Interactive effects of changes in UV radiation and climate on terrestrial ecosystems, biogeochemical cycles, and feedbacks to the climate system

Terrestrial organisms and ecosystems are being exposed to new and rapidly changing combinations of solar UV radiation and other environmental factors because of ongoing changes in stratospheric ozone and climate. In this Quadrennial Assessment, we examine the interactive effects of changes in stratospheric ozone, UV radiation and climate on terrestrial ecosystems and biogeochemical cycles in the context of the Montreal Protocol. We specifically assess effects on terrestrial organisms, agriculture and food supply, biodiversity, ecosystem services and feedbacks to the climate system. Emphasis is placed on the role of extreme climate events in altering the exposure to UV radiation of organisms and ecosystems and the potential effects on biodiversity. We also address the responses of plants to increased temporal variability in solar UV radiation, the interactive effects of UV radiation and other climate change factors (e.g. drought, temperature) on crops, and the role of UV radiation in driving the breakdown of organic matter from dead plant material (i.e. litter) and biocides (pesticides and herbicides). Our assessment indicates that UV radiation and climate interact in various ways to affect the structure and function of terrestrial ecosystems, and that by protecting the ozone layer, the Montreal Protocol continues to play a vital role in maintaining healthy, diverse ecosystems on land that sustain life on Earth. Furthermore, the Montreal Protocol and its Kigali Amendment are mitigating some of the negative environmental consequences of climate change by limiting the emissions of greenhouse gases and protecting the carbon sequestration potential of vegetation and the terrestrial carbon pool.

Prognostic gene expression signature for high-grade serous ovarian cancer

BACKGROUND

Median overall survival (OS) for women with high-grade serous ovarian cancer (HGSOC) is ∼4 years, yet survival varies widely between patients. There are no well-established, gene expression signatures associated with prognosis. The aim of this study was to develop a robust prognostic signature for OS in patients with HGSOC.

PATIENTS AND METHODS

Expression of 513 genes, selected from a meta-analysis of 1455 tumours and other candidates, was measured using NanoString technology from formalin-fixed paraffin-embedded tumour tissue collected from 3769 women with HGSOC from multiple studies. Elastic net regularization for survival analysis was applied to develop a prognostic model for 5-year OS, trained on 2702 tumours from 15 studies and evaluated on an independent set of 1067 tumours from six studies.

RESULTS

Expression levels of 276 genes were associated with OS (false discovery rate < 0.05) in covariate-adjusted single-gene analyses. The top five genes were TAP1, ZFHX4, CXCL9, FBN1 and PTGER3 (P < 0.001). The best performing prognostic signature included 101 genes enriched in pathways with treatment implications. Each gain of one standard deviation in the gene expression score conferred a greater than twofold increase in risk of death [hazard ratio (HR) 2.35, 95% confidence interval (CI) 2.02-2.71; P < 0.001]. Median survival [HR (95% CI)] by gene expression score quintile was 9.5 (8.3 to -), 5.4 (4.6-7.0), 3.8 (3.3-4.6), 3.2 (2.9-3.7) and 2.3 (2.1-2.6) years.

CONCLUSION

The OTTA-SPOT (Ovarian Tumor Tissue Analysis consortium - Stratified Prognosis of Ovarian Tumours) gene expression signature may improve risk stratification in clinical trials by identifying patients who are least likely to achieve 5-year survival. The identified novel genes associated with the outcome may also yield opportunities for the development of targeted therapeutic approaches.

Experiential contributions to social dominance in a rat model of fragile-X syndrome

Social withdrawal is one phenotypic feature of the monogenic neurodevelopmental disorder fragile-X. Using a 'knockout' rat model of fragile-X, we examined whether deletion of the Fmr1 gene that causes this condition would affect the ability to form and express a social hierarchy as measured in a tube test. Male fragile-X 'knockout' rats living together could successfully form a social dominance hierarchy, but were significantly subordinate to wild-type animals in mixed group cages. Over 10 days of repeated testing, the fragile-X mutant rats gradually showed greater variance and instability of rank during their tube-test encounters. This affected the outcome of future encounters with stranger animals from other cages, with the initial phenotype of wild-type dominance lost to a more complex picture that reflected, regardless of genotype, the prior experience of winning or losing. Our findings offer a novel insight into the complex dynamics of social interactions between laboratory living groups of fragile-X and wild-type rats. Even though this is a monogenic condition, experience has an impact upon future interactions with other animals. Gene/environment interactions should therefore be considered in the development of therapeutics.

Guideline for radiotherapy with curative intent in patients with early-stage medically inoperable non-small-cell lung cancer

OBJECTIVES

For this guideline, we investigated the effectiveness of radiotherapy with curative intent in medically inoperable patients with early-stage non-small-cell lung cancer (nsclc).

METHODS

The guideline was developed by Cancer Care Ontario's Program in Evidence-Based Care and by the Lung Cancer Disease Site Group through a systematic review of mainly retrospective studies, expert consensus, and formal internal and external reviews.

RECOMMENDATIONS

■ Stereotactic body radiation therapy (sbrt) with curative intent is an option that should be considered for patients with early-stage, node-negative, medically inoperable nsclc. Qualifying Statements■ Because of the high dose per fraction, the planning process and treatment delivery for sbrt require the use of advanced technology to maintain an appropriate level of safety. Consistent patient positioning and 4-dimensional analysis of tumour and critical structure motion during simulation and treatment delivery are essential.■ Preliminary results for proton-beam therapy have been promising, but the technique requires further clinical study.■ Recommended fractionation schemes for sbrt should result in a biologically effective dose of 100 or greater by the linear quadric model, choosing an α/β value of 10 [bed_10(LQ) ≥ 100]. Qualifying Statements■ Because of the increased risk of treatment-related adverse events associated with centrally located tumours, consideration of tumour size and proximity to critical central structures is required when determining the dose and fractionation.■ Examples of dose-fractionation schemes used in the included studies have been provided.■ Based on the current evidence and the opinion of the authors, radiation doses at bed_10(LQ) greater than 146 might significantly increase toxicity and should be avoided.■ Determination of the radiation bed by the linear quadratic model has limitations for the extreme hypofractionated schemes used in sbrt.

Smooth Muscle Enriched Long Noncoding RNA (SMILR) Regulates Cell Proliferation

BACKGROUND

Phenotypic switching of vascular smooth muscle cells from a contractile to a synthetic state is implicated in diverse vascular pathologies, including atherogenesis, plaque stabilization, and neointimal hyperplasia. However, very little is known about the role of long noncoding RNA (lncRNA) during this process. Here, we investigated a role for lncRNAs in vascular smooth muscle cell biology and pathology.

METHODS AND RESULTS

Using RNA sequencing, we identified >300 lncRNAs whose expression was altered in human saphenous vein vascular smooth muscle cells following stimulation with interleukin-1α and platelet-derived growth factor. We focused on a novel lncRNA (Ensembl: RP11-94A24.1), which we termed smooth muscle-induced lncRNA enhances replication (SMILR). Following stimulation, SMILR expression was increased in both the nucleus and cytoplasm, and was detected in conditioned media. Furthermore, knockdown of SMILR markedly reduced cell proliferation. Mechanistically, we noted that expression of genes proximal to SMILR was also altered by interleukin-1α/platelet-derived growth factor treatment, and HAS2 expression was reduced by SMILR knockdown. In human samples, we observed increased expression of SMILR in unstable atherosclerotic plaques and detected increased levels in plasma from patients with high plasma C-reactive protein.

CONCLUSIONS

These results identify SMILR as a driver of vascular smooth muscle cell proliferation and suggest that modulation of SMILR may be a novel therapeutic strategy to reduce vascular pathologies.

Defining Rehabilitation Success in Older Adults with Dementia--Results from an Inpatient Geriatric Rehabilitation Unit

OBJECTIVE

To quantify the magnitude of functional recovery in older adults with and without dementia admitted to an inpatient geriatric rehabilitation program by measuring change in measures of global physical function and physical therapy treatment outcomes.

DESIGN

Retrospective cohort study.

SETTING

Rehabilitation academic hospital.

PARTICIPANTS

Consecutive subjects, with (N=65, age 81.9±6.0 y) and without (N=157, age 82.8±7.2 y) a dementia diagnosis, had assessment data at admission and discharge from inpatient geriatric rehabilitation unit.

INTERVENTIONS

Not applicable.

MEASUREMENTS

The Functional Independence Measure (FIM) was used to estimate level of independence on activities of daily living. The Berg Balance Scale (BBS), Timed Up and Go Test (TUG) and 2 Minute Walk Test (2MWT) were used to estimate functional mobility and endurance. The FIM (total, motor subscale, cognitive subscale scores) were used to calculate rehabilitation efficacy and efficiency scores.

RESULTS

After controlling for confounding, there was no group difference for gains on the BBS, TUG, 2MWT; there was no group difference on rehabilitation efficacy and efficiency values based on the FIM motor subscale. The magnitude of the rehabilitation gain using the total FIM score was statistically different between groups, people with dementia having smaller gains.

CONCLUSION

Older adults with a diagnosis of dementia are capable of making motor function recovery during inpatient sub-acute rehabilitation comparable to their peers without a dementia diagnosis. The metric used to evaluate functional recovery influences the determination of rehabilitation success between groups. Rehabilitation success should be defined among people with a dementia diagnosis by a change in the motor subscale of the FIM, rather than the total FIM score or the gain relative to the maximal FIM score.

Photonic wire biosensor microarray chip and instrumentation with application to serotyping of Escherichia coli isolates

A complete photonic wire molecular biosensor microarray chip architecture and supporting instrumentation is described. Chip layouts with 16 and 128 independent sensors have been fabricated and tested, where each sensor can provide an independent molecular binding curve. Each sensor is 50 μm in diameter, and consists of a millimeter long silicon photonic wire waveguide folded into a spiral ring resonator. An array of 128 sensors occupies a 2 × 2 mm2 area on a 6 × 9 mm2 chip. Microfluidic sample delivery channels are fabricated monolithically on the chip. The size and layout of the sensor array is fully compatible with commercial spotting tools designed to independently functionalize fluorescence based biochips. The sensor chips are interrogated using an instrument that delivers sample fluid to the chip and is capable of acquiring up to 128 optical sensor outputs simultaneously and in real time. Coupling light from the sensor chip is accomplished through arrays of sub-wavelength surface grating couplers, and the signals are collected by a fixed two-dimensional detector array. The chip and instrument are designed so that connection of the fluid delivery system and optical alignment are automated, and can be completed in a few seconds with no active user input. This microarray system is used to demonstrate a multiplexed assay for serotyping E. coli bacteria using serospecific polyclonal antibody probe molecules.

The central role of myostatin in skeletal muscle and whole body homeostasis

Myostatin is a powerful negative regulator of skeletal muscle mass in mammalian species. It plays a key role in skeletal muscle homeostasis and has now been well described since its discovery. Myostatin is capable of inducing muscle atrophy via its inhibition of myoblast proliferation, increasing ubiquitin-proteasomal activity and downregulating activity of the IGF-Akt pathway. These well-recognized effects are seen in multiple atrophy causing situations, including injury, diseases such as cachexia, disuse and space flight, demonstrating the importance of the myostatin signalling mechanism. Based on this central role, significant work has been pursued to inhibit myostatin's actions in vivo. Importantly, several new studies have uncovered roles for myostatin distinct from skeletal muscle size. Myostatin has been suggested to play a role in cardiomyocyte homeostasis, glucose metabolism and adipocyte proliferation, all of which are examined in detail below. Based on these effects, myostatin inhibition has potential to be widely utilized in many Western diseases such as chronic obstructive pulmonary disease, type II diabetes and obesity. However, if myostatin inhibitors are to successfully translate from bench-top to bedside in the near future, awareness must be raised on these non-traditional effects of myostatin away from skeletal muscle. Indeed, further research into these novel areas is required.

Intermittent exercise with and without hypoxia improves insulin sensitivity in individuals with type 2 diabetes

CONTEXT

Hypoxia and muscle contraction stimulate glucose transport activity in vitro. Exercise and hypoxia have additive effects on insulin sensitivity in type 2 diabetics (T2D).

OBJECTIVE

The objective of the study was to examine the effectiveness of intermittent exercise with and without hypoxia on acute- and moderate-term glucose kinetics and insulin sensitivity in T2D.

SETTING

The study was conducted at a university research center.

DESIGN, PARTICIPANTS, AND INTERVENTIONS

Eight male T2D patients completed the following: 1) 60 min of continuous exercise at 90% lactate threshold in hypoxia (HyEx60); 2) intermittent exercise at 120% lactate threshold, separated by periods of passive recovery (5:5 min) in hypoxia [Hy5:5; O₂ ∼ 14.7 (0.2)%]; and 3) intermittent exercise (5:5 min) at 120% lactate threshold in normoxia (O₂ ∼ 20.93%).

MAIN OUTCOME MEASURES

Glucose appearance and glucose disappearance, using an adapted non-steady-state one-compartment model were measured. Homeostasis models of insulin resistance (HOMA(IR)), fasting insulin resistance index (FIRI), and β-cell function were calculated 24 and 48 h after exercise conditions.

RESULTS

Glucose disappearance increased from baseline (1.85 mg/kg · min⁻¹) compared with 24 h (2.01 min/kg · min⁻¹) after HyEx60 (P = 0.031). No difference was noted for both Hy5:5 (P = 0.064) and normoxia (P = 0.385). Hy5:5 demonstrated improvements in HOMA(IR) from baseline [d 1, 6.20 (0.40)] when comparisons were made with d 2 [4.83 (0.41)] (P = 0.0013). HOMA(IR) and FIRI improved in the 24 h (HOMA(IR), P = 0.002; FIRI, P = 0.003), remaining reduced 48 h after HyEx60 (HOMA(IR), P = 0.028; and FIRI, P = 0.034).

CONCLUSION

HyEx60 offered the greatest improvements in acute and moderate-term glucose control in T2D. Intermittent exercise stimulated glucose disposal and improved post-exercise insulin resistance, which was enhanced when exercise was combined with hypoxia (Hy5:5). The data suggest a use of hypoxic exercise in treatment of T2D.

The effect of hypoxia and work intensity on insulin resistance in type 2 diabetes

CONTEXT

Hypoxia and muscle contraction stimulate glucose transport in vitro. We have previously demonstrated that exercise and hypoxia have an additive effect on insulin sensitivity in type 2 diabetics.

OBJECTIVES

Our objective was to examine the effects of three different hypoxic/exercise (Hy Ex) trials on glucose metabolism and insulin resistance in the 48 h after acute hypoxia in type 2 diabetics.

DESIGN, PARTICIPANTS, AND INTERVENTIONS

Eight male type 2 diabetics completed 60 min of hypoxic [mean (sem) O(2) = ∼14.7 (0.2)%] exercise at 90% of lactate threshold [Hy Ex(60); 49 (1) W]. Patients completed an additional two hypoxic trials of equal work, lasting 40 min [Hy Ex(40); 70 (1) W] and 20 min [Hy Ex(20); 140 (12) W].

MAIN OUTCOME MEASURES

Glucose rate of appearance and rate of disappearance were determined using the one-compartment minimal model. Homeostasis models of insulin resistance (HOMA(IR)), fasting insulin resistance index and β-cell function (HOMA(β-cell)) were calculated at 24 and 48 h after trials.

RESULTS

Peak glucose rate of appearance was highest during Hy Ex(20) [8.89 (0.56) mg/kg · min, P < 0.05]. HOMA(IR) and fasting insulin resistance index were improved in the 24 and 48 h after Hy Ex(60) and Hy Ex(40) (P < 0.05). HOMA(IR) decreased 24 h after Hy Ex(20) (P < 0.05) and returned to baseline values at 48 h.

CONCLUSIONS

Moderate-intensity exercise in hypoxia (Hy Ex(60) and Hy Ex(40)) stimulates acute- and moderate-term improvements in insulin sensitivity that were less apparent in Hy Ex(20). Results suggest that exercise duration and not total work completed has a greater influence on acute and moderate-term glucose control in type 2 diabetics.

Simulation as a tool to improve the safety of pre-hospital anaesthesia--a pilot study

We conducted a pilot study of the effects of simulation as a tool for teaching doctor-paramedic teams to deliver pre-hospital anaesthesia safely. Participants undertook a course including 43 full immersion, high-fidelity simulations. Twenty videos taken from day 4 and days 9/10 of the course were reviewed by a panel of experienced pre-hospital practitioners. Participants' performance at the beginning and the end of the course was compared. The total time from arrival to inflation of the tracheal tube cuff was longer on days 9/10 than on day 4 (mean (SD) 14 min 52 s (2 min 6 s) vs 11 min 28 s (1 min 54 s), respectively; p = 0.005), while the number of safety critical events per simulation were fewer (median (IQR [range]) 1.0 (0-1.8 [0-2]) vs 3.5 (1.5-4.8 [0-8], respectively; p = 0.011). Crew resource management behaviours also improved in later simulations. On a personal training needs analysis, participants reported increased confidence after the course.

Views regarding the provision of prehospital critical care in the UK

AIMS

There is a lack of consensus regarding the role for critical care in the prehospital environment in the UK. It was hypothesised that this related to differences in views and understanding among opinion leaders within influential prehospital care organisations.

METHODS

A 38-item survey was developed by an established paramedic-physician prehospital critical care service. The survey was distributed to individuals in senior positions within seven organisations that have a major influence on UK prehospital services. Analysis comprised a description of the distribution of results, assessment of the level of agreement with each statement by professional background and current involvement in prehospital critical care and evaluation of the overall consistency of responses. Free-text comments were invited to illustrate the reasoning behind each response.

RESULTS

There were 32 respondents. The estimated response rate was 40%. The consistency of the questionnaire responses was very high. Overall, all individuals agreed with most of the statements. Paramedic respondents were more likely to disagree with statements that suggested that critical care involved interventions that exceed the current capability of the NHS ambulance service (p<0.05). Free-text comments revealed wide differences of opinion.

CONCLUSION

Although there appears to be broad agreement among opinion leaders regarding the concepts underpinning existing prehospital critical care services, areas of contention are highlighted that may help explain the current lack of consensus. Cooperative efforts to assess the current demand and clinical evidence would assist in the creation of a joint consensus and allow effective future planning for the provision of prehospital critical care throughout the UK.

Prototype single step lateral flow technology for detection of avian influenza virus and chicken antibody to avian influenza virus

A rapid and effective lateral flow assay (LFA) for detection of avian influenza virus (AIV) was developed. For antigen capture, the assay used monoclonal antibody specific for a conserved nuclear protein (NP) epitope, immobilized on a cellulose acetate matrix, in conjunction with a second NP monoclonal antibody chemically linked to either coloured latex beads or colloidal gold particles contained in a sample pad for detection. Virus sample added to the sample pad flowed into the trapping antibody to form a visible band as well as a second, control band further along the acetate strip. The control band consisted of recombinant protein A/G, also immobilized on the matrix. A second LFA for detection of chicken antibody to AIV was developed where NP antigen was immobilized on the matrix with recombinant protein A/G immobilized as a control band. Latex beads or colloidal gold particles to which monoclonal anti-chicken antibody was attached, were used as the indicator system.

Cuffed endotracheal tube use in paediatric prehospital intubation: challenging the doctrine?

Questioning traditional doctrines is essential if patient care is to improve and progress. Historically accepted teaching is to use uncuffed tubes in all children up to puberty. This has been the practice in anaesthesia, intensive care and paediatric resuscitation both in and out of hospital. The use of cuffed endotracheal tubes (ETTs) in pre-pubertal children is evolving in general anaesthesia and intensive care in hospital practice. In contrast, uncuffed tubes are still widely recommended for use in the prehospital environment in this age group. There are a number of good reasons why a cuffed tube should be considered in preference to an uncuffed tube in children intubated out of hospital, regardless of their age or size. There are also some counterarguments which are worthy of consideration. This article presents the arguments for and against the use of cuffed tubes in children in prehospital care with a view to stimulating open discussion and debate.

Hyperimmune goat serum for amyotrophic lateral sclerosis

The authors report a patient with amyotrophic lateral sclerosis (ALS) who showed a lessening of deterioration in respiratory muscle strength during treatment with hyperimmune goat serum (HGS) (Aimspro). Respiratory function tests (RFTs) were measured by established protocols, and all measurements were expressed as a percentage of normal predicted values. The rate of decline was calculated by linear regression analysis. Respiratory muscle strength decline was less during 13 months of treatment with HGS (mean 1.3% per month, range 0.8-1.7%) compared to the preceding 13 months (mean 2.3% per month, range 1.2-3.1%), while a greater decline would be expected with disease progression. Comparison with similarly affected patients in the literature suggest that a decline of 4-5% per month of predicted values may be expected during the treatment phase.

Competence in prehospital care: evolving concepts

Competence based training and assessment has become central to education and training for healthcare professionals. There continues to be uncertainty about the meaning of competence and how the principles underpinning competence based training and assessment can be applied to evolving subspecialty and multidisciplinary areas such as prehospital care. Considerable development work has been undertaken on a national level with the creation of a Competence Framework for Emergency Care. This article explores the concepts of competence, defines the terminology, and describes the role of a competence framework in education and training.

London bombings July 2005: The immediate pre-hospital medical response

On July 7th 2005 a series of terrorist bombs exploded in London. The transport system was targeted and at least 54 passengers were killed and around 700 injured. This paper describes the immediate pre-hospital medical response to the four scenes. From the perspective of the London Helicopter Emergency Medical Service the deployment, difficulties on scene and the initial lessons learned are discussed.

Idiopathic recurrent stupor: a warning

A proposal that an endogenous benzodiazepine-like agent named endozepine-4 might be responsible for presentations of recurrent stupor has gained wide acceptance. A case of recurrent stupor over two decades is presented with many similarities to previous cases of "endozepine stupor". This case, however, was caused by exogenous benzodiazepine administration and serves as a warning to clinicians to beware of this diagnosis.

Clinical indices of in vivo biocompatibility: The role of ex vivo cell function studies and effluent markers in peritoneal dialysis patients

Clinical indices of in vivo biocompatibility: The role of ex vivo cell function studies and effluent markers in peritoneal dialysis patients. Over the past 20 years, studies of the biocompatibility profile of peritoneal dialysis solutions (PDF) have evolved from initial in vitro studies assessing the impact of solutions on leukocyte function to evaluations of mesothelial cell behavior. More recent biocompatibility evaluations have involved assessments of the impact of PDF on membrane integrity and cell function in peritoneal dialysis (PD) patients. The development of ex vivo systems for the evaluation of in vivo cell function, and effluent markers of membrane integrity and inflammation in patients exposed both acutely and chronically to conventional and new PDF will be interpreted in the context of our current understanding of the biology of the dialyzed peritoneum. The available data indicate that exposure of the peritoneal environment to more biocompatible PDF is associated with improvements in peritoneal cell function, alterations in markers of membrane integrity, and reduced local inflammation. These data suggest that more biocompatible PDF will have a positive impact on host defense, peritoneal homeostasis, and the long-term preservation of peritoneal membrane function in PD patients.

Acute Coronary Syndrome

Acute coronary syndromes encompass a heterogenous group of patients with different clinical presentations, who have differences in both the extent and severity of underlying coronary atherosclerosis and who have different degrees of risk of progression to myocardial infarction. For each patient, the pre-hospital practitioner should make individual treatment decisions based on the history and examination, the ECG findings, the facilities and diagnostic equipment available and the transfer time to the nearest appropriate hospital. Patients with acute ischaemic chest pain should have oxygen, aspirin, nitrates and opioid analgesia. A 12 lead ECG should be performed within 5 minutes of initial assessment. If the ECG reveals ST-segment elevation or presumed new LBBB, this signifies acute myocardial infarction and in most cases immediate reperfusion therapy should be considered. The evidence of benefit in terms of mortality and morbidity following prompt anti-platelet and fibrinolytic therapy in such cases is unequivable. Pre-hospital fibrinolysis is now well established and should be undertaken in patients with acute infarction on clinical and ECG grounds if the transfer to hospital is likely to exceed 30 minutes and it is less than 12 hours since the onset of pain. Patients with no ECG evidence of infarction may still be at considerable risk and should still be conveyed to the nearest appropriate medical facility. Whilst en-route, they should receive aspirin, nitrates, low molecular weight heparin (LMWH) and beta blockers provided there are no contra-indications.

Prevalence and treatment of hypercholesterolaemia in patients with peripheral vascular disease

Background

Hypercholesterolaemia is a recognized risk factor for the development of arteriosclerosis. There is compelling evidence to support the use of lipid-lowering strategies in all hypercholesterolaemic patients with arteriosclerotic disease. In peripheral arterial disease (PAD), national guidelines recommend treatment if total cholesterol exceeds 5·0 mmol l−1. The prevalence of hypercholesterolaemia in patients with PAD was determined and the adequacy of lipid management before vascular referral was examined.

Methods

This was a prospective study of 233 consecutive patients admitted electively to this vascular surgery unit between December 1997 and December 1998. Some 68 patients were admitted with carotid disease, 81 with an aneurysm and 84 with intermittent claudication. A fasting venous blood sample was obtained from each patient.

Results

There were 175 men and 58 women, of median age 67 (range 37–85) and 68 (range 47–85) years respectively. Only 35 patients (15 per cent) were previously known to be hypercholesterolaemic; all but one were receiving treatment (one dietary, 33 statin). Of the remaining 198 patients, 124 (63 per cent) had a serum cholesterol level above 5·0 mmol l−1. A further 17 patients (9 per cent) had total cholesterol/high-density lipoprotein: cholesterol ratio greater than 5·0; these patients may also benefit from lipid-lowering therapy. In total, 141 (80 per cent) of 176 hypercholesterolaemic patients were undiagnosed at the time of hospital admission.

Conclusion

Hypercholesterolaemia is an important and correctable risk factor found in the majority of patients with PAD, but despite national guidelines and clear evidence from randomized controlled trials it is simply not being diagnosed in primary care. All elective patients with PAD should be screened for hypercholesterolaemia during their admission.

Immediate assessment and management of acute medical emergencies

The pre-hospital management of acute medical emergencies can be difficult. Critically ill patients must be evaluated quickly and accurately to ensure that immediately life-threatening problems are identified and treated. Figure 1 and Box 2 provide a structured method for rapid assessment in the pre-hospital phase. Although the majority of medically unwell patients will not require an aggressive resuscitation phase during the primary survey, the use of the structured approach in all patients will ensure that 'time critical' pre-hospital medical emergencies are identified. This approach also emphasizes that once immediately correctable problems have been treated, the priority is transfer the patient to the nearest resuscitation facility.

(E)-2(R)-[1(S)-(Hydroxycarbamoyl)-4-phenyl-3-butenyl]-2'-isobutyl-2'-(methanesulfonyl)-4-methylvalerohydrazide (Ro 32-7315), a selective and orally active inhibitor of tumor necrosis factor-alpha convertase

Tumor necrosis factor-alpha (TNF-alpha), a cytokine secreted by inflammatory cells, has been implicated in several inflammatory disease states. (E)-2(R)-[1(S)-(Hydroxycarbamoyl)-4-phenyl-3-butenyl]-2'-isobutyl-2'-(methanesulfonyl)-4-methylvalerohydrazide (Ro 32-7315), is a potent, orally active inhibitor of the TNF-alpha convertase (TACE), an enzyme responsible for proteolytic cleavage of the membrane bound precursor, pro-TNF-alpha. Ro 32-7315 inhibited a recombinant form of TACE (IC(50) = 5.2 nM) with selectivity over related matrix metalloproteinases. In a cellular assay system, THP-1 cell line, and in human and rat whole blood, Ro 32-7315 significantly reduced lipopolysaccharide (LPS)-induced TNF-alpha release with IC(50) values of 350 +/- 14 nM (n = 5), 2.4 +/- 0.5 microM (n = 5), and 110 +/- 18 nM (n = 5), respectively. Oral administration of Ro 32-7315 to Wistar rats caused a dose-dependent inhibition of LPS-induced release of systemic TNF-alpha with an ED(50) of 25 mg/kg. Treatment (days 0-14) of Allen and Hamburys hooded rats with Ro 32-7315 (2.5, 5, 10, and 20 mg/kg, i.p., twice daily) significantly reduced adjuvant-induced secondary paw swelling (42, 71, 83, and 93%, respectively) as compared with the vehicle group. In the Ro 32-7315-treated group, the reduced paw swelling was associated with improved lesion score and joint mobility. Furthermore, in a placebo-controlled, single-dose study, Ro 32-7315 given orally (450 mg) significantly suppressed ex vivo, LPS-induced TNF-alpha release in the whole-blood samples taken from healthy male and female volunteers (mean inhibition of 42% over a 4-h duration, n = 6). These data collectively support the potential use of such a compound for the oral treatment of inflammatory disorders.

Spinal injuries

The pre-hospital care of patients with suspected spinal injuries involves early immobilisation of the whole spine and the institution of measures to prevent secondary injury from hypoxia, hypoperfusion or further mechanical disruption. Early ventilation and differentiation of haemorrhagic from neurogenic shock are the key elements of pre-hospital resuscitation specific to spinal injuries. Falls from a significant height, high-impact speed road accidents, blast injuries, direct blunt or penetrating injuries near the spine and other high energy injuries should all be regarded as high risk for spinal injury but clinical examination should determine whether the patient requires full, limited or no spinal immobilisation. Although there is little conclusive evidence in the literature that supports pre-hospital clinical clearance of the spine, the similarities between pre-hospital immobilisation decisions and in-hospital radiography decisions are such that it is likely that clinical clearance will be effective for selected patients. This decision can be made at the scene provided the patient has no evidence of: Altered level of consciousness or mental status Intoxication Neurological symptoms or signs A distracting painful injury (e.g. chest injuries, long bone fracture) Midline spinal pain or tenderness. Where there is evidence to support spinal immobilisation, then the full range of devices and techniques should be considered. In the remote or operational environment where pre-hospital times are prolonged, full immobilisation, analgesia and re-assessment may allow localisation of the injury and a reduction in the degree of immobilisation. Common reasons for missing significant spinal injuries include failing to consider the possibility of spinal injuries in patients who are either unconscious, intoxicated or uncooperative (54,55). The application of the decision rule discussed here will ensure that no clinically significant spinal injuries are missed in pre-hospital care.

The injured child

Pre-hospital immediate care for seriously injured children is rarely required, but when it is, the response must be prompt and effective. The key to an effective and confident approach to injured children lies in understanding the age related anatomical and physiological differences between adults and children. These differences are most exaggerated in the first few years of life and excellent training courses and materials are available to help practitioners develop their confidence and skills in this age group. An easy to use length based aide memoire and a set of equipment packed according to size are essential to ensure safe management in the pre-hospital environment. Care of the seriously ill child, emergency childbirth and neonatal resuscitation are beyond the scope of this article. Nonetheless, pre-hospital practitioners should develop an understanding of assessment of ill children and normal delivery and be prepared to assist with emergency childbirth and neonatal resuscitation. Excellent educational material, courses and web based resources are available to achieve this (54). This is the sixth article in the add on series in pre-hospital care. The series is edited by Maj R Mackenzie. Maj RC Sutcliffe is a general practitioner and regimental medical officer. Maj R Mackenzie is a Specialist Registrar in Accident and Emergency Medicine and an immediate care doctor. While every effort has been made to ensure correct drug dosages are quoted, readers should always check these before use.

The discovery of PD 89211 and related compounds: selective dopamine D4 receptor antagonists

The dopamine (DA) D2 family of receptors consists of the D2, D3, and D4 receptors. The DA D4 receptor is of interest as a target for drugs to treat schizophrenia based upon its high affinity for the atypical antipsychotic clozapine and its localization to the limbic and cortical regions of the brain. As part of a program to identify novel DA D4 receptor antagonists, a high-volume screen using the Parke-Davis compound library was initiated. This led to the discovery of PD 89211 (benzenemethanol, 2-chloro-4-[4-[(1H-benzimidazol-2-yl)methyl]-1-piperzinyl]) that displaced [3H]spiperone binding to hD4.2 with an affinity (Ki) of 3.7 nM. PD 89211 exhibited high selectivity for the DA D4.2 receptor (> 800-fold) as compared to other hDA receptor subtypes, rat brain serotonin, and adrenergic receptors. In vitro, PD 89211 had D4 receptor antagonist activity reversing quinpirole-induced [3H]thymidine uptake in CHOpro5 cells (IC50 = 2.1 nM). Limited structure-activity relationship (SAR) studies indicated that compounds with a 4-chloro-, 4-methyl-, and 3-chloro- substituents on the phenyl ring retained high affinity for D4 receptors, while those with a 4-methoxy- and no substituent had less affinity. While all clinically effective antipsychotics increase DA synthesis (DOPA accumulation) in rodents, PD 89211 did not increase DA synthesis in the DA-enriched striatum, indicating no effect on DA turnover and low propensity for exhibiting motor side effects. However, it did increase catecholamine synthesis in rat hippocampus, as did clozapine. Moreover, PD 89211 selectivity increased catecholamine synthesis in the hippocampus of wild type but not in mice lacking D4 receptors, suggesting that one function of D4 receptors may be to modulate DA/norepinephrine (NE) turnover in this brain area known to possess D4 receptors. The discovery of compounds like PD 89211 provides a tool to help in understanding the function of DA D4 receptors in the CNS.

Pre-hospital anaesthesia

Effective management of the airway may have the greatest impact on mortality and morbidity of all pre-hospital interventions. The administration of a pre-hospital anaesthetic may not only facilitate effective management and protection of the airway but may also be fundamental to maintaining adequate ventilation and reducing times to definitive treatment for casualties who are trapped and those with major chest and head injuries. Pre-hospital anaesthesia is a highly skilled technique that requires considerable training and experience. Inappropriate attempts to anaesthetise critically injured casualties may prove fatal if the operator does not have the requisite knowledge, skills and equipment. For those that do, this article provides an operational framework within which pre-hospital anaesthesia can be developed (Box 5).

Bicarbonate/lactate-based peritoneal dialysis solution increases cancer antigen 125 and decreases hyaluronic acid levels

BACKGROUND

In a randomized, controlled trial comparing a pH neutral, bicarbonate/lactate (B/L)-buffered PD solution to conventional acidic, lactate-buffered solution (C), the overnight dialysate levels of markers of inflammation/wound healing [hyaluronic acid (HA)], mesothelial cell mass/membrane integrity [cancer antigen 125 (CA125)], and fibrosis [transforming growth factor-beta1 (TGF-beta1) and procollagen I peptides (PICP)] were assessed over a six-month treatment period.

METHODS

One hundred six patients were randomized (2:1) to either the B/L group or C group. Overnight effluents were collected at entry into the study (time = 0 all patients on control solution) and then at three and six months after randomization. Aliquots were filtered, stored frozen, and assayed for HA, CA125, TGF-beta1, and PICP. Differences between groups were assessed by repeated-measures analysis of variance for unbalanced data using the SAS procedure MIXED.

RESULTS

In patients treated with B/L, there was a significant (P = 0.03) increase in CA125 after six months compared with time = 0 (19.76 +/- 11.8 vs. 24.4 +/- 13.8 U/mL; mean +/- SD; N = 51). In the same group of patients, HA levels were significantly decreased at both three and six months in the B/L-treated group (time = 0, 336.0 +/- 195.2; time = 3 months, 250.6 +/- 167.6; and time = 6 months, 290.5 +/- 224.6 ng/mL; mean +/- SD; P = 0.006, N = 47 and P = 0.003, N = 48, respectively). No significant changes in CA125 or HA levels were observed in the control group. There were no significant changes observed in the levels of PICP or TGF-beta1 in the B/L or C group over the six-month treatment period.

CONCLUSIONS

These results suggest that continuous therapy with the B/L solutions modulates the levels of putative markers of peritoneal membrane integrity and inflammation. In the long term, this may positively impact the peritoneal membrane, increasing its life as a dialyzing organ.