Project SATURN- a real-world evidence data collaboration with existing European datasets in Osteogenesis Imperfecta to support future therapies

Regulatory marketing authorisation is not enough to ensure patient access to new medicinal products. Health Technology Assessment bodies may require data on effectiveness, relative effectiveness, and cost-effectiveness. Healthcare systems may require data on clinical utility, savings, and budget impact. Furthermore, the exact requirements of these bodies vary country by country and sometimes even region to region, resulting in a patchwork of different data requirements to achieve effective, reimbursed patient access to new therapies. In addition, clinicians require data to make informed clinical management decisions. This requirement is of key importance in rare diseases where there is often limited data and clinical experience at the time of regulatory approval.This paper describes an innovative initiative that is called Project SATURN: Systematic Accumulation of Treatment practices and Utilization, Real world evidence, and Natural history data for the rare disease Osteogenesis Imperfecta. The objective of this project is to generate a common core dataset by utilising existing data sources to meet the needs of the various stakeholders and avoiding fragmentation through multiple approaches (e.g., a series of individual national requests/approaches, and unconnected with the regulators' potential requirements). It is expected that such an approach will reduce the time for patient access to life-changing medications. Whilst Project SATURN applies to Osteogenesis Imperfecta, it is anticipated that the principles could also be applied to other rare diseases and reduce the time for patient access to new medications.

Osimertinib and anti-HER3 combination therapy engages immune dependent tumor toxicity via STING activation in trans

Over the past decade, immunotherapy delivered novel treatments for many cancer types. However, lung cancer still leads cancer mortality, and non-small-cell lung carcinoma patients with mutant EGFR cannot benefit from checkpoint inhibitors due to toxicity, relying only on palliative chemotherapy and the third-generation tyrosine kinase inhibitor (TKI) osimertinib. This new drug extends lifespan by 9-months vs. second-generation TKIs, but unfortunately, cancers relapse due to resistance mechanisms and the lack of antitumor immune responses. Here we explored the combination of osimertinib with anti-HER3 monoclonal antibodies and observed that the immune system contributed to eliminate tumor cells in mice and co-culture experiments using bone marrow-derived macrophages and human PBMCs. Osimertinib led to apoptosis of tumors but simultaneously, it triggered inositol-requiring-enzyme (IRE1α)-dependent HER3 upregulation, increased macrophage infiltration, and activated cGAS in cancer cells to produce cGAMP (detected by a lentivirally transduced STING activity biosensor), transactivating STING in macrophages. We sought to target osimertinib-induced HER3 upregulation with monoclonal antibodies, which engaged Fc receptor-dependent tumor elimination by macrophages, and STING agonists enhanced macrophage-mediated tumor elimination further. Thus, by engaging a tumor non-autonomous mechanism involving cGAS-STING and innate immunity, the combination of osimertinib and anti-HER3 antibodies could improve the limited therapeutic and stratification options for advanced stage lung cancer patients with mutant EGFR.

A comparison of standard two-dimensional ultrasound to three-dimensional volume sonography for routine second-trimester fetal imaging

OBJECTIVE

In comparison with standard two-dimensional (2D) imaging of fetal structure and biometry, we aimed to evaluate the role of three-dimensional (3D) imaging as a screening tool in the mid-trimester.

STUDY DESIGN

Pregnant women presenting between 18and 22 weeks for routine anatomical survey and biometric measurements were recruited. Six volumes of fetal anatomic regions were obtained and archived for later reconstruction, along with three volumes of extra-fetal structures (placenta, cervix, amniotic fluid). The 2D standard fetal images were then obtained. Offline reconstruction of 3D volumes was performed for comparative analysis (2D vs 3D). Subsequently, 3D volumes were reconstructed to mirror traditional 2D and allow biometric comparison between the two techniques. Data of 98 patients were analyzed.

RESULTS

Complete visualization of vital anatomic structures was seen ⩾85% of the time with 3D ultrasound. The 3D imaging improved the assessment of the four heart chambers (P=0.003), thoracic spine (P=0.008) and lumbar spine (P=0.012) views. The 2D imaging was superior for the fetal head, placenta and upper limbs. Conditional probabilities were used to assess the clinical value of 3D when standard 2D views were incomplete (mean 0.8830; 95% confidence interval 0.8059 to 0.9320). Overall diagnostic accuracy of 3D ultrasound is not superior for all fetal anatomic structures. Fetal biometric measurements assessed by both techniques demonstrated substantial to excellent agreement.

CONCLUSION

The use of 3D imaging as a primary screening tool is limited and may be best utilized as a second-stage test. Overall, there is good correlation between fetal biometry assessed by either 2D or 3D technology.

Long-term treatment with oral N-acetylcysteine: affects lung function but not sputum inflammation in cystic fibrosis subjects. A phase II randomized placebo-controlled trial

PURPOSE

To evaluate the effects of oral N-acetylcysteine (NAC), which replenishes systemic glutathione, on decreasing inflammation and improving lung function in CF airways.

METHODS

A multicenter, randomized, double-blind proof of concept study in which 70 CF subjects received NAC or placebo orally thrice daily for 24 weeks.

ENDPOINTS

primary, change in sputum human neutrophil elastase (HNE) activity; secondary, FEV(1) and other clinical lung function measures; and safety, the safety and tolerability of NAC and the potential of NAC to promote pulmonary hypertension in subjects with CF.

RESULTS

Lung function (FEV(1) and FEF(25-75%)) remained stable or increased slightly in the NAC group but decreased in the placebo group (p=0.02 and 0.02). Log(10) HNE activity remained equal between cohorts (difference 0.21, 95% CI -0.07 to 0.48, p=0.14).

CONCLUSIONS

NAC recipients maintained their lung function while placebo recipients declined (24 week FEV1 treatment effect=150 mL, p<0.02). However no effect on HNE activity and other selected biomarkers of neutrophilic inflammation were detected. Further studies on mechanism and clinical outcomes are warranted.

Antibodies to 70 kD and 90 kD heat shock proteins are associated with graft-versus-host disease in peripheral blood stem cell transplant recipients

The development of graft-versus-host disease (GVHD) can be modified by non-MHC factors. Based on our previous studies that showed an involvement of 70kD heat shock protein (hsp70) in the pathology of acute GVHD in a rat model, we determined serum levels of antibodies to hsp70, hsp90 and hsp60 in human recipients after allogeneic peripheral blood stem cell transplantation (PBSCT). Serum levels of these antibodies were correlated with GVHD status in the recipients. Twenty-nine recipients with high-risk haematological malignances, who received G-CSF mobilized allogeneic PBSCT from HLA matched family donors, were evaluated between 30 and 960 days after transplantation. Two recipients had no GVHD, 18 developed acute followed by chronic GVHD and nine developed only chronic GVHD. Patients with acute GVHD had a significant increase in IgM anti-hsp70 and/or anti-hsp90 early (30-90 days) after transplantation. In addition, an increase in IgM anti-hsp70 and/or anti-hsp90 antibodies preceded or accompanied chronic GVHD. Antibody levels returned to normal within the next 400 days in the majority of patients. Anti-hsp60 antibody levels were not different from control levels regardless of GVHD status. This study implies that the development of acute and/or chronic GVHD in humans is accompanied by an increase in anti-hsp70 and anti-hsp90 antibodies. Monitoring levels of anti-hsp70 and anti-hsp90 antibodies in stem cell transplant recipients may serve as a diagnostic tool and help to predict the onset of GVHD.

Comparison of oral and intravenous morphine following acute injury in children

The objective of this research was to examine the speed of onset and effectiveness of pain relief between oral and intravenous morphine in acutely injured children. An observational study of children aged 3 to 13 years with closed forearm fractures was performed in three accident and emergency departments. The study gathered information on age, gender, body weight, time of arrival, dose, route and time of morphine administration. Pain assessment using a Faces Scale was documented on arrival and repeated at 10, 30 and 60 minutes after morphine was given. Forty-seven children were studied. Of these, 25 were given intravenous morphine, 22 were given oral morphine. There was no statistically significant difference in age, body weight or time until morphine was administered. The change in median pain scores was analysed using the Mann-Whitney U test. This showed that there was a statistically significant reduction in pain score in the intravenous group compared with the oral group between arrival and 10 minutes after giving morphine and between arrival and 60 minutes after giving morphine. Intravenous morphine appears to give more rapid onset and more prolonged pain relief than oral morphine for children with acute injuries. We recommend that in accident and emergency departments where staff are experienced in paediatric cannulation, morphine should be given via the intravenous route in acutely injured children. However we do not advocate inexperienced staff attempting multiple venepunctures in a child resulting in increased anxiety.

The biosciences and fitness for practice: a time for review?

The learning of biosciences by preregistration students has been recognized as being problematic, and the need for better resourcing of education has been identified. The Project 2000 initiative (UKCC, 1988) expanded the breadth and dept of the curriculum content in order to support the delivery of holistic care, and so the resources for bioscience education seemed likely to remain limited. However, the UKCC has concluded that there has been a shortfall in the acquisition of practice skills by preregistration students (UKCC, 2001). To address this, new directives indicate that curricula should move to competency-based outcomes and use student-focused learning. However, there is a lack of clarity as to what the basic expectation is for bioscience learning at registration, and how this might be continued in postregistration programmes. The authors argue that if resources for bioscience teaching in preregistration curricula cannot be improved then it is time to review the situation to ensure that expectations are realistic and attainable. Criteria are required to establish exactly what life-long learning means in relation to the biosciences, from registration through to specialist practice.

Induction of the progesterone receptor gene in estrogen target cells monitored by branched DNA signal amplification

Estrogens have multiple effects on the growth and development of cells in their target tissues, including the uterus, ovary, breast, bone marrow and brain. The hormone regulates the transcription of diverse genes in these tissues via the estrogen receptor, a nuclear transcription factor. Naturally occurring estrogens and estrogen analogs including selective estrogen receptor modulators (SERMs), constitute important therapies for breast cancer and osteoporosis, and are major components of oral contraceptives. The in vitro biologic activities of pharmaceutical estrogen agonists and antagonists have frequently been monitored by cotransfection assay, where exogenous estrogen receptor and reporter genes are transiently inserted into a heterologous, non receptor-containing cell line, such as those derived from kidney cells. Here we describe an alternative to this method, where induction of an endogenous estrogen-responsive gene, the progesterone receptor gene, is monitored by branched DNA signal amplification. Assays are performed with cultured cells derived from estrogen-responsive tissues; namely, breast, uterine endothelium and bone. Hormonal induction occurs via the endogenous estrogen receptor of these cells. Our data show that SERMs, which are estrogen agonists on bone in vivo, antagonize estrogen-dependent target gene induction in conditionally immortalized osteoblast-like cells.

Know your heart

In this article in our Concepts in Anatomy series, Mriga Williams joins John Clancy and Andrew McVicar in an examination of the heart, identifying and describing its component parts, its relationship to the circulatory system and some of the abnormalities it might develop. The article includes a range of activities readers may carry out to test and improve their knowledge. The series is based on the text by John Clancy and Andrew McVicar, Physiology and Anatomy--a homeostatic approach, Arnold, London (in print September 2001).

Latex allergy within the perioperative area

Latex allergy is a subject which is causing concern both amongst healthcare workers and in the Department of Health, with reports that significant numbers of NHS staff may have latex hypersensitivity. With this informative article, Janet Cox joins John Clancy and Andrew McVicar to explain the mechanisms that underlie latex hypersensitivity and to make recommendations about how hospitals can deal more effectively with it. The article is based on the text, Physiology and Anatomy, a homeostatic approach, 2nd ed, John Clancy and Andrew McVicar, Arnold, London (in print September 2001).

Gastroentological investigations

In this fourth article in the Concepts in Anatomy series, Anne-Marie Ramsay joins John Clancy and Andrew McVicar in examining the upper and lower gastrointestinal tract and identifies some common homeostatic imbalances. Diagnostic tests for detecting abnormalities are described, highlighting the importance of the nurse's role in caring for the patient throughout these procedures. This series is based on Physiology and Anatomy, a homeostatic approach, 2nd ed, John Clancy and Andrew McVicar (eds), Edward Arnold, London, 1995, currently in print.

The surgical neonate

This is the third article in the Concepts in Anatomy series, based on Physiology and Anatomy, a homeostatic approach, by John Clancy and Andrew McVicar. In this article, Stevie Boyd discusses some of the problems encountered in neonatal surgery.

Getting it right? An exploration of issues relating to the biological sciences in nurse education and nursing practice

Concerns have been expressed that bioscience education is not meeting the needs of nursing students in the UK. This paper explores the situation further by comparing student perceptions with those of experienced practitioners (Part One of the study) and also evaluates the confidence of staff nurses in explaining the rationale for care applied to a common but specific disorder (influenza; Part Two). Questionnaires were used. Responses were elicited from DipHE Nursing (Project 2000) adult/child branch students (n=153) from two universities and from adult/child care staff from their local clinical placements (n=171 in Part One of study; n=266 in Part Two). The questions asked followed two themes: (1) confidence in understanding biological science and (2) issues of teaching and learning. Most questions utilized a rating scale from 1 to 10; this scale provides no central value and a vertical line was drawn to encourage respondents to identify which half of the scale their responses came under (basically, a negative or positive viewpoint). The significance of the data distribution either side of the midline was analysed statistically (simple sign test), as were any differences in distribution between the groups (chi-square test). Median values were also determined. The data do not provide support for views that the biosciences are being significantly diminished by modern curricula, but also show no evidence for a great improvement in the bioscience knowledge base in recent years. What was surprising was the lack of confidence expressed by staff nurses: one illuminating finding was the lack of confidence in articulating their knowledge to patients and, even less so, to other health professionals. The paper reiterates a need for a national teaching and learning strategy for pre- and postregistration education in the biosciences. In particular, a means to raise the level of understanding of staff nurses must be identified urgently so that the mentoring of students in these subjects is improved.

The musculo-skeletal system. The spine

This is the second of a series of articles based on Physiology and Anatomy, a homeostatic approach by John Clancy and Andrew McVicar. This article looks at the musculo-skeletal system, with particular emphasis on the spine. It identifies spinal deformities, injuries and maladies, and various types of surgical intervention.

From the outside looking in. The surgical approach

This series of articles will draw on Physiology and Anatomy, a homeostatic approach (hereafter referred to as 'the reader'), written by John Clancy and Andrew McVicar. There will also be cross-references to the series of articles entitled 'Homeostasis--the key concept to physiological control' published in the British Journal of Theatre Nursing 1996-98. The articles will include some activities which the readers can carry out to test their understanding and deepen their knowledge base of the anatomy explored in each article. The introductory article will cover the common anatomical structures involved in the 'surgical approach', looking first at the anatomy and then relating it to surgical practice. Homeostasis is the key underlying principle to which the surgical practice will refer.

Reduced levels of Hsp70 result in a therapeutic effect of 15-deoxyspergualin on acute graft-versus-host disease in (DA x LEW)F1 rats

We have shown previously that increased levels of hsp70, and antibodies reactive with hsp70 parallel the onset and severity of graft-versus-host disease (GVHD) in a parent --> (DA x LEW)F1 rat model. In this study we have assessed the effect of reducing the levels of the 70 kDa heat shock protein (hsp70), on the morbidity and mortality of acute GVHD in (DA x LEW)F1 rats. The reduction was accomplished by the administration of 15-deoxyspergualin (DSG), an immunosuppressive agent which binds to a constitutively expressed member of the 70 kDa heat shock protein family. DSG administered via three different protocols reduced GVHD-associated morbidity. One of the regimens, which consisted of intermittent DSG administration, also significantly reduced GVHD associated mortality. This DSG treatment reduced hsp70 levels in spleen and lymph nodes, inhibited anti-hsp70 antibody production, and diminished the serum levels of IL-2, IFN-gamma, TNF-alpha, and IL-10. IL-4 levels in the serum did not change during GVHD and were not effected by DSG. These results show that the mechanism of DSG immunosuppressive effect in rat GVHD may involve DSG's capacity to bind to hsp70, which in turn may lead to a decrease in levels of circulating anti-hsp70 antibodies, and reduced production of cytokines.

Rabbit corpus cavernosum smooth muscle shows a different phosphodiesterase profile than human corpus cavernosum

PURPOSE

Cyclic nucleotide phosphodiesterases (PDEs) are important regulators of cAMP/cGMP secondary messenger systems. Fluctuations in the level of cyclic nucleotides control the smooth muscle tone of corpus cavernosum. It had been shown that milrinone, a PDE3 inhibitor, was as potent as sildenafil, a PDE5 inhibitor, in relaxing human corpus cavernosum. However, milrinone is much less effective in relaxing rabbit corpus cavernosum than sildenafil. PDEs in rabbit corpus cavernosum were characterized and organ bath experiments were carried out in an attempt to search for the biochemical basis of this species difference.

MATERIALS AND METHODS

In a biochemical study, PDE isozymes from rabbit corpus cavernosum were isolated by FPLC and characterized by PDE assay. In organ bath experiments, rabbit corpus cavernous tissue strips were precontracted and increasing doses of various inhibitors were added.

RESULTS

The major PDE in rabbit corpus cavernosum is PDE5. There are small amounts of PDE2 and PDE1. PDE3, which contributes significantly to the total PDE activity in human corpus cavernosum, is apparently lacking in rabbit corpus cavernosum. Organ bath experiments with isotype-specific inhibitors confirm this conclusion.

CONCLUSION

The distribution of PDE isozymes in corpus cavernosum is different in human and in rabbit. This could be the biochemical basis for the differential effects of milrinone in relaxing rabbit and human corpus cavernosum. Our study emphasizes the importance of a more complete understanding of the tissue distribution of targeted proteins in an animal model before applying the results to humans.

hsp70, hsp32, and grp78 are increased in thermally injured skin with and without antithrombin(human) concentrate infusion

An acquired deficiency of antithrombin (AT), an anti-inflammatory protein, develops in patients with thermal injuries. Skin thermotolerance is regulated by heat shock protein (hsp) genes. hsp70, hsp32, hsp27, and glucose-regulated protein78 (grp78) were studied in burned and unburned human skin to determine whether correction of the AT deficiency modulated the intensity of expression of these proteins. Fifty-four human skin samples were prepared by Western blot analysis: 11 unburned and 22 burned control skin samples and 7 unburned and 14 burned skin samples from patients treated with AT(Human), or AT(H). The intensity of hsp32 expression in burned AT(H)-treated skin (P < .001) and in burned control skin (P < .01) was significantly increased compared with unburned control skin. The intensity of expression of hsp70 was statistically significant in burned AT(H)-treated skin compared with unburned control skin (P < .02), as was that of grp78 (P < .01). Thermally injured skin with or without AT(H) treatment had an increased expression of hsp70, hsp32, and grp78 compared with unburned control skin.

An ultrahigh-throughput screening assay for estrogen receptor ligands

Members of the steroid and thyroid hormone receptor superfamily (nuclear receptors) play diverse roles in mammalian physiology, in both normal and pathological states. For this reason, and because nuclear receptors are natural receptors for lipophilic small molecules, they are important therapeutic targets for the pharmaceutical industry. Here we describe a method for screening for ligands for one of these receptors, the estrogen receptor. The method is rapid, robust, and reliable, and has been used in an ultrahigh-throughput robotic screen. The receptor is crosslinked to a scintillant-containing solid support (FlashPlate) via a receptor-specific antibody. Test compounds are assayed for competition with a radiolabeled estrogen for binding to the immobilized receptor. Receptor-ligand complexes are allowed to form and receptor-bound radioactivity is detected in a scintillation counter. The assay has been designed for both isoforms of the estrogen receptor, alpha and beta, using separate antibodies for each. Given a radioactive tracer and an appropriate antibody, many of which are now commercially available, the assay could be established for any nuclear receptor.

Barmah Forest virus epidemic on the south coast of New South Wales, Australia, 1994-1995: viruses, vectors, human cases, and environmental factors

In 1995, the largest recorded outbreak of human disease resulting from infection with the mosquito transmitted alphavirus Barmah Forest (BF) virus occurred along the south coast of New South Wales, Australia. The virus was first isolated in early January from mosquitoes collected at Batemans Bay and predisposed the recognition of 135 human clinical cases. The cases of BF virus were identified initially from Batemans Bay during late January, and the majority (30%) of all cases came from this town. After 5 wk, all major centers on the south coast had clinical patients. Aedes vigilax (Skuse) were especially abundant at Batemans Bay, with levels up to 8 times greater than normal. This species yielded 111 isolates and appeared to be the major vector of BF virus. Attempts to examine if BF virus was maintained in the field by vertical transmission within Ae. vigilax populations were unsuccessful; no evidence of vertical transmission with BF virus, nor any other arbovirus, was found in > 17,000 adults emerging from field-collected larvae from the region following peak virus activity. In addition to BF virus, other viruses were recovered from field-collected adult mosquitoes, including Ross River (10 isolates), Edge Hill (21), and Stratford (10). Ae. vigilax again yielded the majority of these viral isolates. The BF virus outbreak appeared to be associated with several factors. A lack of recent BF virus activity in the region provided a highly susceptible human population, and unusual weather conditions of above average rainfall coupled with high tides resulted in extraordinarily large populations of Ae. vigilax.

'Uncharted waters'--consolidation of two academic psychiatric services: a case study

Surviving during times of mergers and acquisitions is difficult but possible. Following is a case study of how one service managed not only to survive, but to thrive, during consolidation.

Effect of d-fenfluramine on the lymphocyte response of HIV+ humans

The objective of this study was to analyse the effect of d-dexfenfluramine (d-FEN) on the human lymphocyte response, in vitro. Experiments were designed to determine whether d-FEN augments specific human immune parameters associated with protection from opportunistic microbial pathogens and particularly focuses on d-FEN as a means by which to augment the function of CD8+ and CD4+ lymphocytes. Lymphocytes were examined for three reasons: (1) for their ability to inhibit the growth of Candida albicans; (2) for their ability to proliferate in response to a mitogen; and, (3) their cytokine profile (vis., production of IL-2, IFN-gamma and TNF-alpha). Peripheral blood mononuclear cells (PBMC) were obtained from 20 HIV+ patients. The patients were diagnosed as HIV+ within the past 0.5-9 years. d-FEN was found to augment the capacity of CD8+ lymphocytes to inhibit the growth of the opportunistic microbial pathogen, C. albicans. d-FEN enhanced the capacity of CD4+ lymphocytes to proliferate in response to the mitogen, Concanavalin A, and to increase the amount of IL-2 produced by CD4+ and CD8+ lymphocytes from AIDS patients. d-FEN increased the number of CD4+ and CD8+ lymphocytes that produced IFN-gamma from either non-AIDS or AIDS patients and increased the number of AIDS patient's CD8+ lymphocytes that produce TNF-alpha. These in vitro data suggest that d-FEN may be effective in enhancing immune function in immunocompromised individuals.

Homeostasis--the key concept to physiological control. Surgery, stress and metabolic homeostasis

In this series of articles we have illustrated how physiological processes enable adaptation to changing situations such as those associated with surgery. Homeostasis has formed the central theme for relating physiology to well being, and the articles have largely been concerned with the homeostatic regulation of specific systems or processes within the body (a list of articles in the series is provided at the end of this one). This final article maintains the theme but is concerned with the broader, whole-body responses that occur when the body is subjected to the trauma of surgery. Some of these responses have briefly been touched upon in earlier articles, but are expanded upon here to illustrate the adaptability of metabolic homeostasis when the body has been injured.

Homeostasis: a framework for integrating the life sciences

Nurse education curricula continue to emphasize the holistic nature of health and ill-health. As a concept, holism recognizes that the interactions between a person and his/her environment are significant factors in shaping the individual, and important determinants of wellbeing. Psychosocial interactions as a basis for health now figure prominently in nursing curricula. In contrast, the applied biological sciences have increasingly become marginalized, yet knowledge of the biological construct of the individual, and an understanding of how it is influenced by psychosocial interactions, are also necessary if holistic care is the aim. Nursing models attempt to reinforce holistic principles, but the integrative nature of health and illness needs to be established before their application. This article proposes that the concept of homeostasis, and its relationship to systems theory, provides a workable framework for teaching the basis of health, and so forms a foundation for the application of nursing theory and nursing models.

Expression of 70-kDa heat-shock protein during acute graft-versus-host disease

Acute lethal graft-versus-host disease (GVHD) was induced in unirradiated (LEW x DA)F1 rats by injection of DA parental lymphoid cells. Control rats received the same dose of (LEW x DA)F1 cells. The level of hsp70 at different stages of GVHD was examined in the spleen, lymph nodes, thymus, liver, lung, kidney, heart, and skeletal muscles of GVHD and control animals. Hsp70 was present in all organs analyzed in both groups and, with the exception of the spleen and lymph nodes, detectable levels remained constant during the disease. However, the spleen and lymph nodes of GVHD rats showed distinct changes in the hsp70 levels throughout the course of the disease. Expression of hsp70 in spleen and lymph nodes was augmented 7 and 14 days after induction of the disease. During the last stages of GVHD, 18-21 days after the induction, expression of hsp70 diminished to a level similar to that in untreated and control animals. Elevated levels of hsp70 in lymphoid organs during GVHD suggest an involvement of hsp70 in the pathology of the disease.

Perioperative pain management: a gate control perspective

The assessment and management of perioperative pain are critical skills for the surgical nurse, hence, the subjective nature of pain should be reflected in their approach to pain control. Unfortunately, many studies (Seers 1987, Kuhns et al 1990, Royal College of Surgeons and Royal College of Anaesthetists 1990, Closs 1992 and Field 1996) suggest that the nurse's knowledge of perioperative management is inadequate. However, as Carr (1997) reported, nurses are not the only group of health care professionals who demonstrate a lack of 'expertise' in providing analgesic relief. Carr reviewed the survey of 27 medical schools by Marcer and Deighton in 1988 which revealed that 4 schools undertook no formal teaching on pain control, and the remainder averaged only 3.5 hours during a four year course. Clearly, perioperative pain management remains a major problem! We have suggested that surgical nurses must have a sound knowledge of the neurophysiology associated with this subjective phenomenon (Clancy and McVicar 1998) since such an understanding is paramount in assisting the decision making process which underpins effective individualised perioperative pain management.

Cloning and characterization of a novel macrolide efflux gene, mreA, from Streptococcus agalactiae

A strain of Streptococcus agalactiae displayed resistance to 14-, 15-, and 16-membered macrolides. In PCR assays, total genomic DNA from this strain contained neither erm nor mef genes. EcoRI-digested genomic DNA from this strain was cloned into lambda Zap II to construct a library of S. agalactiae genomic DNA. A clone, pAES63, expressing resistance to erythromycin, azithromycin, and spiramycin in Escherichia coli was recovered. Deletion derivatives of pAES63 which defined a functional region on this clone that encoded resistance to 14- and 15-membered, but not 16-membered, macrolides were produced. Studies that determined the levels of incorporation of radiolabelled erythromycin into E. coli were consistent with the presence of a macrolide efflux determinant. This putative efflux determinant was distinct from the recently described Mef pump in Streptococcus pyogenes and Streptococcus pneumoniae and from the multicomponent MsrA pump in Staphylococcus aureus and coagulase-negative staphylococci. Its gene has been designated mreA (for macrolide resistance efflux).

Homeostasis--the key concept to physiological control

The maintenance of body water content is a classic example of homeostasis at work. Water is continuously lost and added to the systems. The regulation of a balance between the factors involved demonstrates the dynamic nature of homeostatic processes. Surgery places additional demands on such processes, partly because there are additional factors in the balance equation and partly because of the hormonal responses to trauma which also affect water balance. Promoting the return to a balance state and maintaining it, during and after surgery, is important to patient well-being and may even facilitate recovery. The risks associated with a disturbance in water balance are of potentially greater consequence if there is water overload, particularly if the patient has underlying cardiovascular or respiratory problems. Slight dehydration is probably a better target to aim for in order to reduce such risk but there are no easy ways to achieve this state as individuals will vary in their responses to surgery. The hydration, and electrolyte, needs, will vary between patients so fluid therapies should be individualised. Whilst a patient's fluid balance chart provides a means of assessing water balance, the interpretation is complicated after surgery. An awareness of other signs is therefore essential.

mefE is necessary for the erythromycin-resistant M phenotype in Streptococcus pneumoniae

Recently, it was shown that a significant number of erythromycin-resistant Streptococcus pneumoniae and Streptococcus pyogenes strains contain a determinant that mediates resistance via a putative efflux pump. The gene encoding the erythromycin-resistant determinant was cloned and sequenced from three strains of S. pneumoniae bearing the M phenotype (macrolide resistant but clindamycin and streptogramin B susceptible). The DNA sequences of mefE were nearly identical, with only 2-nucleotide differences between genes from any two strains. When the mefE sequences were compared to the mefA sequence from S. pyogenes, the two genes were found to be closely related (90% identity). Strains of S. pneumoniae were constructed to confirm that mefE is necessary to confer erythromycin resistance and to explore the substrate specificity of the pump; no substrates other than 14- and 15-membered macrolides were identified.

Chronic carbachol pretreatment decreases adenylyl cyclase activity in airway smooth muscle

In airway smooth muscle, the regulation of adenylyl cyclase, the enzyme that synthesizes adenosine 3',5'-cyclic monophosphate, is under dual regulation by G protein-coupled receptors. It is unknown if chronic activation of muscarinic receptors in airway smooth muscle alters the stimulatory adenylyl cyclase cascade to decrease airway relaxation. Bovine airway smooth muscle pretreated with carbachol for 18 h, but not for 30 min or 2 h, showed decreased adenylyl cyclase activity under basal conditions and in response to isoproterenol, prostaglandin E1, GTP, and forskolin. The quantity of beta-adrenergic receptors or of Gi alpha proteins was unaffected by carbachol pretreatment. The effect of carbachol pretreatment was blocked by the inclusion of atropine or the protein kinase C (PKC) inhibitor staurosporine. These results suggest that chronic but not acute agonist pretreatment of muscarinic receptors decreases in adenylyl cyclase stimulation at a site distal to receptors and that this effect is mediated by the chronic activation of PKC via the M3 muscarinic receptor.

Homeostasis--the key concept to physiological control

Water in the body forms the fluid compartments inside and outside cells, but it is more than just a space filler. A continuous exchange of water between the compartments partly facilitates regulation of the compartment volume but also permits the exchange of substances dissolved within it. Some of these latter are ions that form the electrolyte environment in which cells must operate. Body fluid physiology is concerned with the actions and regulation of the major electrolyte constituents. The use of infusions provides clinicians with the means of supporting this physiology when homeostatic mechanisms have failed or are insufficient to meet demands.