Contactless skin perfusion monitoring with video cameras: tracking pharmacological vasoconstriction and vasodilation using photoplethysmographic changes

Objectives.Clinical assessment of skin perfusion informs prognosis in critically ill patients. Video camera monitoring could provide an objective, continuous method to monitor skin perfusion. In this prospective, interventional study of healthy volunteers, we tested whether video camera-derived photoplethysmography imaging and colour measurements could detect drug-induced skin perfusion changes.Approach.We monitored the lower limbs of 30 volunteers using video cameras while administering phenylephrine (a vasoconstrictor) and glyceryl trinitrate (a vasodilator). We report relative pixel intensity changes from baseline, as absolute values are sensitive to environmental factors. The primary outcome was the pre- to peak- infusion green channel amplitude change in the pulsatile PPGi waveform component. Secondary outcomes were pre-to-peak changes in the photoplethysmographic imaging waveform baseline, skin colour hue and skin colour saturation.Main results.The 30 participants had a median age of 29 years (IQR 25-34), sixteen (53%) were male. A 34.7% (p= 0.0001) mean decrease in the amplitude of the pulsatile photoplethysmographic imaging waveform occurred following phenylephrine infusion. A 30.7% (p= 0.000004) mean increase occurred following glyceryl trinitrate infusion. The photoplethysmographic imaging baseline decreased with phenylephrine by 2.1% (p= 0.000 02) and increased with glyceryl trinitrate by 0.5% (p= 0.026). Skin colour hue changed in opposite direction with phenylephrine (-0.0013,p= 0.0002) and glyceryl trinitrate (+0.0006,p= 0.019). Skin colour saturation decreased with phenylephrine by 0.0022 (p= 0.0002), with no significant change observed with glyceryl trinitrate (+0.0005,p= 0.21).Significance.Drug-induced vasoconstriction and vasodilation are associated with detectable changes in photoplethysmographic imaging waveform parameters and skin hue. Our findings suggest video cameras have great potential for continuous, contactless skin perfusion monitoring.

Effects of physical activity and feed and water restriction at reimplanting time on feed intake patterns, growth performance, and carcass characteristics of finishing beef steers

In the feedlot, there can be a decrease in dry matter intake (DMI) associated with reimplanting cattle that negatively affects growth performance. This study was conducted to determine the mechanisms causing a decrease in DMI after reimplanting and identify a strategy to mitigate the decrease. Crossbred steers (n = 200; 10 pens/treatment; initial bodyweight [BW] = 386 ± 4.9 kg) were used in a randomized complete block design experiment. Cattle were implanted with Revalor-IS on day 0. Treatments included a Revalor-200 implant on day 90 before feeding with the following management practices imposed: 1) steers were returned to their home pen immediately after reimplant (PCON); 2) steers were placed in pens and restricted from feed and water for 4 h (RES); 3) steers were walked an additional 805 m after reimplant and then returned home (LOC); 4) steers were restricted from feed and water for 4 h and walked an additional 805 m (RES + LOC); 5) steers were given an oral bolus of Megasphaera elsdenii (Lactipro; MS Biotec, Wamego, KS) and were restricted from feed and water for 4 h, and then walked an additional 805 m (LACT). One hundred steers were given an ear tag to record minutes of activity (ESense Flex Tags, Allflex Livestock Intelligence, Madison, WI). As a percentage of BW, DMI was 5% greater (P = 0.01) from reimplant to end for PCON vs. RES, LOC, and RES + LOC treatments. Likewise, as a percentage of BW, DMI was 6.6% greater (P = 0.03) from reimplant to end and 4.0% greater (P = 0.05) overall for the PCON treatment vs. the LOC treatment. Overall, DMI as a percentage of BW was 3.3% greater (P = 0.02) for PCON vs. RES, LOC, and RES + LOC treatments. There was an increase in G:F from reimplant to end (P = 0.05) for RES + LOC vs. the LACT treatment. From these data, we conclude that restricting cattle from feed and water for 4 h after reimplanting did not alter subsequent DMI. Increasing locomotion had the greatest negative effect on DMI and growth performance. Management strategies to decrease locomotion associated with reimplanting would be beneficial to DMI and overall growth performance of finishing beef steers.

A multi‐institutional randomized controlled trial comparing first‐generation transrectal high‐resolution micro‐ultrasound with conventional frequency transrectal ultrasound for prostate biopsy

Objectives

To study high‐frequency 29 MHz transrectal side‐fire micro‐ultrasound (micro‐US) for the detection of clinically significant prostate cancer (csPCa) on prostate biopsy, and validate an image interpretation protocol for micro‐US imaging of the prostate.

Materials and methods

A prospective randomized clinical trial was performed where 1676 men with indications for prostate biopsy and without known prostate cancer were randomized 1:1 to micro‐US vs conventional end‐fire ultrasound (conv‐US) transrectal‐guided prostate biopsy across five sites in North America. The trial was split into two phases, before and after training on a micro‐US image interpretation protocol that was developed during the trial using data from the pre‐training micro‐US arm. Investigators received a standardized training program mid‐trial, and the post‐training micro‐US data were used to examine the training effect.

Results

Detection of csPCa (the primary outcome) was no better with the first‐generation micro‐US system than with conv‐US in the overall population (34.6% vs 36.6%, respectively, P = .21). Data from the first portion of the trial were, however, used to develop an image interpretation protocol termed PRI‐MUS in order to address the lack of understanding of the appearance of cancer under micro‐US. Micro‐US sensitivity in the post‐training group improved to 60.8% from 24.6% (P < .01), while specificity decreased (from 84.2% to 63.2%). Detection of csPCa in the micro‐US arm increased by 7% after training (32% to 39%, P < .03), but training instituted mid‐trial did not affect the overall results of the comparison between arms.

Conclusion

Micro‐US provided no clear benefit over conv‐US for the detection of csPCa at biopsy. However, it became evident during the trial that training and increasing experience with this novel technology improved the performance of this first‐generation system.

In this work high‐frequency 29 MHz transrectal side‐fire micro‐ultrasound (US) for the detection of clinically significant prostate cancer on prostate biopsy is studied, and an image interpretation protocol for micro‐US imaging of the prostate is validated.

The YouTube link is here: https://youtu.be/U2Svj-4Ae_k

Development of gynecomastia following initiation of bictegravir/emtricitabine/tenofovir alafenamide

Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) is a recently approved single-tablet antiretroviral regimen and is recommended as a first-line agent. No cases of gynecomastia were reported in clinical trials. We report development of ultrasound-confirmed gynecomastia in a previously antiretroviral-naïve patient approximately two months after starting BIC/FTC/TAF, which resolved ten weeks after discontinuing bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) based therapy.

Availability and performance of image-based, non-contact methods of monitoring heart rate, blood pressure, respiratory rate, and oxygen saturation: a systematic review

OBJECTIVE

Over the last 15 years, developments in camera technology have coincided with increased availability and affordability. This has led to an increasing interest in using these technologies in healthcare settings. Image-based monitoring methods potentially allow multiple vital signs to be measured concurrently using a non-contact sensor. We have undertaken a systematic review of the current availability and performance of these monitoring methods.

APPROACH

A multiple database search was conducted using MEDLINE, Embase, CINAHL, Cochrane Library, OpenGrey, IEEE Xplore Library and ACM Digital Library to July 2018. We included studies comparing image-based heart rate, respiratory rate, oxygen saturation and blood pressure monitoring methods against one or more validated reference device(s). Each included study was assessed using the modified GRRAS criteria for reporting bias.

MAIN RESULTS

Of 30 279 identified studies, 161 were included in the final analysis. Twenty studies (20/161, 12%) were carried out on patients in clinical settings, while the remainder were conducted in academic settings using healthy volunteer populations. The 18-40 age group was best represented across the identified studies. One hundred and twenty studies (120/161, 75%) estimated heart rate, followed by 62 studies (62/161, 39%) estimating respiratory rate. Fewer studies focused on oxygen saturation (11/161, 7%) or blood pressure (6/161, 4%) estimation. Fifty-one heart rate studies (51/120, 43%) and 24 respiratory rate studies (24/62, 39%) used Bland-Altman analysis to report their results. Of the heart rate studies, 28 studies (28/51, 55%) showed agreement within industry standards of [Formula: see text]5 beats per minute. Only two studies achieved this within clinical settings. Of the respiratory rate studies, 13 studies (13/24, 54%) showed agreement within industry standards of [Formula: see text]3 breaths per minute, but only one study achieved this in a clinical setting. Statistical analysis was heterogeneous across studies with frequent inappropriate use of correlation. The majority of studies (99/161, 61%) monitored subjects for under 5 min. Three studies (3/161, 2%) monitored subjects for over 60 min, all of which were conducted in hospital settings.

SIGNIFICANCE

Heart rate and respiratory rate monitoring using video images is currently possible and performs within clinically acceptable limits under experimental conditions. Camera-derived estimates were less accurate in the proportion of studies conducted in clinical settings. We would encourage thorough reporting of the population studied, details of clinically relevant aspects of methodology, and the use of appropriate statistical methods in future studies. Systematic review registration: PROSPERO CRD42016029167 Protocol: https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-017-0615-3.

Mapping sources of noise in an intensive care unit

Excessive noise in hospitals adversely affects patients' sleep and recovery, causes stress and fatigue in staff and hampers communication. The World Health Organization suggests sound levels should be limited to 35 decibels. This is probably unachievable in intensive care units, but some reduction from current levels should be possible. A preliminary step would be to identify principal sources of noise. As part of a larger project investigating techniques to reduce environmental noise, we installed a microphone array system in one with four beds in an adult general intensive care unit. This continuously measured locations and sound pressure levels of noise sources. This report summarises results recorded over one year. Data were collected between 7 April 2017 and 16 April 2018 inclusive. Data for a whole day were available for 248 days. The sound location system revealed that the majority of loud sounds originated from extremely limited areas, very close to patients' ears. This proximity maximises the adverse effects of high environmental noise levels for patients. Some of this was likely to be appropriate communication between the patient, their caring staff and visitors. However, a significant proportion of loud sounds may originate from equipment alarms which are sited at the bedside. A redesign of the intensive care unit environment to move alarm sounds away from the bed-side might significantly reduce the environmental noise burden to patients.

Risk of neurosyphilis in HIV-infected persons with syphilis lacking signs or symptoms of central nervous system infection

OBJECTIVES

People living with HIV (PLWH) are at increased risk of asymptomatic neurosyphilis; thus, it has been common practice to perform a lumbar puncture (LP) in all PLWH presenting with syphilis regardless of stage, signs or symptoms. However, this practice varies widely among clinicians. Our objective was to elucidate the number of LPs required to diagnose a single case of asymptomatic neurosyphilis.

METHODS

We performed an electronic health record (EHR) review of PLWH who were diagnosed with syphilis of any stage over a 10-year period. EHRs were reviewed to determine the number of subjects who had an LP performed, what proportion had neurological signs or symptoms, and whether a diagnosis of neurosyphilis was made at presentation or follow-up.

RESULTS

In 261 separate episodes of syphilis in 230 subjects, we found the major risk factors for asymptomatic neurosyphilis to be low CD4 T-cell count (P = 0.0007), high rapid plasma reagin (RPR) titre (P = 0.019) and lack of HIV virological suppression (P = 0.003). The majority of our subjects (78%) with neurosyphilis presented with central nervous system (CNS) symptoms. We estimate, if standard practice is to perform LP in all patients, that the number needed to test (NNTT) = 38.

CONCLUSIONS

This large number of potentially unnecessary LPs, along with heterogeneity of presentation, and the never-nil risk of asymptomatic neurosyphilis should be incorporated into clinical decision-making. The majority of PLWH presenting with a serological diagnosis of syphilis, but no neurological signs or symptoms, do not necessarily require an LP for an evaluation of asymptomatic neurosyphilis.

Changes in health-related quality of life after discharge from an intensive care unit: a systematic review

Quality of life after critical illness is becoming increasingly important as survival improves. Various measures have been used to study the quality of life of patients discharged from intensive care. We systematically reviewed validated measures of quality of life and their results. We searched PubMed, CENTRAL, CINAHL, Web of Science and Open Grey for studies of quality of life, measured after discharge from intensive care. We categorised studied populations as: general; restricted to level‐3 care or critical care beyond 5 days; and septic patients. We included quality of life measured at any time after hospital discharge. We identified 48 studies. Thirty‐one studies used the Medical Outcomes Study 36‐Item Short Form Health Survey (SF‐36) and 19 used the EuroQol‐5D (EQ‐5D); eight used both and nine used alternative validated measures. Follow‐up rates ranged from 26–100%. Quality of life after critical care was worse than for age‐ and sex‐matched populations. Quality of life improved for one year after hospital discharge. The aspects of life that improved most were physical function, physical role, vitality and social function. However, these domains were also the least likely to recover to population norms as they were more profoundly affected by critical illness.

Towards elucidating the photochemistry of the sunscreen filter ethyl ferulate using time-resolved gas-phase spectroscopy

Ultrafast time-resolved ion yield (TR-IY) and velocity map imaging spectroscopies are employed to reveal the relaxation dynamics after photoexcitation in ethyl 4-hydroxy-3-methoxycinnamate (ethyl ferulate, EF), an active ingredient in commercially available sunscreens. In keeping with a bottom-up strategy, the building blocks of EF, 2-methoxy-4-vinylphenol (MVP) and 4-hydroxy-3-methoxycinnamyl alcohol (coniferyl alcohol, ConA), were also studied to assist in our understanding of the dynamics of EF as we build up in molecular complexity. In contrast to the excited state dynamics of MVP and ConA, which are described by a single time constant (>900 ps), the dynamics of EF are described by three time constants (15 ± 4 ps, 148 ± 47 ps, and >900 ps). A mechanism is proposed involving internal conversion (IC) between the initially excited S₁(1¹ππ*) and S₂(1¹nπ*) states followed by intramolecular vibrational redistribution (IVR) on both states, in competition with intersystem crossing onto neighbouring triplet states (15 ± 4 ps). IVR and IC within the triplet manifold then ensues (148 ± 47 ps) to populate a low-lying triplet state (>900 ps). Importantly, the fluorescence spectrum of EF at the S₁ origin, along with the associated lifetime (6.9 ± 0.1 ns), suggests that population is trapped, during initial IVR, on the S₁(1¹ππ*) state. This serves to demonstrate the complex, competing dynamics in this sunscreen filter molecule.

Prevalence of HIV-1 transmitted drug resistance in the incarcerated population

OBJECTIVES

The aim of the study was to determine the prevalence of transmitted drug resistance (TDR)-associated mutations among treatment-naïve, incarcerated individuals with HIV-1 infection in the USA as well as the class TDR and antiretroviral (ARV) mutations present at baseline.

METHODS

Patients over the age of 18 years were included in the study if they had been diagnosed with HIV infection, if their HIV infection was managed through telemedicine and if they were incarcerated in the State of Illinois Department of Corrections between 10 July 2010 and 29 April 2016. Additionally, the patients were required to have a documented genotype and be ARV-naïve. A medical chart review was conducted to assess demographic information, disease burden, and risk factors for acquiring the virus.

RESULTS

The inclusion criteria were met for 105 patients. A total of 24 patients (23%) had a clinically significant mutation associated with resistance to any drug class. The prevalence of mutations conferring clinically significant resistance was 19% for nonnucleoside reverse transcriptase inhibitors (NNRTIs), 18% for nucleoside reverse transcriptase inhibitors (NRTIs), and 4% for protease inhibitors (PIs). Five per cent of patients had dual-class TDR to both NRTI and NNRTI drug classes and 2% of patients had mutations to both NNRTI and PI drug classes. There was no significant increase in the prevalence of clinically relevant drug resistance mutations based on demographics, burden of disease, or risk factors for acquiring the virus.

CONCLUSIONS

A high prevalence of TDR was identified in the ARV-naïve incarcerated population. The results of this study indicate an increased prevalence of TDR in a largely unstudied incarcerated population, demonstrating the need for increased monitoring of resistance in HIV-infected patients world-wide.

Probing Rotational Motion in 4-tert-Butylcatechol through H Atom Photofragmentation: Deviations from Axial Recoil

The time-resolved photofragmentation dynamics of 4-tert-butylcatechol were studied following one photon excitation to the S1 (1(1)ππ*) state with ultraviolet radiation in the range 260 ≤ λ ≤ 286 nm. The preparation of an aligned molecular ensemble via photoexcitation leads to anisotropy in the H atom photofragments. These H atoms originate from the decay of the S1 state through coupling onto the S2 ((1)πσ*) state, which is dissociative along the nonintramolecular hydrogen bonded "free" O-H bond. The degree of anisotropy of these photogenerated H atoms decreases with increasing pump-probe time delay. This is attributed to rotational dephasing of the initially aligned molecular ensemble. The measured dephasing occurs on a time scale akin to the appearance time of these H atoms, which likely places an intrinsic lower bound on the dephasing lifetime. The present work demonstrates how a careful balance between the appearance time of the H atoms, determined by the S1 lifetime, and the rotational dephasing in 4-tert-butylcatechol provides an opportune window to probe rotational motion in real time.

A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators

PURPOSE

To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic shock.

METHODS

Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay.

RESULTS

From 2395 initially eligible abstracts, five randomised clinical trials (n = 4735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2% [495/2134] versus control: 22.4% [582/2601]; pooled OR 1.01 [95% CI 0.88-1.16], P = 0.9, with heterogeneity [I(2) = 57%; P = 0.055]). The pooled estimate of 90-day mortality from the three recent multicentre studies (n = 4063) also showed no difference [pooled OR 0.99 (95% CI 0.86-1.15), P = 0.93] with no heterogeneity (I(2) = 0.0%; P = 0.97). EGDT increased vasopressor use (OR 1.25 [95% CI 1.10-1.41]; P < 0.001) and ICU admission [OR 2.19 (95% CI 1.82-2.65); P < 0.001]. Including six non-ED randomised trials increased heterogeneity (I(2) = 71%; P < 0.001) but did not change overall results [pooled OR 0.94 (95% CI 0.82 to 1.07); P = 0.33].

CONCLUSION

EGDT is not superior to usual care for ED patients with septic shock but is associated with increased utilisation of ICU resources.

Beta-Agonist Lung injury TrIal-2 (BALTI-2): a multicentre, randomised, double-blind, placebo-controlled trial and economic evaluation of intravenous infusion of salbutamol versus placebo in patients with acute respiratory distress syndrome

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a major cause of mortality in intensive care patients and lacks effective treatments. A previous randomised controlled Phase II trial suggested that an intravenous (i.v.) infusion of salbutamol may be beneficial, as it reduced extravascular lung water and plateau airway pressure. The Beta-Agonist Lung injury TrIal-2 (BALTI-2) was initiated to evaluate the effects of this intervention on mortality in patients with ARDS.

OBJECTIVES

To evaluate whether or not, in patients with ARDS, an i.v. infusion of salbutamol given at 15 μg/kg ideal body weight (IBW)/hour for up to 7 days, compared with a placebo (0.9% sodium chloride) infusion, reduces 28-day all-cause mortality and other clinical outcomes. To evaluate salbutamol's clinical effectiveness and its cost-effectiveness in subgroups of patients.

DESIGN

A multicentre, randomised, placebo-controlled trial.

SETTING

Forty-six intensive care units (ICUs) in the UK.

PARTICIPANTS

Patients were eligible if they (1) were intubated and mechanically ventilated patients in participating ICUs; (2) were within 72 hours of onset of ARDS; (3) fulfilled American-European Consensus Conference definition for ARDS {acute-onset, severe hypoxaemic respiratory failure [partial pressure of oxygen in arterial blood/fraction of inspired oxygen ≤ 26.7 kPa (200 mmHg)] and bilateral infiltrates on the chest radiograph in the absence of clinical evidence of left atrial hypertension}; and (4) were aged ≥ 16 years.

INTERVENTIONS

Intravenous infusion of salbutamol (15 μg/kg IBW/hour) or placebo (0.9% saline) for up to 7 days.

MAIN OUTCOME MEASURES

All-cause mortality 28 days after randomisation, mortality at (first) discharge from ICU, mortality at (first) discharge from hospital, number of ventilator-free days, number of organ failure-free days, mortality at 12 months post randomisation, side effects (tachycardia/new arrhythmia/lactic acidosis) sufficient to stop treatment with trial drug, health-related quality of life (European Quality of Life-5 Dimensions and Short Form questionnaire-12 items at 6 and 12 months after randomisation), length of stay in critical care unit and length of stay in hospital.

RESULTS

Forty-six ICUs recruited patients to the trial. A total of 326 patients were randomised; 162 were allocated to salbutamol and 164 to placebo. One patient in each group withdrew consent. Recruitment was stopped after the second interim analysis because of safety concerns. Salbutamol increased 28-day mortality: 55 (34%) of 161 patients died in the salbutamol group compared with 38 (23%) of 163 in the placebo group (risk ratio 1.47, 95% confidence interval 1.03 to 2.08).

CONCLUSIONS

Treatment with i.v. salbutamol early in the course of ARDS was poorly tolerated, is unlikely to be beneficial and could worsen outcomes. Further trials of β-agonists in patients with ARDS are unlikely to be conducted. Some questions remain, such as whether or not there may be benefit at a different dose or in specific populations, but any studies investigating these would require a very strong rationale.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN38366450.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

The economic impact of anastomotic leakage after anterior resections in English NHS hospitals: are we adequately remunerating them?

AIM

Our aim was to determine the frequency and economic impact of anastomotic leakage (AL) at local and national levels in England.

METHOD

All patients who underwent AR in Oxford between 2007 and 2009 were evaluated for AL. Hospital Episode Statistics (HES) data were used to determine reoperation rates after elective AR (n = 23 388) in England between 2000 and 2008. Hospital episode remuneration costs were calculated by the local commissioning department and compared with Department of Health (DH) reference index costs.

RESULTS

The frequency of AL following anterior resection was 10.9% (31 out of 285) in Oxford. Laparotomy for leakage was performed in 5.6% of cases. The 30-day hospital mortality rate for all ARs was 2.1%, compared with 3.2% after AL. The national relaparotomy rate (within 28 days) and 30-day hospital mortality in English National Health Service (NHS) trusts following AR were 5.9% and 2.9%, respectively. Institutional remunerated tariffs (£6233 (SD ± 965)) were similar to DH reference costs (£6319 (SD ± 1830)) after uncomplicated AR. However, there was a significant (P = 0.008) discrepancy between the remunerated tariff for AL (£9605 (SD ± 6908)) and the actual cost (£17 220 (SD ± 9642)). AL resulted in an additional annual cost of approximately £1.1 million to £3.5 million when extrapolated nationally.

CONCLUSION

The estimated economic burden of anastomotic leakage following AR is approximately double that of the remunerated tariff.

PPARγ isoforms differentially regulate metabolic networks to mediate mouse prostatic epithelial differentiation

Recent observations indicate prostatic diseases are comorbidities of systemic metabolic dysfunction. These discoveries revealed fundamental questions regarding the nature of prostate metabolism. We previously showed that prostate-specific ablation of PPARγ in mice resulted in tumorigenesis and active autophagy. Here, we demonstrate control of overlapping and distinct aspects of prostate epithelial metabolism by ectopic expression of individual PPARγ isoforms in PPARγ knockout prostate epithelial cells. Expression and activation of either PPARγ 1 or 2 reduced de novo lipogenesis and oxidative stress and mediated a switch from glucose to fatty acid oxidation through regulation of genes including Pdk4, Fabp4, Lpl, Acot1 and Cd36. Differential effects of PPARγ isoforms included decreased basal cell differentiation, Scd1 expression and triglyceride fatty acid desaturation and increased tumorigenicity by PPARγ1. In contrast, PPARγ2 expression significantly increased basal cell differentiation, Scd1 expression and AR expression and responsiveness. Finally, in confirmation of in vitro data, a PPARγ agonist versus high-fat diet (HFD) regimen in vivo confirmed that PPARγ agonization increased prostatic differentiation markers, whereas HFD downregulated PPARγ-regulated genes and decreased prostate differentiation. These data provide a rationale for pursuing a fundamental metabolic understanding of changes to glucose and fatty acid metabolism in benign and malignant prostatic diseases associated with systemic metabolic stress.

A national survey of the management of delirium in UK intensive care units

BACKGROUND

Delirium is an acute organ dysfunction common amongst patients treated in intensive care units. The associated morbidity and mortality are known to be substantial. Previous surveys have described which screening tools are used to diagnose delirium and which medications are used to treat delirium, but these data are not available for the United Kingdom.

AIM

This survey aimed to describe the UK management of delirium by consultant intensivists. Additionally, knowledge and attitudes towards management of delirium were sought. The results will inform future research in this area.

METHODS

A national postal survey of members of the UK Intensive Care Society was performed. A concise two page questionnaire survey was sent, with a second round of surveys sent to non-respondents after 6 weeks. The questionnaire was in tick-box format.

RESULTS

Six hundred and eighty-one replies were received from 1308 questionnaires sent, giving a response rate of 52%. Twenty-five percent of respondents routinely screen for delirium, but of these only 55% use a screening tool validated for use in intensive care. The majority (80%) of those using a validated instrument used the Confusion Assessment Method for the Intensive Care Unit. Hyperactive delirium is treated pharmacologically by 95%; hypoactive delirium is treated pharmacologically by 25%, with haloperidol the most common agent used in both. Over 80% of respondents agreed that delirium prolongs mechanical ventilation and hospital stay and requires active treatment.

CONCLUSION

This UK survey demonstrates screening for delirium is sporadic. Pharmacological treatment is usually with haloperidol in spite of the limited evidence to support this practice. Hypoactive delirium is infrequently treated pharmacologically.

Genetic variation in the purine nucleoside phosphorylase activity of sheep red cells

The purine nucleoside phosphorylase (NP) activity of sheep red cells was determined by starch gel electrophoresis and by a spectrophotometric assay technique. Some sheep had high activity (NP-high type) and some had low or zero activity (NP-low type). The enzyme deficiency is apparently confined to the red cell since other tissues from NP-low type animals had activities similar to those from NP-high type individuals. Family data indicated that NP activity is controlled by a pair of autosomal allelic genes, designated NPH and NPL. Sheep heterozygous for the NP genes had lower enzymic activities than homozygous high-type individuals. The frequency of NP types in different breeds of sheep was determined. Barbary and Mouflon sheep had activities similar to NP-high type domestic sheep; goats had high enzyme activities but their NP had a slower electrophoretic mobility than that of sheep.

Sheep twin chimaeras with admixtures of red cell amino acid and potassium transport phenotypes

A pair of sheep twins each had two populations of red cells. Population 1 was positive for antigens Aa, Ma and Mb, was low-potassium type, possessed an amino acid transport system and was lysine-negative phenotype. Population 2 was negative for antigens Aa, and Mb, was high-potassium type, lacked the amino acid transport system and was lysine-positive phenotype. Population 2 disappeared from both sheep over a period of 8 years.

Human equilibrative nucleoside transporter (ENT) family of nucleoside and nucleobase transporter proteins

1. The human (h) SLC29 family of integral membrane proteins is represented by four members, designated equilibrative nucleoside transporters (ENTs) because of the properties of the first-characterized family member, hENT1. They belong to the widely distributed eukaryotic ENT family of equilibrative and concentrative nucleoside/nucleobase transporter proteins. 2. A predicted topology of eleven transmembrane helices has been experimentally confirmed for hENT1. The best-characterized members of the family, hENT1 and hENT2, possess similar broad permeant selectivities for purine and pyrimidine nucleosides, but hENT2 also efficiently transports nucleobases. hENT3 has a similar broad permeant selectivity for nucleosides and nucleobases and appears to function in intracellular membranes, including lysosomes. 3. hENT4 is uniquely selective for adenosine, and also transports a variety of organic cations. hENT3 and hENT4 are pH sensitive, and optimally active under acidic conditions. ENTs, including those in parasitic protozoa, function in nucleoside and nucleobase uptake for salvage pathways of nucleotide synthesis and, in humans, are also responsible for the cellular uptake of nucleoside analogues used in the treatment of cancers and viral diseases. 4. By regulating the concentration of adenosine available to cell surface receptors, mammalian ENTs additionally influence physiological processes ranging from cardiovascular activity to neurotransmission.

External Validity of a Mortality Prediction Model in Patients After Open Abdominal Aortic Aneurysm Repair Using Multi-level Methodology

OBJECTIVES

Evaluation of the prognostic ability of the APACHE-AAA model in an independent group of post-operative (open) Abdominal Aortic Aneurysm (AAA) patients.

METHODS

The model was applied to predict in-hospital mortality in 541 patients (325 elective and 216 emergencies; 489 from Oxford; 52 from Lewisham). Multi-level modelling was used to adjust for both the local structure and process of care and patient case-mix. Model performance was assessed using goodness-of-fit and subgroup analyses.

RESULTS

The model's predictive ability to discriminate between dead and alive patients was very good (ROC area=0.84). The model achieved a good fit across all strata of risk (Hosmer-Lemeshow C-test (8, N=476)=7.777, p=0.456) and in all subgroups. The model was able to rank the ICUs according to their performance independently of the patient case-mix.

CONCLUSION

The APACHE-AAA model accurately predicted in-hospital mortality in a population of patients independent of the one used to develop it, confirming its validity. The multi-level methodology employed has shown that patient outcome is not only a function of the patient case-mix but instead predictive models should also adjust for the individual hospital-related factors (structure and process of care).

A comparison of the laryngeal mask airway with facemask and oropharyngeal airway for manual ventilation by critical care nurses in children

The laryngeal mask airway is included as a first line airway device during adult resuscitation by first responders. However, there is little evidence for its role in paediatric resuscitation. Using anaesthetised children as a model for paediatric cardiopulmonary arrest, we compared the ability of critical care nurses to manually ventilate the anaesthetised child via the laryngeal mask airway compared with the facemask and oropharyngeal airway. The airway devices were inserted in random order and chest expansion was measured using an ultrasound distance transducer. The critical care nurses were able to place the laryngeal mask airway and achieve successful ventilation in 82% of children compared to 70% using the facemask and oropharyngeal airway, although the difference was not statistically significant (p = 0.136). The median time to first successful breath using the laryngeal mask airway was 39 s compared to 25 s using the facemask (p < 0.001). In this group of nurses, we did not show a difference in ventilation via a laryngeal mask airway or facemask, although facemask ventilation was achieved more quickly.

Nucleoside transport and its significance for anticancer drug resistance

This article discusses the role of nucleoside transport processes in the cytotoxicity of clinically important anticancer nucleosides. This article summarizes recent advances in the molecular biology of nucleoside transport proteins, review the current state of knowledge of the transportability of therapeutically useful anticancer nucleosides, and provide an overview of the role of nucleoside transport deficiency as a mechanism of resistance to nucleoside cytotoxicity are summarized. Several strategies for utilization of nucleoside transport processes to improve the therapeutic index of anticancer therapies, including the use of nucleoside-transport inhibitors to modulate toxicity of both nucleoside and non-nucleoside antimetabolite drugs are also presented.

Comparison of Mortality Prediction Models after Open Abdominal Aortic Aneurysm Repair

OBJECTIVES

Comparison of the accuracy of prediction of contemporary mortality prediction models after open Abdominal Aortic Aneurysm (AAA) surgery.

METHODS

Post-operative data were collected from AAA patients from 2 UK Intensive Care Units (ICU). POSSUM and VBHOM based models were compared to the APACHE-AAA model which was able to adjust for the hospital-related effect on outcome. Model performance was assessed using measures of calibration, discrimination and subgroup analysis.

RESULTS

541 patients were studied. The in-hospital mortality rate for elective AAA repair (325 patients) was: 6.2% (95% confidence interval (c.i.) 3.5 to 8.8) and for emergency repair (216 patients) was: 28.7% (95% c.i. 22.5-34.9). The APACHE-based model had the best overall fit to the whole population of AAA patients, and also separately in elective and emergency patients. The V-POSSUM physiology-only (p<0.001) and VBHOM (p=0.011) models had a poor fit in elective patients. The RAAA-POSSUM physiology-only (p<0.001) and VBHOM models (p=0.010) had a poor fit in emergency patients.

CONCLUSIONS

The APACHE-AAA model with its ability to adjust for both the hospital-related "effect" as well as the patient case-mix, was a more accurate risk stratification model than other contemporary models, in the post-operative AAA patient managed in ICU.

Use of helium-oxygen mixture in adult patients presenting with exacerbations of asthma and chronic obstructive pulmonary disease: a systematic review

We examined systematically all controlled and cross-over randomised trials in patients with acute exacerbations of asthma and chronic obstructive pulmonary disease comparing Heliox against air-oxygen mixtures. Fourteen studies were identified. In asthma studies, peak expiratory flow rate (PEFR) was increased by an average of 29.6% (95% CI 16.6-42.6) by Heliox-driven nebulisers, or by 13.3 l.min(-1) (95% CI 3.71-22.81) absolute. In studies of patients with chronic obstructive pulmonary disease receiving non-invasive ventilation the arterial carbon dioxide tension (P(a)co(2)) and respiratory rate were unchanged: weighted mean difference for P(a)co(2)-0.29kPa (95% CI - 0.64-0.07) favoured Heliox, and for respiratory rate 1.6 breaths.min(-1) (95% CI - 0.93, 4.14) favoured control. Heliox minimally reduced the work of breathing in intubated patients, and reduced intrinsic positive end expiratory pressure (iPEEP). The use of Heliox to drive nebulisers in patients with acute asthma slightly improves airflow measures. We were unable to determine whether this improved recovery.

A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients

We conducted a randomised controlled trial of mandated five-channel physiological monitoring vs standard care, in acute medical and surgical wards in a single UK teaching hospital. In all, 402 high-risk medical and surgical patients were studied. The primary outcome was the proportion of patients experiencing one or more major adverse events, including urgent staff calls, changes to higher care levels, cardiac arrests or death, in 96 h following randomisation. Secondary outcomes were the proportion of patients requiring acute treatment changes, and the 30-day and hospital mortality. In the 96 h following randomisation, 113 (56%) patients in the monitored arm and 116 (58%) in the control arm (OR 0.94, 95% CI 0.63-1.40, p = 0.76) had a major event. An acute change in treatment was necessary in 107 (53%) monitored patients and 101 (50%) control patients (OR 0.55, 95% CI 0.87-1.29). Thirty-four (17%) monitored patients and 35 (17%) control patients died within 30 days. Thirteen patients in the control group received full five-channel monitoring at the request of the ward staff. We conclude that mandated electronic vital signs monitoring in high risk medical and surgical patients has no effect on adverse events or mortality.

A national survey of intensive care follow-up clinics

Intensive care follow-up clinics allow extended review of survivors of critical illness. However, the current provision of intensive care follow-up clinics in the UK is unknown. We performed a survey of intensive care follow-up clinic practice in the UK. A questionnaire was sent to 298 intensive care units in the UK to determine the number of follow-up clinics and details of current follow-up practice. Responses were received from 266 intensive care units, an 89% response rate. Eighty units (30%) ran a follow-up clinic. Only 47 (59%) of these clinics were funded. Of those intensive care units without a follow-up clinic, 158 (88%) cited 'financial constraints' as the reason. Over half of the follow-up clinics (44 clinics, 55%) were nurse-led, and the majority (56 clinics, 77%) only routinely review patients treated on the intensive care unit for 3 or 4 days or longer. Nearly half of the follow-up clinics (39 clinics, 49%) have pre-negotiated access to at least one other out-patient service.

Nitric oxide synthase is downregulated, while haem oxygenase is increased, in patients with septic shock

BACKGROUND

The vasodilatation characteristic of human septic shock is conventionally attributed to increased nitric oxide production, primarily by extrapolation of animal and human in vitro studies. There are no conclusive studies of human disease, and the cellular source of nitric oxide in human sepsis is not known. Haem oxygenase is upregulated by oxidative stress, but little is known about haem oxygenase expression in human sepsis. Haem oxygenase may modulate nitric oxide production, and may also have a direct effect on vascular tone.

METHODS

Mesenteric arterial smooth muscle (ASM) (obtained during laparotomy) and peripheral blood mononuclear cells (PBMCs) were obtained from patients with early septic shock and from control patients. mRNA levels were determined by real-time RT-PCR.

RESULTS

mRNA for inducible and endothelial nitric oxide synthase was reduced in both ASM and PBMCs from septic patients. In contrast, inducible haem oxygenase mRNA was increased in sepsis in both cell types.

CONCLUSIONS

These results suggest that, rather than being induced, the enzymes which produce nitric oxide are reduced at this time point in human septic shock. Thus many of the in vitro models of sepsis studied to date may not fully replicate human disease. The increase in haem oxygenase expression confirms that these cells have been subjected to oxidative stress in sepsis. The activity of induced haem oxygenase may limit nitric oxide production, while possibly causing vasodilation through production of carbon monoxide.

New method to evaluate the practice of positive pressure ventilation in intensive care units

BACKGROUND

There is good evidence to support the use of a "protective" ventilation strategy, using small tidal volumes and inspiratory pressures, in patients with acute respiratory distress syndrome. Many general intensive care units in the UK are being slow to adopt this approach and we therefore set out to devise a method to audit ventilation and possibly influence practice in these units.

METHODS

Using variables that are routinely documented by intensive care nurses, we assessed the relationship between ventilator settings and arterial blood gas values on 30 consecutive ventilated patients admitted to intensive care units at both a teaching and a district hospital. Data were recorded twice daily and the proportions of data points where there was unnecessary hyperventilation were recorded at each centre.

RESULTS

The initial audit results showed clear differences in practice between the teaching hospital and the district hospital. After an intensive education programme, during which an active role for nursing staff in ventilator management was encouraged, supported by simple protocols, practice in the district hospital was re-audited and found to closely mirror that in the teaching centre.

CONCLUSIONS

To assist progress towards the use of a "protective" ventilation strategy in intensive care units in the UK, we devised a simple, robust audit method. We have shown how this method can give a more uniform practice of ventilation in critical care units, with the introduction of nurse-run protocols.

Coupling of CFTR-mediated anion secretion to nucleoside transporters and adenosine homeostasis in Calu-3 cells

The purpose of this study was to characterize the role of adenosine-dependent regulation of anion secretion in Calu-3 cells. RT-PCR studies showed that Calu-3 cells expressed mRNA for A2A and A2B but not A1 or A3 receptors, and for hENT1, hENT2 and hCNT3 but not hCNT1 or hCNT2 nucleoside transporters. Short-circuit current measurements indicated that A2B receptors were present in both apical and basolateral membranes, whereas A2A receptors were detected only in basolateral membranes. Uptake studies demonstrated that the majority of adenosine transport was mediated by hENT1, which was localized to both apical and basolateral membranes, with a smaller hENT2-mediated component in basolateral membranes. Whole-cell current measurements showed that application of extracellular nitrobenzylmercaptopurine ribonucleoside (NBMPR), a selective inhibitor of hENT1-mediated transport, had similar effects on whole-cell currents as the application of exogenous adenosine. Inhibitors of adenosine kinase and 5'-nucleotidase increased and decreased, respectively, whole-cell currents, whereas inhibition of adenosine deaminase had no effect. Single-channel studies showed that NBMPR and adenosine kinase inhibitors activated CFTR Cl- channels. These results suggested that the equilibrative nucleoside transporters (hENT1, hENT2) together with adenosine kinase and 5'-nucleotidase play a crucial role in the regulation of CFTR through an adenosine-dependent pathway in human airway epithelia.

Immunocytochemical demonstration of the equilibrative nucleoside transporter rENT1 in rat sinoatrial node

Adenosine exerts multiple receptor-mediated effects in the heart, including a negative chronotropic effect on the sinoatrial node. The aim of this study was to investigate the distribution of the equilibrative nucleoside transporter rENT1 in rat sinoatrial node and atrial muscle. Immunocytochemistry and/or immunoblotting revealed abundant expression of this protein in plasma membranes of sinoatrial node and in atrial and ventricular cells. Because rENT1-mediated transport is likely to regulate the local concentrations of adenosine in the sinoatrial node and other parts of the heart, it represents a potential pharmacological target that might be exploited to ameliorate ischemic damage during heart surgery.

Regulation of K(+) current in human airway epithelial cells by exogenous and autocrine adenosine

The regulatory actions of adenosine on ion channel function are mediated by four distinct membrane receptors. The concentration of adenosine in the vicinity of these receptors is controlled, in part, by inwardly directed nucleoside transport. The purpose of this study was to characterize the effects of adenosine on ion channels in A549 cells and the role of nucleoside transporters in this regulation. Ion replacement and pharmacological studies showed that adenosine and an inhibitor of human equilibrative nucleoside transporter (hENT)-1, nitrobenzylthioinosine, activated K(+) channels, most likely Ca(2+)-dependent intermediate-conductance K(+) (I(K)) channels. A(1) but not A(2) receptor antagonists blocked the effects of adenosine. RT-PCR studies showed that A549 cells expressed mRNA for I(K)-1 channels as well as A(1), A(2A), and A(2B) but not A(3) receptors. Similarly, mRNA for equilibrative (hENT1 and hENT2) but not concentrative (hCNT1, hCNT2, and hCNT3) nucleoside transporters was detected, a result confirmed in functional uptake studies. These studies showed that adenosine controls the function of K(+) channels in A549 cells and that hENTs play a crucial role in this process.

Topology of a human equilibrative, nitrobenzylthioinosine (NBMPR)-sensitive nucleoside transporter (hENT1) implicated in the cellular uptake of adenosine and anti-cancer drugs

The human equilibrative nucleoside transporter hENT1, the first identified member of the ENT family of integral membrane proteins, is the primary mechanism for the cellular uptake of physiologic nucleosides, including adenosine, and many anti-cancer nucleoside drugs. We have produced recombinant hENT1 in Xenopus oocytes and used native and engineered N-glycosylation sites in combination with immunological approaches to experimentally define the membrane architecture of this prototypic nucleoside transporter. hENT1 (456 amino acid residues) is shown to contain 11 transmembrane helical segments with an amino terminus that is intracellular and a carboxyl terminus that is extracellular. Transmembrane helices are linked by short hydrophilic regions, except for a large glycosylated extracellular loop between transmembrane helices 1 and 2 and a large central cytoplasmic loop between transmembrane helices 6 and 7. Sequence analyses suggest that this membrane topology is common to all mammalian, insect, nematode, protozoan, yeast, and plant members of the ENT protein family.

Nucleoside transporter subtype expression: effects on potency of adenosine kinase inhibitors

1. Adenosine kinase (AK) inhibitors can enhance adenosine levels and potentiate adenosine receptor activation. As the AK inhibitors 5' iodotubercidin (ITU) and 5-amino-5'-deoxyadenosine (NH(2)dAdo) are nucleoside analogues, we hypothesized that nucleoside transporter subtype expression can affect the potency of these inhibitors in intact cells. 3. Three nucleoside transporter subtypes that mediate adenosine permeation of rat cells have been characterized and cloned: equilibrative transporters rENT1 and rENT2 and concentrative transporter rCNT2. We stably transfected rat C6 glioma cells, which express rENT2 nucleoside transporters, with rENT1 (rENT1-C6 cells) or rCNT2 (rCNT2-C6 cells) nucleoside transporters. 3. We tested the effects of ITU and NH(2)dAdo on [(3)H]-adenosine uptake and conversion to [(3)H]-adenine nucleotides in the three cell types. NH(2)dAdo did not show any cell type selectivity. In contrast, ITU showed significant inhibition of [(3)H]-adenosine uptake and [(3)H]-adenine nucleotide formation at concentrations < or =100 nM in rENT1-C6 cells, while concentrations > or =3 microM were required for C6 or rCNT2-C6 cells. 4. Nitrobenzylthioinosine (NBMPR; 100 nM), a selective inhibitor of rENT1, abolished the effects of nanomolar concentrations of ITU in rENT1-C6 cells. 5. This study demonstrates that the effects of ITU, but not NH(2)dAdo, in whole cell assays are dependent upon nucleoside transporter subtype expression. Thus, cellular and tissue differences in expression of nucleoside transporter subtypes may affect the pharmacological actions of some AK inhibitors.

Acquisition of human concentrative nucleoside transporter 2 (hcnt2) activity by gene transfer confers sensitivity to fluoropyrimidine nucleosides in drug-resistant leukemia cells

CEM-ARAC leukemia cells with resistance to cytarabine were shown to lack equilibrative transporter (hENT1) expression and activity. Stable transfer of hCNT2 cDNA into CEM-ARAC enabled Na(+)-dependent transport of purine and pyrimidine nucleoside analogs and provided a unique in vitro model for studying hCNT2. Analysis of [(3)H]uridine inhibitory activity by test substances in hCNT2 transfectant ARAC/D2 revealed structural requirements for interaction with hCNT2: 1) ribosyl and 2'-deoxyribosyl nucleosides were better inhibitors than 3'-deoxyribosyl, 2',3'-dideoxyribosyl or arabinosyl nucleosides; 2) uridine analogs with halogens at position 5 were better inhibitors than 5-methyluridine or thymidine; 3) 2-chloroadenosine was a better inhibitor than 2-chloro-2'-deoxyadenosine (cladribine); and 4) cytosine-containing nucleosides, 7-deazaadenosine and nucleobases were not inhibitors. Quantification of inhibitory capacity yielded K(i) values of 34-50 microM (5-halogenated uridine analogs, 2'-deoxyuridine), 82 microM (5-fluoro-2'-deoxyuridine), 197-246 microM (5-methyluridine < 5-bromo-2'-deoxyuridine < 5-iodo-2'-deoxyuridine), and 411 microM (5-fluoro-5'-deoxyuridine, capecitabine metabolite). Comparisons of hCNT2-mediated transport rates indicated halogenated uridine analogs were transported more rapidly than halogenated adenosine analogs, even though hCNT2 exhibited preference for physiologic purine nucleosides over uridine. Kinetics of hCNT2-mediated transport of 5-fluorouridine and uridine were similar (K(m) values, 43-46 microM). The impact of hCNT2-mediated transport on chemosensitivity was assessed by comparing antiproliferative activity of nucleoside analogs against hCNT2-containing cells with transport-defective, drug-resistant cells. Chemosensitivity was restored partially for cladribine, completely for 5-fluorouridine and 5-fluoro-2'-deoxyuridine, whereas there was little effect on chemosensitivity for fludarabine, 7-deazaadenosine, or cytarabine. These studies, which demonstrated hCNT2 uptake of halogenated uridine analogs, suggested that hCNT2 is an important determinant of cytotoxicity of this class of compounds in vivo.

Mechanisms of uptake and resistance to troxacitabine, a novel deoxycytidine nucleoside analogue, in human leukemic and solid tumor cell lines

Troxacitabine (Troxatyl; BCH-4556; (-)-2'-deoxy-3'-oxacytidine), a deoxycytidine analogue with an unusual dioxolane structure and nonnatural L-configuration, has potent antitumor activity in animal models and is in clinical trials against human malignancies. The current work was undertaken to identify potential biochemical mechanisms of resistance to troxacitabine and to determine whether there are differences in resistance mechanisms between troxacitabine, gemcitabine, and cytarabine in human leukemic and solid tumor cell lines. The CCRF-CEM leukemia cell line was highly sensitive to the antiproliferative effects of troxacitabine, gemcitabine, and cytarabine with inhibition of proliferation by 50% observed at 160, 20, and 10 nM, respectively, whereas a deoxycytidine kinase (dCK)-deficient variant (CEM/dCK(-)) was resistant to all three drugs. In contrast, a nucleoside transport-deficient variant (CEM/ARAC8C) exhibited high levels of resistance to cytarabine (1150-fold) and gemcitabine (432-fold) but only minimal resistance to troxacitabine (7-fold). Analysis of troxacitabine transportability by the five molecularly characterized human nucleoside transporters [human equilibrative nucleoside transporters 1 and 2, human concentrative nucleoside transporter (hCNT) 1, hCNT2, and hCNT3] revealed that short- and long-term uptake of 10-30 microM [(3)H]troxacitabine was low and unaffected by the presence of either nucleoside transport inhibitors or high concentrations of nonradioactive troxacitabine. These results, which suggested that the major route of cellular uptake of troxacitabine was passive diffusion, demonstrated that deficiencies in nucleoside transport were unlikely to impart resistance to troxacitabine. A troxacitabine-resistant prostate cancer subline (DU145(R); 6300-fold) that exhibited reduced uptake of troxacitabine was cross-resistant to both gemcitabine (350-fold) and cytarabine (300-fold). dCK activity toward deoxycytidine in DU145(R) cell lysates was <20% of that in DU145 cell lysates, and no activity was detected toward troxacitabine. Sequence analysis of cDNAs encoding dCK revealed a mutation of a highly conserved amino acid (Trp(92)-->Leu) in DU145(R) dCK, providing a possible explanation for the reduced phosphorylation of troxacitabine in DU145(R) lysates. Reduced deamination of deoxycytidine was also observed in DU145(R) relative to DU145 cells, and this may have contributed to the overall resistance phenotype. These results, which demonstrated a different resistance profile for troxacitabine, gemcitabine, and cytarabine, suggest that troxacitabine may have an advantage over gemcitabine and cytarabine in human malignancies that lack or have low nucleoside transport activities.

Development and testing of a hierarchical method to code the reason for admission to intensive care units: the ICNARC Coding Method. Intensive Care National Audit & Research Centre

A computer-based hierarchical method was developed to code conditions leading to admission to intensive care in the UK. The hierarchy had five tiers: surgical status, body system, anatomical site, physiological or pathological process and medical condition. The hierarchy was populated initially using the free-text descriptions of the reason for admission from 10,806 admissions recorded as part of the Intensive Care Society's UK APACHE II study. After refinement and error-checking, a prospective evaluation was undertaken on 22,059 admissions to 62 UK intensive care units. Individual units coded between 60 and 1610 (mean 356) admissions. All but 50 (0.2%) of the admissions could be coded and 38 units coded every admission. Fifty admissions (0.2%) could not be coded within 24 h of admission but were coded subsequently when more information became available. Of the admissions, 96.1% were coded at all levels of the hierarchy in the coding method. Six hundred and thirty-seven of the 741 unique conditions (85.9%) were used in one of the five reasons for admission and 564 (76.1%) in the primary reason for admission. Five conditions account for 19.4% of all primary reasons for admission. This is the first method to be developed empirically for coding the reason for intensive care admission.

Equilibrative nucleoside transporters: mapping regions of interaction for the substrate analogue nitrobenzylthioinosine (NBMPR) using rat chimeric proteins

The rat equilibrative nucleoside transporters rENT1 and rENT2 belong to a family of integral membrane proteins with 11 potential transmembrane segments (TMs) and are distinguished functionally by differences in sensitivity to inhibition by nitrobenzylthioinosine (NBMPR). Structurally, the proteins have a large glycosylated extracellular loop between TMs 1 and 2 and a large cytoplasmic loop between TMs 6 and 7. In the present study, we have generated chimeras between NBMPR-sensitive rENT1 and NBMPR-insensitive rENT2, using splice sites at rENT1 residues 99 (end of TM 2), 171 (between TMs 4 and 5), and 231 (end of TM 6) to identify structural domains of rENT1 responsible for transport inhibition by NBMPR. Transplanting the amino-terminal half of rENT2 into rENT1 rendered rENT1 NBMPR-insensitive. Domain swaps within the amino-terminal halves of rENT1 and rENT2 identified two contiguous regions, TMs 3-4 (rENT1 residues 100-171) and TMs 5-6 (rENT1 residues 172-231), as the major sites of NBMPR interaction. Since NBMPR is a nucleoside analogue and functions as a competitive inhibitor of zero-trans nucleoside influx, TMs 3-6 are likely to form parts of the substrate translocation channel.

Subcellular Distribution and Membrane Topology of the Mammalian Concentrative Na+-Nucleoside Cotransporter rCNT1

The rat transporter rCNT1 is the archetype of a family of concentrative nucleoside transporters (CNTs) found both in eukaryotes and in prokaryotes. In the present study we have used antibodies to investigate the subcellular distribution and membrane topology of this protein. rCNT1 was found to be expressed predominantly in the brush-border membranes of the polarized epithelial cells of rat jejunum and renal cortical tubules and in the bile canalicular membranes of liver parenchymal cells, consistent with roles in the absorption of dietary nucleosides, of nucleosides in the glomerular filtrate, or of nucleosides arising from the action of extracellular nucleotidases, respectively. The effect of endoglycosidase F treatment on wild-type and mutant rCNT1 expressed in Xenopus oocytes revealed that the recombinant transporter could be glycosylated at either or both of Asn605 and Asn643, indicating that its C terminus is extracellular. In contrast, potential N-glycosylation sites introduced near the N terminus, or between putative transmembrane (TM) helices 4 and 5, were not glycosylated. The deduced orientation of the N terminus in the cytoplasm was confirmed by immunocytochemistry on intact and saponin-permeabilized Chinese hamster ovary cells expressing recombinant rCNT1. These results, in conjunction with extensive analyses of CNT family protein sequences using predictive algorithms, lead us to propose a revised topological model, in which rCNT1 possesses 13 TM helices with the hydrophilic N-terminal and C-terminal domains on the cytoplasmic and extracellular sides of the membrane, respectively. Furthermore, we show that the first three TM helices, which are absent from prokaryote CNTs, are not essential for transporter function; truncated proteins lacking these helices, derived either from rCNT1 or from its human homolog hCNT1, were found to retain significant sodium-dependent uridine transport activity when expressed in oocytes.

Abnormal cerebral blood volume in regions of contused and normal appearing brain following traumatic brain injury using perfusion magnetic resonance imaging

Following traumatic brain injury, there may be secondary alterations in cerebrovascular parameters leading to ischemia and further cellular damage. To assess possible subacute hemodynamic disturbances following traumatic brain injury, we used conventional and perfusion magnetic resonance imaging (MRI) in 18 patients, on average 10 days following injury. Six of the 18 patients had focal contusions or edema visible on conventional MRI. These six patients had a significantly reduced normalized regional cerebral blood volume (rCBV) in the regions of focal pathology compared to equivalent areas in control subjects (patients 0.47 +/- 0.20 [means +/- SD], controls 1.02 +/- 0.11, p < 0.001). In addition, four of these six patients had an increased rCBV (outside control range) in the region of normal appearing brain immediately surrounding the contusion. These six patients were more significantly injured and had a worse clinical outcome compared to the remaining patients (p = 0.004,p = 0.03, respectively). There were five patients who had a region of reduced rCBV (outside control range) in a quadrant of normal appearing white matter, away from any visible abnormality, who were not more significantly injured than the remaining patients but went on to have a significantly poorer clinical outcome (p = 0.27, p = 0.01, respectively). Traumatic brain injury is a heterogeneous insult causing a variety of pathology, not all of which is visible using conventional imaging methods. The current study has shown that regions of both normal appearing and contused brain may have an abnormal rCBV and that alterations in rCBV may play a role in determining the clinical outcome of patients.