of widespread ischaemic disease to the splanchnic bed. Histopathology from the perforation site showed evidence of focal ischaemic necrosis, presumably from a vascular accident. One infant later died of multiple organ failure with major brain damage, but the other survived without long-term sequelae. These two cases appear to represent an unreported variation of the ischaemic intestinal complications of TTTS.

Patterns of antropyloric motility in fed healthy preterm infants

BACKGROUND

Antropyloric motility is important for regulation of gastric emptying and has not been adequately characterised in premature infants.

AIM

To evaluate fed patterns of antropyloric motility in premature infants.

SUBJECTS

Forty three healthy premature infants, 30-38 weeks of postmenstrual age.

METHODS

Postprandial antropyloric motility was measured using a micromanometric feeding assembly (outer diameter 1.8 mm) incorporating a pyloric sleeve sensor. The occurrence of isolated pyloric pressure waves (IPPWs) and antral pressure wave sequences (PWSs) was characterised. Sequences were further classified as being antegrade, synchronous, antegrade-synchronous, and retrograde according to the direction of propagation.

RESULTS

A total of 7289 pressure wave events were recorded, 48% IPPWs and 52% PWSs (18% antegrade, 12% synchronous, 13% antegrade-synchronous, 2% retrograde, and 7% undefined). IPPWs predominated in the first postprandial hour, peaking at 30-60 minutes. PWSs predominated in the period after one hour postprandially. Mean (SEM) half gastric emptying time was 42 (4) minutes.

CONCLUSIONS

Monitoring of antropyloric motor patterns in healthy premature infants indicates that the neuroregulatory mechanisms responsible for the coordination of antropyloric motility and gastric emptying are well developed by 30 weeks of postmenstrual age.

Short-term plasticity of crassulacean acid metabolism expression in the epiphytic bromeliad Tillandsia usneoides

This paper originates from a presentation at the IIIrd International Congress on Crassulacean Acid Metabolism, Cape Tribulation, Queensland, Australia, August 2001. The regulation and flexibility of the crassulacean acid metabolism (CAM) pathway has been investigated in the 'extreme epiphyte' Tillandsia usneoides (L.). Submerging strands of T. usneoides under water, thereby inhibiting the supply of atmospheric CO2, allowed non-invasive in vivo manipulation of the supply of CO2 during the nocturnal Phase I of CAM. Once the plants were removed from submersion, T. usneoides maintained open stomata, and net CO2 uptake occurred throughout most of the photoperiod. Variability in the expression of CAM allowed T. usneoides to compensate for restricted CO2 availability through Phase I of CAM by adjusting gas exchange rates through the photoperiod and subsequent dark period to maintain a constant internal supply of CO2 in the light. Furthermore, T. usneoides demonstrated a gradual, rather than rapid, change in phosphoenolpyruvate carboxylase (PEPC) activation across the day-night cycle, such that PEPC and Rubisco appear to work in tandem in order to maintain carbon balance for this extreme atmospheric bromeliad.

A comparison of acupuncture with advice and exercises on the symptomatic treatment of osteoarthritis of the hip--a randomised controlled trial

Acupuncture is becoming a common technique within the physiotherapy profession as a treatment modality for pain relief; however, few randomised controlled trials have been undertaken to assess the effectiveness of acupuncture, particularly in the treatment of osteoarthritis (OA) of the hip. Therefore, a randomised trial to compare the effectiveness of acupuncture with advice and exercises on the symptomatic treatment of OA of the hip was carried out. Thirty-two patients awaiting a total hip arthroplasty were randomly allocated to either the experimental group, (A), to have six sessions of acupuncture each lasting up to 25 minutes, or the control group, (B), to be given advice and exercises for their hip over a six week period. Group A consisted of three men and 13 women, and group B consisted of four men and eight women. The average age in group A was 66 years and in group B it was 68 years. Patients were assessed for pain and functional ability, using a modified version of the WOMAC questionnaire, pre-treatment, immediately post-treatment and at eight weeks post-treatment. The pre-treatment WOMAC scores in the two groups were similar (p=0.85). There was a significant improvement in group A (decrease in WOMAC score) immediately post-treatment (p=0.002) and this was maintained at the eight-week follow-up (p=0.03). There were no significant changes in group B. When the changes in WOMAC scores were compared between groups, a significantly greater improvement was found between pre-treatment and immediately post-treatment in group A, compared with group B (p=0.02). The changes between pre-treatment and the eight-week follow-up also showed a significant improvement in group A compared with group B (p=0.03). In conclusion, this trial supports the hypothesis that acupuncture is more effective than advice and exercises in the symptomatic treatment of OA of the hip.

Eighteenth and nineteenth century dental restoration, treatment and consequences in a British nobleman

This paper examines unusual eighteenth and nineteenth century dental treatment and its consequences, in a nobleman excavated from beneath St. Nicholas' Church, Sevenoaks, Kent, UK in the early 1990s. This rare archaeological case exhibits erosion of dental enamel on the labial surface of all the anterior dentition. A programme of historical research suggests that this might be attributed to the application of an acid-based dental tincture or the use of an abrasive substance to whiten the teeth. Palliative treatment for the consequence of this application was prescribed by Dr Robert Blake of Dublin. Further, it bears witness to three dental restorations, two of gold and one tin. The two gold (foil) fillings are an occlusal in the upper-right second molar and a cervical on the labial surface of the upper left canine. The tin filling is an occlusal in the upper left second molar. Excavation of the carious tissue appears to have been undertaken using a spoon shaped implement.

Quality of life of mothers and families caring for preterm infants requiring home oxygen therapy: a brief report

OBJECTIVE

To investigate the impact on mothers and families of caring for a premature infant receiving home oxygen therapy (HOT).

METHODS

Standard questionnaires were used to compare the functioning of mothers and families of 10 premature infants receiving HOT, 10 premature infants who were discharged from hospital on HOT but who no longer required it and 20 premature infants who had never required treatment with HOT.

RESULTS

After adjustment for gestational age, chronological age, birthweight and place of residence (urban/rural), the care required by premature infants receiving HOT had a significantly greater impact on their families than the care of infants not receiving HOT. Mothers of premature infants receiving HOT reported significantly less vitality and more mental health problems than mothers of infants not receiving HOT.

CONCLUSIONS

The use of HOT for premature infants may have a significant adverse impact on their mothers and families.

Interactive television for an urban adult mental health service: the Guy's Psychiatric Intensive Care Unit Telepsychiatry Project

We carried out a feasibility study of an interactive television (IATV) system to enhance the provision of psychiatric intensive care services to a remote adult acute psychiatric ward in the same National Health Service mental health trust. The system used videoconferencing equipment connected by ISDN at 128 kbit/s. The system was used for patient referral, assessment and monitoring by staff at the remote site 8 km away.

Mechanism of gastroesophageal reflux in premature infants with chronic lung disease

BACKGROUND/PURPOSE

The aim of this study was to characterize the motor events responsible for gastroesophageal reflux (GER) and esophageal acid clearance in a cohort of preterm infants with chronic lung disease (CLD).

METHODS

Esophageal motility was recorded for 2 to 3 hours postprandially in 14 preterm infants with mild-moderate or moderate-severe CLD at 33 to 39 weeks postmenstrual age using a sleeve-side hole micromanometric assembly into which a pH probe had been installed.

RESULTS

Twenty-six acid GER episodes were recorded by pH probe. Of these, 22 (85%) were associated with transient lower esophageal sphincter (LES) relaxation. Transient LES relaxations were significantly longer in duration than single swallows (13.7 seconds v 4.6 seconds, P < .001) and had lower nadir pressures (1.1 mm Hg v 2.5 mm Hg, P < .001). During periods of esophageal acidification (pH below 4), peristaltic esophageal body pressure wave sequences cleared acid refluxate more effectively than nonperistaltic pressure wave sequences.

CONCLUSIONS

In preterm infants with CLD, transient LES relaxations are the predominant mechanism underlying GER, and esophageal clearance mechanisms are fully functional, which is similar to that seen in healthy preterm infants.

Measurement of upper esophageal sphincter tone and relaxation during swallowing in premature infants

Upper esophageal sphincter (UES) motor function has not been previously evaluated in premature infants. The motor patterns associated with tonic activity and swallow-related relaxation of the UES were recorded for 1 h after completion of gavage feeding in 11 healthy preterm neonates (postmenstrual age 33-37 wk) with a micromanometric assembly, which included a sleeve sensor specifically adapted for UES recordings. A clearly defined UES high-pressure zone was observed in all premature infants studied. Resting UES pressure ranged from 2.3 to 26.2 mmHg and was higher during periods of irritability and apparent discomfort. During dry swallows, UES pressure relaxed from a resting pressure of 28.2 +/- 4.0 mmHg to a nadir of 1.1 +/- 3.3 mmHg. The mean UES relaxation interval (the time from relaxation onset to relaxation offset) was 0. 31 +/- 0.11 s. We conclude that in premature infants >/=33 wk postmenstrual age the motor mechanisms regulating UES resting pressure and the onset of UES relaxation are well developed.

Reproducibility of the 13C-octanoic acid breath test for assessment of gastric emptying in healthy preterm infants

BACKGROUND

The 13C-octanoic acid breath test has been used to measure gastric emptying in preterm infants, but the reproducibility of the test has not been evaluated in this population.

METHODS

Fifty-six paired breath test analyses were performed on 28 healthy preterm infants 1 to 5 days apart using the same food type, volume, and energy content for each paired sample. Breath samples were taken before the feeding, at 5-minute intervals after feeding for 30 minutes, then each 15 minutes for 4 hours. Samples were analyzed using an isotope-ratio mass spectrometer, and 3C recovery was used to calculate values for gastric-emptying coefficient and gastric half-emptying time.

RESULTS

There was no significant difference between test results on different days in the paired samples studied. gastric-emptying coefficients for the first and subsequent samples were 2.6+/-0.1 (mean+/-SEM) and 2.7+/-0.1, respectively, and half-emptying times were 44.5+/-3.7 minutes and 41.4+/-3.2 minutes.

CONCLUSION

The 13C-octanoic acid breath test is a reliable, noninvasive, and reproducible measure of gastric emptying in preterm infants that should have wide application for use in this population.

Growth and neurodevelopmental outcome in extremely-low-birth-weight infants after laparotomy

Twenty-one extremely-low-birth-weight (ELBW) and premature infants (<29 weeks' gestation and/or <1,000 g) underwent emergency laparotomy for acute intra-abdominal pathology (necrotising enterocolitis [NEC] 16, other bowel pathology 5) during the 4-year period from 1990 to 1993; 11 died. The neurodevelopmental outcome of the 10 survivors was assessed and compared with 20 living, otherwise normal controls matched for gestational age, birth weight, and year of birth to asses the effect of the abdominal event on quality of survival. Those who survived after laparotomy had a worse neurodevelopmental outcome than controls (P < 0.05). During this period, we also compared 24 infants in the ELBW category who developed NEC but did not require a laparotomy with the 16 ELBW infants with NEC who required a laparotomy. Those who required a laparotomy had worse disease and had significantly worse neurodevelopmental outcomes (P < 0.01). ELBW and premature infants who have acute intra-abdominal pathology requiring a laparotomy are thus at increased risk of neurodevelopmental problems and poor growth. Close long-term follow-up is important, and the families of such infants should be made aware before surgery of the increased risk the abdominal event has on their babies' developmental outcome if they survive.

Mechanisms of gastroesophageal reflux in healthy premature infants

OBJECTIVES

The aim of this study was to characterize the motor events responsible for gastroesophageal reflux (GER) and esophageal acid clearance in a cohort of healthy preterm infants.

STUDY DESIGN

Esophageal motility was recorded for 2 to 3 hours after a feeding in 24 preterm infants, 31 to 38 weeks' postmenstrual age, by using a sleeveside hole micromanometric assembly incorporating a pH probe.

RESULTS

Sixty acid GER episodes were recorded by pH probe, and 133 non-acid GER episodes were recorded manometrically by the presence of esophageal common cavities. Of the 193 GER episodes, 159 (82%) were associated with transient lower esophageal sphincter relaxation (TLESR). TLESRs were significantly longer in duration than single swallows (15.1 seconds vs 5.6 seconds, P < .001) and had lower nadir pressures (0.8 mm Hg vs 2.3 mm Hg, P < .001). A total of 3216 esophageal body pressure waves were analyzed; 70% of swallow-induced pressure waves were peristaltic in sequence compared with 5% of swallow-unrelated pressure waves. During periods of esophageal acidification (pH below 4), peristaltic esophageal body pressure wave sequences cleared acid refluxate more effectively than nonperistaltic pressure wave sequences.

CONCLUSIONS

In healthy preterm infants, TLESRs are the predominant mechanism underlying GER, and esophageal clearance mechanisms are well developed by at least 31 weeks' postmenstrual age.