Exploring advanced clinical practitioner perspectives on training, role identity and competence: a qualitative study

BACKGROUND

Advanced Clinical Practitioners (ACPs) are a new role that have been established to address gaps and support the existing medical workforce in an effort to help reduce increasing pressures on NHS services. ACPs have the potential to practice at a similar level to mid-grade medical staff, for example independently undertaking assessments, requesting and interpreting investigations, and diagnosing and discharging patients. These roles have been shown to improve both service outcomes and quality of patient care. However, there is currently no widespread formalised standard of training within the UK resulting in variations in the training experiences and clinical capabilities of ACPs. We sought to explore the training experiences of ACPs as well as their views on role identity and future development of the role.

METHODS

Five online focus groups were conducted between March and May 2021 with trainee and qualified advanced clinical practitioners working in a range of healthcare settings, in the North of England. The focus groups aimed to explore the experiences of undertaking ACP training including supervision, gaining competence, role identity and career progression. Thematic analysis of the focus group transcripts was performed, informed by grounded theory principles.

RESULTS

Fourteen advanced clinical practitioners participated. Analysis revealed that training was influenced by internal and external perceptions of the role, often acting as barriers, with structural aspects being significant contributory factors. Key themes identified (1) clinical training lacked structure and support, negatively impacting progress, (2) existing knowledge and experience acted as both an enabler and inhibitor, with implications for confidence, (3) the role and responsibilities are poorly understood by both advanced clinical practitioners and the wider medical profession and (4) advanced clinical practitioners recognised the value and importance of the role but felt changes were necessary, to provide security and sustainability.

CONCLUSIONS

Appropriate structure and support are crucial throughout the training process to enable staff to have a smooth transition to advanced level, ensuring they obtain the necessary confidence and competence. Structural changes and knowledge brokering are essential, particularly in relation to role clarity and its responsibilities, sufficient allocated time to learn and practice, role accreditation and continuous appropriate supervision.

What impact would reducing low-acuity attendance have on emergency department length of stay? A discrete event simulation modelling study

BACKGROUND

Long waiting times in the ED have been shown to cause negative outcomes for patients. This study aims to assess the effect in reducing length of stay of (1) preventing low-acuity attenders from attending the ED and (2) diverting low-acuity attenders at triage to a colocated general practice (GP) service.

METHODS

Discrete event simulation was used to model a large urban teaching hospital in the UK, as a case study, with a colocated GP service. The Centre for Urgent and Emergency Care research database patient-level database (May 2015-April 2016), secondary literature and expert elicitation were used to inform the model. The model predicted length of stay, the percentage of patients being seen within 4 hours and the incremental cost-effectiveness of the colocated GP service.

RESULTS

The model predicted that diverting low-acuity patients to a colocated GP open 9:00 to 17:00 reduces the average time in the system for higher acuity attenders by 29 min at an estimated additional cost of £6.76 per patient on average. The percentage of higher acuity patients being seen within 4 hours increased from 61% to 67% due to the reduction in the length of stay of those who were in the ED for the longest time. However, the model is sensitive to changes in model inputs and there is uncertainty around ED activity durations, for which further primary data collection would be useful.

CONCLUSION

Reducing the proportion of low-acuity attenders at the ED could have an impact on the time in the ED for higher acuity patients due to their use of shared resources, but is insufficient alone to meet current targets. The simulation model could be adapted for further analyses to understand which other changes would be needed to meet current government targets.

Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study

BACKGROUND

Ambulance services need to identify and prioritise patients with sepsis for early hospital assessment. We aimed to determine the accuracy of early warning scores alongside paramedic diagnostic impression to identify sepsis that required urgent treatment.

METHODS

We undertook a retrospective diagnostic cohort study involving adult emergency medical cases transported to Sheffield Teaching Hospitals ED by Yorkshire Ambulance Service in 2019. We used routine ambulance service data to calculate 21 early warning scores and categorise paramedic diagnostic impressions as sepsis, infection, non-specific presentation or other presentation. We linked cases to hospital records and identified those meeting the sepsis-3 definition who received urgent hospital treatment for sepsis (reference standard). Analysis determined the accuracy of strategies that combined early warning scores at varying thresholds for positivity with paramedic diagnostic impression.

RESULTS

We linked 12 870/24 955 (51.6%) cases and identified 348/12 870 (2.7%) with a positive reference standard. None of the strategies provided sensitivity greater than 0.80 with positive predictive value greater than 0.15. The area under the receiver operating characteristic curve for the National Early Warning Score, version 2 (NEWS2) applied to patients with a diagnostic impression of sepsis or infection was 0.756 (95% CI 0.729, 0.783). No other early warning score provided clearly superior accuracy to NEWS2. Paramedic impression of sepsis or infection had sensitivity of 0.572 (0.519, 0.623) and positive predictive value of 0.156 (0.137, 0.176). NEWS2 thresholds of >4, >6 and >8 applied to patients with a diagnostic impression of sepsis or infection, respectively, provided sensitivities and positive predictive values of 0.522 (0.469, 0.574) and 0.216 (0.189, 0.245), 0.447 (0.395, 0.499) and 0.274 (0.239, 0.313), and 0.314 (0.268, 0.365) and 0.333 (0.284, 0.386).

CONCLUSION

No strategy is ideal but using NEWS2 alongside paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2.

TRIAL REGISTRATION NUMBER

researchregistry5268, https://www.researchregistry.com/browse-the-registry%23home/registrationdetails/5de7bbd97ca5b50015041c33/.

Bone Structural, Biomechanical and Histomorphometric Characteristics of the Hindlimb Skeleton in the Marsh Rice Rat (Oryzomys palustris)

INTRODUCTION

The rice rat (Oryzomys palustris) is a non-conventional laboratory rodent species used to model some human bone disorders. However, no studies have been conducted to characterize the postcranial skeleton. Therefore, we aimed to investigate age- and gender-related features of the hindlimb skeleton of this species.

METHODS

We used femurs and tibiae from 94 rats of both genders aged 4-28 wks. Bone mineral content (BMC), volumetric bone mineral density (vBMD), and biomechanical properties were determined in femurs. In addition, bone histomorphometry of tibiae was conducted to assess bone cell activities and bone turnover over time.

RESULTS

Bone length, total metaphysis BMC and vBMD, mid-diaphyseal BMC and vBMD, cortical thickness, and cortical area progressively augmented with age. Whereas the increase in these parameters plateaued at age 16-22 wks in female rats, they continued to rise to age 28 wks in male rats. Furthermore, bone strength parameters increased with age, with few differences between genders. We also observed a rapid decrease in longitudinal growth between ages 4-16 wks. Whereas young rats had a greater bone formation rate and bone turnover, older rice rats had greater bone volume and trabecular thickness, with no differences between genders.

CONCLUSIONS

1) Sexual dimorphism in the rice rat becomes grossly evident at age 16 wks; 2) the age-related increases in bone mass, structural cortical parameters, and in some biomechanical property parameters plateau at an older age in male than in female rats; and 3) bone growth and remodeling significantly decreased with age irrespective of the gender.

Patient compliance with NHS 111 advice: Analysis of adult call and ED attendance data 2013-2017

The NHS 111 telephone advice and triage service is a vital part of the management of urgent and emergency care (UEC) services in England. Demand for NHS 111 advice has increased since its introduction in 2013, and the service is of particular importance in light of the current pandemic and resulting increased demand for emergency care. Currently, little is known about the effectiveness of NHS 111 in terms of the appropriateness of the advice given, or about the compliance of patients with that advice. We aimed to address this issue by analysing a large linked routine dataset of all NHS 111 calls (n = 3,631,069) and subsequent emergency department (ED) attendances made in the Yorkshire & Humber region from March 2013-March 2017. We found that many patients do not comply with advice, with 11% (n = 289,748) of patients attending ED when they are advised to self-care or seek primary care. We also found that a considerable number of these patients are further classed as urgent (88%, n = 255,931) and a substantial minority (37%, 106,207) are subsequently admitted to hospital. Further, many patients who are sent an ambulance or told to attend ED are classed as non-urgent upon attending ED (9%, n = 42,372). This research suggests that the level at which NHS 111 is currently triaging results in many hundreds of thousands of mis-triaged cases annually. Additionally, patients frequently do not comply with the advice they receive. This has implications for understanding the accuracy and efficiency of triaging systems.

Preventing or controlling periodontitis reduces the occurrence of osteonecrosis of the jaw (ONJ) in rice rats (Oryzomys palustris)

INTRODUCTION

Osteonecrosis of the jaw (ONJ) is an adverse event that requires association of both systemic risk factors, such as powerful anti-resorptives (pARs; e.g. zoledronic acid [ZOL]), and local oral risk factors (e.g. tooth extraction, periodontitis). Whereas optimal oral health prior to initiate pARs is recognized as critically important for minimizing ONJ risk, the efficacy of preventive/maintenance measures in patients who are taking pARs is understudied. Rice rats fed a standard diet (STD), rich in insoluble fiber, develop localized periodontitis. STD-rats with localized periodontitis treated with ZOL for 18-24 wk develop ONJ. Hence, we hypothesized that controlling/preventing localized periodontitis in the ZOL-treated rats, reduces ONJ occurrence.

METHODS

We used two approaches to attempt reducing periodontitis prevalence: 1) periodontal cleaning (PC); and 2) replacing the STD-diet with a nutritionally-equivalent diet high in soluble fiber (SF). 75 four-week-old male rats were weight-randomized into five groups (n = 15) in a 24-week experiment. Three groups ate the STD-diet and two the high SF-diet. STD-diet groups received intravenous (IV) vehicle (VEH) q4wks (STD + VEH), 80 μg/kg ZOL q4wks IV (STD + ZOL), or ZOL plus PC q2wks (STD + ZOL + PC). The SF-diet groups received VEH (SF + VEH) or ZOL (SF + ZOL). Jaws were processed for histopathology and evaluated for ONJ prevalence and tissue-level periodontitis.

RESULTS

1) 40% of STD + VEH rats developed maxillary localized periodontitis with no ONJ; 2) 50% of STD + ZOL rats developed ONJ; 3) 7% of STD + ZOL + PC rats developed ONJ (p < 0.01 vs. STD + ZOL); and 4) one SF + ZOL rat developed localized periodontitis, and no SF + VEH or SF + ZOL rats developed ONJ (p < 0.001 vs. STD + ZOL).

CONCLUSIONS

1) Periodontal cleaning in ZOL-treated rats decreases localized periodontitis severity and reduces ONJ prevalence; and 2) feeding a SF-diet to ZOL-treated rats reduces both incidence of localized periodontitis and ONJ. Our data indicates strong oral microbial community shifts according to oral health condition and trends in the shifts associated with diet.

Measurement of single- and double-escape HPGe efficiency ratios for 60Co

As a by-product of another measurement, ratios of the single-escape (SE) and double-escape (DE) efficiencies relative to the full-energy-peak efficiency (FE) have been measured for two HPGe detectors for ⁶⁰Co. For a 2.5-cm-thick 95 cm³ crystal the results were SE/FE = 0.000 48 ± 0.000 20 and 0.003 25 ± 0.000 24 for 1173 and 1332 keV gamma-rays, respectively, and DE/FE = 0.000 90 ± 0.000 17 and 0.003 41 ± 0.000 11 for 1173 and 1332 keV, respectively. For a 3.0-cm-thick 84 cm³ crystal the results were SE/FE = 0.000 67 ± 0.000 32 and 0.003 79 ± 0.000 27 for 1173 and 1332 keV respectively, and DE/FE = 0.001 05 ± 0.000 28 and 0.004 29 ± 0.000 16 for 1173 and 1332 keV, respectively. These measurements may be of relevance in connection with Monte Carlo calculations of HPGe detector efficiencies, and may also suggest a path towards improved atomic cross-section measurements.

Exploring the characteristics, acuity and management of adult ED patients at night-time

Objectives

ED care is required for acutely unwell and injured patients 24 hours a day, 7 days a week. The aim of this study was to compare characteristics and activity of type 1 ED attendances according to whether their time of arrival was during the day (08:00–18:00) or at night (18:00–08:00).

Methods

Hospital Episode Statistics (HES) data from NHS Digital for all A&E and admitted patient care activity provided by all acute (not mental health or primary care) NHS hospital trusts in Yorkshire and Humber (1 April 2011 to 31 March 2014) for adult patients were analysed. Adjusted linear and logistic regression was used to model the data.

Results

Adjusted regression analysis results show that patients who attended ED at night waited an extra 18.76 (95% CI 18.62 to 18.89) min to be seen by a clinician. They also spent an additional 13.64 (95% CI 13.47 to 13.81) min total in ED. Patients who attended at night were OR 2.20 (95% CI 2.17 to 2.23) times more likely to leave without being seen. They were also OR 1.26 (95% CI 1.25 to 1.27) times more likely to re-attend the ED and were OR 1.20 (95% CI 1.19 to 1.21) times more likely to present with non-urgent conditions. Overnight patients were more likely to be admitted to hospital, OR 1.09 (95% CI 1.09 to 1.10) times, however, those admitted were more likely to have a short-stay admission.

Conclusion

There is an ‘overnight effect’ of patients attending EDs. Patients wait longer, leave without being seen, attend with non-urgent problems and are more likely to be admitted for a short stay. Further work is required to identify the potential underlying causes of these differences.

China-Africa and China-Asia Collaboration on Schistosomiasis Control: A SWOT Analysis

Schistosomiasis, a disease caused by a trematode, parasitic worm, is a worldwide public health problem. In spite of great progress with regard to morbidity control, even elimination of this infection in recent decades, there are still challenges to overcome in sub-Saharan Africa and endemic areas in Southeast Asia. Regarded as one of the most successful countries with respect to schistosomiasis control, The People's Republic of China has accumulated considerable experience and learnt important lessons in various local settings that could benefit schistosomiasis control in other endemic countries. Based on an analysis of conceived strengths, weaknesses, opportunities and threats (SWOT) of potential collaborative activities with regard to schistosomiasis in Africa and Asia, this article addresses the importance of collaborative efforts and explores the priorities that would be expected to facilitate the transfer of Chinese experience to low- and middle-income countries in Africa and Asia.

Least-squares fitting with errors in the response and predictor

Least squares regression is commonly used in metrology for calibration and estimation. In regression relating a response y to a predictor x, the predictor x is often measured with error that is ignored in analysis. Practitioners wondering how to proceed when x has non-negligible error face a daunting literature, with a wide range of notation, assumptions, and approaches. For the model ytrue = β0 + β1   xtrue, we provide simple expressions for errors in predictors (EIP) estimators β̂0, EIP for β0 and β̂1, EIP for β1 and for an approximation to covariance (β̂0, EIP, β̂1, EIP). It is assumed that there are measured data x = xtrue + ex, and y = ytrue + ey with errors ex in x and ey in y and the variances of the errors ex and ey are allowed to depend on xtrue and ytrue, respectively. This paper also investigates the accuracy of the estimated cov(β̂0, EIP, β̂1, EIP) and provides a numerical Bayesian alternative using Markov Chain Monte Carlo, which is recommended particularly for small sample sizes where the approximate expression is shown to have lower accuracy than desired.

Do delays between diagnosis and surgery in resectable oesophageal cancer affect survival? A study based on West Midlands cancer registration data

This retrospective study investigates if delays between the diagnosis of cancer of the oesophagus and surgical resection influence long-term survival. Data held by the West Midlands Cancer Intelligence Unit on 800 patients who underwent oesophagectomy for a diagnosis of cancer of the oesophagus or oesophagogastric junction between 1995 and 2000 were reviewed. Six hundred and thirty-two patients treated with curative intention and who had not received neo-adjuvant treatment in the form of radio- or chemotherapy were included in the analysis. The time interval between histological diagnosis and surgical resection was stratified into four groups: less than 3, 3–6, 6–9 and more than 9 weeks. The Cox proportional hazard model was used to test for the independent effect of delays. The results showed no difference in long-term survival according to the delay between histological diagnosis and surgical resection. On multivariate analysis adverse prognostic factors were advanced age, incomplete resection and lymph node involvement. Patients with a longer delay had a higher rate of complete tumour resection suggesting that they were more appropriately selected for the surgical treatment approach. In conclusion we have found no evidence that shorter delays from the date of histological diagnosis to surgical resection are beneficial to long-term survival.

Miltefosine: issues to be addressed in the future

Future issues that need to be addressed for miltefosine are efficacy against non-Indian visceral leishmaniasis, efficacy in HIV-coinfected patients, efficacy against the many forms of cutaneous and mucosal disease, effectiveness under clinical practice conditions, generation of drug resistance and the need to provide a second antileishmanial agent to protect against this disastrous event, and the ability to maintain reproductive contraceptive practices under routine clinical conditions.

Uncertainty in rate loss corrections based on counting a periodic pulser

Tomographic gamma scanning of waste produces three-dimensional transmission and emission images. These are used to derive item-specific attenuation correction factors that improve the accuracy of non-destructive waste assay. For each vertical layer, data grabs of short duration are acquired as the waste item is rotated and translated. The image reconstruction demands accurate rate loss corrections to minimize assay bias. For this application a pulser was used to perform the necessary rate loss corrections. In this work, we summarize the benefits of the pulser approach and review the basic principles on which the method is based. We extend the treatment to include a derivation of the expression for the uncertainty in the net pulser peak area in the presence of an underlying continuum. We report experimental results, taken using a Canberra model WM2900 Tomographic Gamma Scanner, over a broad range of count-rates and peak-to-continuum ratios. Repeat counts under controlled conditions allowed the correction factor and its variance to be determined and compared against expectations. These results confirm the validity of the correction factor formula and the corresponding expression for its uncertainty. The rate loss analysis has been built into a Monte Carlo Replicate engine to allow the uncertainty to be propagated into the total measurement uncertainty of the final assay.

The on-line characterization of a radium slurry by gamma-ray spectrometry

We have developed an in-line monitor to directly measure the (226)Ra concentration in a nuclear waste stream using quantitative gamma-ray spectrometry applied to the 186keV emission. The waste stream is in the form of a slurry composed of the solid waste material mixed with water. The concentration measurement includes a self-attenuation correction factor determined from a transmission measurement using the 122keV gamma from (57)Co. Presented here is the model for the measurement system and results from some initial tests.

Mast cells at the host-pathogen interface: host-protection versus immune evasion in leishmaniasis

Infection of a susceptible host with Leishmania, a protozoan parasite, causes the disease leishmaniasis, which is characterized by neutrophil, eosinophil, macrophage, lymphocyte and mast cell infiltration into the infected tissue followed by parasite growth. Although the roles played by other cells in leishmaniasis are known, the role of mast cells remains to be ascertained. Here, we demonstrate that Leishmania regulates mast cell infiltration to the site of infection, mast cell production and mast cell function resulting in differential growth of the parasite in resistant (C57BL/6 or CBA/T6T6) and susceptible (BALB/c) macrophages. An interleukin-3-dependent augmentation in mast cell committed progenitors is observed in BALB/c but not in C57BL/6 mice during Leishmania infection. The mast cell supernatants inhibit IFN-gamma-dependent restriction of Leishmania growth in macrophages in BALB/c mice whereas the reverse phenomenon occurs in C57BL/6 mice. Our data reveals a different facet of host-pathogen interaction.

The measurement of U, Th and K concentrations in building materials

A shielded high purity germanium detector has been used to measure the abundance of U, Th and K in aggregate, sand and cement. The measurements were performed in order to demonstrate that the materials contained less than 10 ppm U and less than 20 ppm Th and were therefore suitable for the construction of a low background shielding enclosure. A particular feature of this work is the simplicity of the absolute efficiency calibration. In brief the relative U and Th contents of each sample were derived by first determining the relative detection efficiency curve for each sample using the known relative gamma-ray emission probabilities of the U- and Th-decay series lines from the radionuclides naturally present. To obtain the true activities, the relative efficiency curves for each sample were scaled so that they passed through the absolute efficiency value measurement at 1461 keV using a sample containing KCl bought as an analytical reagent and requiring no special radiological handling precautions. A small experimentally estimated correction was applied for the difference in self absorption between the KCl and building materials due to the differences in material density. The 40K content of the unknown samples was obtained directly from the density adjusted KCl calibration. The measurements are believed to be accurate to approximately +/- 5% absolute.

In vitro antitrypanosomal activity of Moringa stenopetala leaves and roots

The leaves and the root extracts of Moringa stenopetala were tested in vitro against trypomastigotes of Trypanosoma brucei, Trypanosoma cruzi and L. donovani amastigotes. The fresh root wood ethanol extract and the dried leaves acetone extract were found to be active against T. brucei with an ED(50) value of 9.2 microg/mL and 10.0 microg/mL respectively. All the other extracts were inactive against all the tested parasite forms.

SPECT monitoring of improved cerebral blood flow during long-term treatment of elderly patients with nootropic drugs

PURPOSE

In normal aging persons, oxygen and glucose consumption progressively decreases with reduced cerebral blood flow (CBF), which could be responsible for age-related changes in cognitive functions. A data processing model with the use of Tc-99m SPECT of the human brain has been developed and found to be sensitive for monitoring the effects of drugs that increase CBF. In this study, the effect of two vasodilator drugs (the combination of pentifylline and nicotinic acid versus piracetam) was compared with the effect of placebo on CBF.

MATERIALS AND METHODS

Thirty elderly volunteers had three different procedures using the Peelproc method to spatially standardize and compare CBF patterns by SPECT before and after drug intervention. The 30 patients were divided into five groups of six persons each who were randomly assigned in a 1:1 ratio to the treatment sequences consisting of three phases: the combination of pentifylline and nicotinic acid (C), piracetam (N), and placebo (P), or C-N-P; P-N-C; P-C-N; N-C-P; C-P-N; or N-P-C. Phases 1 to 3 each consisted of a baseline recording of parameters (day 0), treatment for 60 days (days 1 to 60), and recording of parameters after treatment (day 61).

RESULTS

In elderly human volunteers (ages, 52 to 70 years), after 2 months of oral treatment with a combination of pentifylline and nicotinic acid (800 mg pentifylline, 200 mg nicotinic acid daily), SPECT results for the Peel-proc program indicated a statistically significant improvement in CBF of the total brain, with a more pronounced improvement in the cerebellum and frontal regions, where a definite shift from abnormal to normal blood flow was detected. Spontaneous communication from most of the volunteers suggested that they experienced an improvement in memory and general well-being from the combination treatment. After 2 months of oral treatment with piracetam (2.4 g daily) in elderly human volunteers, SPECT results indicated a regional improvement in CBF, particularly in the cerebellum. However, no beneficial effects with this drug were spontaneously reported.

CONCLUSION

The in vivo method to quantitatively monitor the progress of long-term drug therapy on CBF described here could be useful to assess and even direct changes in therapy.

Targeted radiotherapy with Sm-153-EDTMP in nine cases of canine primary bone tumours

Nine dogs with primary bone tumours were treated with Samarium-153-EDTMP (Sm-153-EDTMP). Conventional treatment protocols were precluded by the size of the dogs and the owners' refusal of limb amputation. All the tumours were of the appendicular skeleton; 4 were confirmed osteosarcomas. The other 5 tumours were radiologically suspect for osteosarcoma. Bone scans were performed on all dogs using Technetium-99m-methylene diphosphonate (Tc-99m-MDP) before administration of Sm-153-EDTMP. Regions of interest were identified over the contralateral limb at the same site as the tumour and counts per pixel were recorded for the tumour and contralateral limb and expressed as a ratio. The dogs were given 1 injection of 37 MBq/kg (1 mCi/kg) of Sm-153-EDTMP intravenously. Thoracic and primary tumour site radiographs were taken at monthly or 2-monthly intervals to monitor progression of the primary tumour and search for evidence of metastasis. Two dogs showed no response to treatment, with an increase in bone pain, and were euthanased within 1 month. In 1 dog, a tumour of the scapula underwent complete involution and the dog is considered free of disease at 20 months post Sm-153-EDTMP treatment. The overall tumourcidal effect of a single dose of Sm-153-EDTMP on primary bone tumours was difficult to evaluate in this group of dogs, as, with one exception, all the primary tumours progressed over time and the dogs were euthanased. Pain control, for which Sm-155-EDTMP is used in man, was not evident, except in the dog that responded completely to treatment.

Characterisation of protein isoprenylation in procyclic form Trypanosoma brucei

Protein modification by isoprenylation is essential in mammals and other eukaryotes, but has not been demonstrated in the parasitic protozoa of the order kinetoplastida. A key regulatory enzyme of the mevalonate pathway, hydroxymethylglutaryl-coenzyme A reductase (HMG-R), and end products of the path, including dolichols, are present in Trypanosoma brucei. By metabolical labelling of procyclic form trypanosomes in the presence of compactin, an efficient inhibitor of HMG-R, followed by one-dimensional gel electrophoresis, we demonstrate that protein isoprenylation indeed takes place in this organism and at least 14 polypeptides bear the modification. Further characterization of labelled isoprenyl groups by methyl iodide cleavage and high pressure liquid chromatography identified both the farnesyl and geranylgeranyl moieties found covalently attached to proteins in other eukaryotes. The latter moiety was more abundant, as found in mammalian systems. Prolonged incubation with compactin grossly affected cell morphology and altered a number of subcellular structures as seen by electron microscopy. High concentrations of compactin were toxic, whilst lower concentrations were cytostatic. The primary morphological lesion is distinct from that of synvinolin, another inhibitor of HMG-R. The morphological changes correlated with a complete inhibition of HMG-R activity by compactin. Surprisingly there was a complete lack of HMG-R activity in procyclic cells grown for 1 or several days in 100 microM compactin, suggesting that degradation of the enzyme had occurred and compensatory upregulation mechanisms could not be successfully exploited by the parasite to overcome HMG-R inhibition. Subsequent alterations to the overall cell shape are seen after 3 days of compactin exposure. Overall these data indicate that T. brucei has an essential protein isoprenylation pathway that is conserved with the higher eukaryotes. Additionally, products of the MVA pathway are implicated in maintenance of cell architecture.

A vaccine conjugate of 'ISCAR' immunocarrier and peptide epitopes of the E7 cervical cancer-associated protein of human papillomavirus type 16 elicits specific Th1- and Th2-type responses in immunized mice in the absence of oil-based adjuvants

TraT protein, known as ISCAR (= Immunostimulatory Carrier), is one of a family of integral membrane proteins (Imps) of Escherichia coli representing powerful carrier molecules which when injected into experimental animals generate substantial antibody and T proliferative responses to molecules conjugated to it. We extend these findings to show that ISCAR functions to stimulate Th1- and Th2-type responses, including specific cytotoxic T cells and tumour protection. We report here that by conjugating to ISCAR a 19mer peptide containing linear B epitopes, a T helper (Th) epitope, and a H-2b-restricted T cytotoxic (CTL) epitope of E7 protein of human papillomavirus type 16 (HPV16), and immunizing C57B1/6 (H-2b) mice, we elicited (i) specific IgG2a and IgG1 antibodies; (ii) IL-2 and IL-4 production by specifically recalled lymph node cells in vitro; (iii) cytotoxic T lymphocytes which specifically killed both E7 peptide-pulsed, and whole E7 gene-transfected tumour target cells; and (iv) in vivo protection against an E7 gene-transfected tumour cell inoculum. These findings have implications for the design of vaccines to stimulate immune responses to endogenously processed target antigens (e.g. tumour-associated antigens) without the unwanted side effects of oil-based adjuvants. In addition they support the case for a E7-targeted therapeutic vaccine for HPV-associated human cervical cancer.

Augmentation of HIV-specific lymphoproliferation in HIV-infected individuals by TraT: a novel T-cell immunopotentiating agent

OBJECTIVE

To evaluate the potential of TraT to restore HIV-specific cell-mediated immunity.

DESIGN

CD4+ T cell-associated antiviral and recall antigen-specific lymphoproliferative responses are generally impaired or absent in HIV-infected individuals.

METHODS

Using peripheral blood mononuclear cells (PBMC) from a group of asymptomatic and symptomatic HIV-infected individuals, we compared the immunomodulatory effects of exogenous interleukin-2 (IL-2) with the effects elicited by the bacterial integral membrane protein, TraT.

RESULTS

Exogenous IL-2 enhanced lymphoproliferation induced by an immunodominant synthetic HIV gp41 analogue, gp41[8] (amino acids 593-604), in four out of 10 asymptomatics and six out of 19 symptomatics. In contrast, TraT acted synergistically with gp41[8] to augment HIV-specific proliferation with higher frequency and greater magnitude than exogenous IL-2. Moreover, this TraT-mediated enhancement of HIV-specific lymphoproliferation occurred in the majority of HIV-infected individuals, irrespective of CD4+ T-cell count in peripheral blood or disease status, and thus appears not to be major histocompatibility complex-restricted. TraT also augmented lymphoproliferation induced by well-known recall antigens and other less immunodominant HIV analogues.

CONCLUSIONS

These findings suggest that TraT, in combination with HIV-derived peptides, could be used to maintain or restore cell-mediated immune functions of HIV-infected individuals, as well as cellular immune functions in individuals suffering from other immunodeficiency disorders.

An E.S.R. investigation of the reactive intermediate generated in the reaction between FeII and H2O2 in aqueous solution. Direct evidence for the formation of the hydroxyl radical

The technique of E.S.R. spectroscopy, when employed in conjunction with a continuous flow system, provides direct evidence for the nature of free radicals formed from organic substrates in the presence of FeII and H2O2 in aqueous solution. It is shown, both via the identification of hydroxyl-radical adducts to alkenes and via the observed site-selectivity of radical attack, that the hydroxyl radical is formed as the reactive intermediate in the presence of various chelators (e.g. EDTA, DTPA). This approach also allows the rate constants for the FeII-H2O2 reaction in the presence of the different chelates to be determined; values obtained are in reasonable agreement with most of those measured by other methods. Examples of radical oxidation (by FeIII) and reduction (by FeII) are revealed.

TraT: a powerful carrier molecule for the stimulation of immune responses to protein and peptide antigens

A number of integral membrane proteins (Imps) isolated from Escherichia coli have been examined for their ability to generate serum antibody responses in the absence of adjuvant. These proteins were found to stimulate high titers of serum antibody when injected into rabbits or mice in saline. The antibody titers elicited were not significantly increased by the addition of a powerful adjuvant such as IFA. Covalent conjugation of BSA, of the DNP group, and of a peptide Ag from Plasmodium falciparum to these protein carriers resulted in a significant enhancement of the immune response to the conjugated material in comparison with the response elicited when the immunogen was injected without adjuvant or was not conjugated to Imps. The antibody response to these conjugates could not be significantly increased by the addition of IFA. Thus, the Imps of E. coli represent powerful carrier molecules which, when injected into mice and rabbits, are not only capable of generating high titers of antibody to themselves, but also to molecules conjugated to them. Immunization with immunogens coupled to these proteins results in the production of high titers of antibody without the need for oil-based adjuvants, thereby avoiding the unwanted side effects of such adjuvants.

TraT: a powerful carrier molecule for the stimulation of immune responses to protein and peptide antigens

A number of integral membrane proteins (Imps) isolated from Escherichia coli have been examined for their ability to generate serum antibody responses in the absence of adjuvant. These proteins were found to stimulate high titers of serum antibody when injected into rabbits or mice in saline. The antibody titers elicited were not significantly increased by the addition of a powerful adjuvant such as IFA. Covalent conjugation of BSA, of the DNP group, and of a peptide Ag from Plasmodium falciparum to these protein carriers resulted in a significant enhancement of the immune response to the conjugated material in comparison with the response elicited when the immunogen was injected without adjuvant or was not conjugated to Imps. The antibody response to these conjugates could not be significantly increased by the addition of IFA. Thus, the Imps of E. coli represent powerful carrier molecules which, when injected into mice and rabbits, are not only capable of generating high titers of antibody to themselves, but also to molecules conjugated to them. Immunization with immunogens coupled to these proteins results in the production of high titers of antibody without the need for oil-based adjuvants, thereby avoiding the unwanted side effects of such adjuvants.

A comparison of methods of dietary assessment in Australian children aged 11-12 years

A total of 225 children attending year 7 classes in state primary schools in Perth, Australia, participated in the study. Nutrient intakes were determined by a number of low-intensity methods and compared with intakes determined by a reference method based on 14 24-h diet records collected over several months and covering each day of the week twice. The low-intensity methods were (i) a food frequency questionnaire (FFQ) administered to the children in school, (ii) the same FFQ administered to the children's parents by post and (iii) a small number (one, two or three) of 24-h diet records completed by the children. The FFQ included 175 food items, the time frame was 'during the previous week' and information on size of servings was not requested. The results indicated poor agreement between the reference method and the FFQ methods. In contrast, agreement between the reference method and methods based on two or three diet records in the series was relatively good.

Localization and immunogenicity of tubulin in the filarial nematodes Brugia malayi and B. pahangi

Tubulin was identified in the filarial nematodes Brugia malayi and B. pahangi by several approaches. Initially, a monoclonal antibody (6D8) was selected for its unusual binding to B. malayi microfilariae in indirect immunofluorescence assays: 6D8 showed granular, heterogeneously dispersed fluorescence on fixed parasites but did not bind to unfixed microfilariae. The microfilarial sheath did not bind 6D8, although it did bind fluoresceinated wheatgerm agglutinin. By Western blotting against microfilarial sonicate, 6D8 reacted with a 50,000-55,000 mol. wt protein, and also bound to purified chicken brain beta-tubulin. Additionally, this monoclonal antibody reacted with a recombinant fusion protein expressed by a clone (Bpa-7) originally isolated from an adult B. pahangi cDNA expression library by its reaction with chronic human filariasis serum. This clone encodes a small 40 amino acid C-terminal segment corresponding to residues 409-449 of beta-tubulin, and shows complete amino acid sequence homology with vertebrate beta-tubulin from 409 to 430 but 55% divergence (six amino acid substitutions, four insertions and one deletion) from human and chicken beta-tubulin over positions 431-449 at the C terminus. Antibody to both parasite and vertebrate (chicken) tubulin was found in filarial infection sera, with higher levels of autoreactive antibody apparent in amicrofilaraemic individuals. Immunogold electron microscopy was then used to localize beta-tubulin in B. malayi microfilariae and adult worms. Tubulin was shown not to be exposed on the microfilarial sheath or in the cuticle of either stage, but was found to be abundant in the somatic tissues. In microfilariae, 6D8 bound myofibril structures under the hypodermal layer, and also bound within cell nuclei. In the adult stage, tubulin was associated with muscle blocks, as well as the intestinal brush border and the embryonic uterine microfilariae.