694 IMPROVING OPIATE PRESCRIBING IN OLDER ADULTS WITH HIP FRACTURES TO COMBAT THE IATROGENIC FALLOUT

Background

The number of opioid prescriptions in older patients has increased dramatically and it is recognised that opioids are the fourth most likely drug to cause preventable hospital admissions. The adverse effects of opioids occur more frequently in the geriatric population. Little is known about the impact of postoperative pain in older adults. NICE recommends paracetamol with additional opioids if there is insufficient postoperative pain relief. Multidisciplinary management with early and then daily physiotherapy is critical. We have assessed pre-morbid, immediate and prolonged use of opioids in patients following hip fracture. Local problem Pre-intervention analysis identified 79% (57/72) of all patients being discharged on opiates. At 4-months, 37% (17/46) of those were still using them. This represents 28% (17/61) of all patients.

Methods

Analysis of all patients (excluding poly-trauma) with hip fractures over the age of 60 years admitted to St Mary’s Hospital. Interventions Development of local guideline on analgesia prescribing; particularly focusing senior geriatrician led decision making. Prescribing oxycodone for first 72-hours and initially using nerve block. Avoidance of transdermal preparations and withdrawing stronger opioids prior to discharge. Clear instructions for GP’s on a stop date and need for community review. Patient information leaflet dispensed with all discharge opioid prescriptions.

Results

Post-intervention cycle; 17% (11/63) of patients were taking prescribed opioids prior to admission (similar to the pre-cohort). 52% (33/63) were discharged on opiates, down from 79%. At 4-months, of those discharged on opioids, 30% (9/30) were still using them; lower than in the first cycle (37%). Overall reduction from 28% to 16% of patients on opioids at 4-months.

Conclusion

The use of specific hip fracture analgesia guideline, senior geriatrician decision-making and support to community colleagues can reduce in-patient and community opiate prescribing, and stem the growing problem of opioid addiction, misuse and iatrogenic re-admission.

Inhibition of human cytochrome p450 1b1 further clarifies its role in the activation of dibenzo[a,l]pyrene in cells in culture

Metabolic activation and DNA adduct formation of the carcinogenic aromatic hydrocarbon dibenzo[a,l]pyrene (DBP) was investigated in human mammary carcinoma MCF-7 cells and human cytochrome P450 (CYP) 1B1-expressing Chinese hamster V79 cells in culture. It has been shown that DBP is metabolically activated to DNA-binding diol epoxides both in vitro and in vivo. To further establish the role of human CYP1B1 in the activation of DBP, both cell lines were cotreated with DBP and a selective chemical inhibitor of CYP1B1, 2,4,3' ,5'-tetramethoxy-stilbene (TMS). Results from DBP-DNA adduct analyses revealed the complete inhibition of DNA binding when cells were cotreated with DBP and TMS in comparison to DBP alone. Inactivation of CYP1B1 by TMS was also demonstrated through a decrease in the 7-ethoxyresorufin O-deethylase (EROD) activity in microsomes isolated from these cells. Emodin, 3-methyl-1,6,8-trihydroxyanthraquinone, an active ingredient of an herb, has been recently shown of being able to induce CYP1 gene expression. Examination of human CYP1B1 induction and EROD activity confirmed an increase in protein levels upon cotreatment with emodin and DBP. Despite increases in protein levels and enzyme activity, there was no significant change in DBP-DNA binding levels at very low substrate concentrations (17 nM). The data obtained in this study emphasize the central role of CYP1B1 in the activation of DBP in human cells in culture.

Investigation of the genotoxicity of dibenzo[c,p]chrysene in human carcinoma MCF-7 cells in culture

Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous environmental pollutants that have been linked to certain human cancers. The fjord region PAH dibenzo[a,l]pyrene exhibits the highest levels of carcinogenic activity of all PAH as yet tested in rodent tumor models. Another hexacyclic aromatic hydrocarbon, dibenzo[c,p]chrysene (DBC), is a unique PAH that possesses one bay region and two fjord regions within the same molecule. Due to its structure, which is a merger of the fjord region PAHs benzo[c]phenanthrene, benzo[c]chrysene, and benzo[g]chrysene, DBC is of considerable research interest. In order to investigate the pathway of regioselective metabolism we have studied the cytotoxicity, metabolic activation and DNA adduct formation of DBC in human mammary carcinoma MCF-7 cells in culture. The cytotoxicity assay indicated undisturbed cell proliferation even at concentrations as high as 4.5 microM (1.5 micro g/ml) DBC. Concurrently, DNA adducts were detected in MCF-7 cells treated with DBC only in low amounts (0.6 pmol adducts/mg DNA). On the contrary, exposure to anti-DBC-1,2-diol-3,4-epoxide and anti-DBC-11,12-diol-13,14-epoxide, two putatively genotoxic metabolites of DBC, resulted in high levels of DNA adducts (33 and 51 pmol adducts/mg DNA, respectively). Although DBC was not efficiently transformed into DNA-reactive metabolites in MCF-7 cells in culture, the results from our study indicate that the two fjord region diol-epoxide derivatives of DBC may serve as ultimate genotoxic metabolites once they are enzymatically generated under certain circumstances in vitro or in vivo.

Dibenzo[a,l]pyrene induced DNA adduct formation in lung tissue in vivo

Polycyclic aromatic hydrocarbons (PAHs) are environmental carcinogens present in the atmosphere from combustion sources such as cigarette smoke, diesel exhaust, residential heating processes, and industrial coke production. To date, dibenzo[a,l]pyrene (DBP) has been found to be the strongest tumor-initiating PAH ever tested in rodent skin and mammary tumor models. Here we show for the first time that systemic exposure to DBP causes DNA damage in mouse lung tissue. C57BL/6 mice were gavaged with 1, 5 or 20 mg DBP/kg body weight, daily for 10 days. Toxicity of DBP was revealed by a decrease in body and organ weight of mice while no apparent cell death was observed on P815 mastocytoma cells (allograft model) in vitro. However, treatment of P815 cells in vitro with the ultimate carcinogenic metabolite of DBP, the fjord region (-)-anti-11,12-diol 13,14-epoxide [(-)-anti-DBPDE], resulted in the total loss of cell viability. Lungs from the animals were removed and subjected to DBP-DNA adduct analysis. A dose dependent adduct formation was revealed by 33P-postlabeling analysis of DNA from lung tissue. The majority of DNA adducts formed in lungs of mice after systemic exposure to DBP were contributed by (-)-anti-DBPDE. The data from this in vivo model are consistent with previous metabolic activation results obtained with DBP in human cells in culture.

Imprinting status of 11p15 genes in Beckwith-Wiedemann syndrome patients with CDKN1C mutations

Beckwith-Wiedemann syndrome (BWS) is an imprinting disorder characterized by somatic overgrowth, congenital malformations, and predisposition to childhood tumors. Aberrant expression of multiple imprinted genes, including H19, IGF2, KCNQ1OT1, and CDKN1C, has been observed in BWS patients. It has been estimated that mutations in CDKN1C occur in 12-17% of BWS patients. We have screened 10 autosomal dominant pedigrees and 65 sporadic BWS cases by PCR/heteroduplex analysis and DNA sequencing and have identified four mutations, two of which were associated with biallelic IGF2 expression and normal H19 and KCNQ1OT1 imprinting. One patient demonstrated phenotypic expression of paternally transmitted mutation in this maternally expressed gene, a second proband is the child of one of a pair of monozygotic twin females who carry the mutation de novo, and a third patient exhibited unusual skeletal changes more commonly found in other overgrowth syndromes. When considered with other studies published to date, this work reveals the frequency of CDKN1C mutations in BWS to be only 4.9%. This is the first report of an analysis of the imprinting status of genes in the 11p15 region where CDKN1C mutations were associated with loss of IGF2 imprinting and maintenance of H19 and KCNQ1OT1 imprinting.

District nurses and home carers 3: project evaluation

This article, the last in a series of three, discusses the evaluation of a project established to provide a programme of education for social services' home carers that focused on the development of skills relating to care work. This education was delivered by district nurses (DNs) to address a number of problems associated with the provision of personal care identified by the home carers and their DN colleagues. An action research framework was used to improve collaborative working between the staff of the two disciplines. The article outlines some of the key findings from the evaluation of the project in relation to the structure, the process and the outcome of the project. The project evaluation was mainly positive and this success can be partly attributed to the fact that an action research method was used to drive the project.

First-trimester prenatal sonographic findings associated with OEIS (omphalocele-exstrophy-imperforate anus-spinal defects) complex: a case and review of the literature

First-trimester sonographic findings associated with omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex and review of the literature regarding this rare congenital anomaly are presented.

Alterations in glomerular permeability in streptozotocin-induced diabetic rats

The alteration in glomerular basement membrane permeability associated with microangiopathy in streptozotocin-induced diabetic rats was studied by determining the movement across the glomerular basement membrane of anionic ferritin probes injected into rats at different points in the development of the disease. Visualization of the concentration gradient of anionic ferritin and changes in ultrastructure was accomplished by electron microscopic examination of renal tissue prepared from both control and diabetic rats. In all control rats, the anionic ferritin did not leave the glomerular capillary lumen, nor were there any changes in the normal morphology of the glomerular capillary wall. In the diabetic animals, the concentration of anionic ferritin shifted from the capillary lumen in the abluminal direction. Distinct morphologic changes, such as widening of endothelial intercellular junctions, focal detachment of podocyte foot processes, and extensive thickening of the glomerular basement membrane, were noted in the diabetic rat, and these changes appear to correlate with the observed increase in permselectivity of anionic ferritin across the glomerular capillary wall.

Prenatally detected fragile X females: long-term follow-up studies show high risk of mental impairment

The prenatal detection of a positive fragile X [fra(X)] female raises difficult counseling issues. In order to address questions regarding the long term outlook, we have conducted follow-up studies on 4 fra(X) positive females which were carried to term. Three were prenatally detected, and one was a false negative. The subjects were between 3 and 7 years old when follow-up investigation of mental status was conducted. The first case age, 6 and 9/12 years, had an IQ of 106. On measures of achievement she had some difficulty with arithmetic. The second and third cases were clearly affected. They were judged to be mildly to moderately mentally retarded. The fourth case was borderline normal. The prenatal amniocentesis cytogenetic frequencies had a mean of 3.74% (range 0-8.5%). On postnatal follow-up testing of blood, the mean cytogenetic frequency increased to 31.75% (range 24-47%), an 8.5 fold increase. Follow-up DNA samples from 3 of the 4 subjects were analyzed for underlying DNA mutations using probe StB12.3 which detects insertions and methylation status of the FMR-1 gene. All 3 showed an affected female genotype with a large insert (greater than 500bp) and complete CpG island methylation. We conclude: (1) prenatally detected cytogenetic frequencies of females increase by an average 8.5 fold on follow-up postnatal studies, (2) genetic counseling should indicate the risks to be affected are approximately 75% when a positive female is prenatally detected, (3) DNA testing can help determine carrier status but may not accurately predict whether a female will be mentally affected.

Electron microscopy of changes in lower extremity muscles in Duchenne muscular dystrophy

Duchenne muscular dystrophy is a genetic disease with a sex-linked pattern of inheritance. This disease is present at birth, becomes symptomatic during early childhood, leads to inability to walk near the end of the first decade, and usually results in death by the end of the second decade. In this study, the extensor digitorum longus and soleus muscles from genetically dystrophic mice were examined at the electron microscopic level. The authors describe their results and discuss how these findings might provide some insight into one of the mechanisms of fiber necrosis in Duchenne muscular dystrophy.

Significance of capillary basement membrane changes in diabetes mellitus

Diabetes mellitus is a disease in which the capillary basement membranes are substantially altered. This diabetic microangiopathy is characterized by a thickening of the basement membrane and changes in its permeability characteristic due to a disturbance in the production and distribution of its functional components. Glucose metabolism and insulin imbalance have been implicated in these basement membrane modifications. The authors describe normal capillary basement membrane architecture and then discuss how pathologic changes caused by diabetes mellitus are related to diabetic foot pathology.

Absence of binding and impermeability to ferritins of gill endothelium in marine teleosts

The surface binding characteristics and permeability properties of the endothelium of secondary lamellae from the gills of several species of marine teleosts were investigated by introducing cationized ferritin and native ferritin into the microcirculation under normal environmental conditions. Neither type of ferritin bound to the luminal surface of the gill endothelium. No transcellular movement of cationized ferritin was detected, either via transendothelial channels or individual vesicles, nor was passage of cationized ferritin through the tight intercellular junctions of the endothelium observed. Anionic binding sites in the endothelial basement membranes could not be identified. Binding and transport of ferritin were unaffected by normal changes in environmental temperatures over the range of -2 to + 15°C. These findings suggest that the endothelial cell surface of the gills from these fishes is a primary barrier to the extracapillary movement of blood borne constituents.

Colocalization of prolactin and growth hormone within specific adenohypophyseal cells in male, female, and lactating female rats

The localization of PRL and GH within adenohypophysial cells has been investigated with immunocytochemical methodology using colloidal gold of different sizes. Classically, using morphological criteria at the light and electron microscope levels, two types of individual cells have been described which, it is believed, exclusively produce either PRL or GH, i.e. mammotrophs and somatotrophs. Since it has been reported that some gonadotrophs may colocalize and secrete both FSH and LH, and that some unidentified cells release both PRL and GH, we designed a study to investigate whether PRL and GH are present only in their respective specific cells or may be colocalized in mammotrophs and somatotrophs or possibly other types of cells within the pars distalis. Using immunocytochemistry at the electron microscope level we were able to label the two hormones with different sizes of colloidal gold bound to a second antibody and visualize them within pituitary cells. Two different primary antibodies to PRL and GH as well as a more purified antibody to GH were used. Pituitaries from cycling and lactating female rats and adult males were processed appropriately for electron microscopic studies. After sectioning, individual grids were treated with either primary antibodies for PRL or GH, or the same grid was treated sequentially with these two antibodies. All primary antibodies were absorbed with the heterologous hormone before usage. The second antibodies were bound to colloidal gold particles of either 10 nm (for GH) or 20 nm (for PRL) diameter, so that selective visualization of the two hormones could be achieved within the same cells. It was observed that mammotrophs immunolabeled only for PRL, and somatotrophs labeled only for GH regardless of the source of the antibody. However, an atypical small granule cell, a possible mammosomatotroph, colabeled consistently for both PRL and GH in all types of animals used and with antibodies from all of above sources. This report gives for the first time morphological evidence for the existence of pituitary cells that colocalize both PRL and GH in the normal rat pituitary gland. The possibility that these bihormonal cells represent stem cells which may give rise to both mammotrophs and somatotrophs under appropriate stimulation or that they may release both hormones under the influence of unspecific stimuli is suggested.

Hepatitis associated antigen and the ABO locus in Down's syndrome

The recent observation by Arndt-Hansen et al. (1974) of increased frequency of blood group A over group O in blood donors positive for the hepatitis associated antigen has been investigated in Down's syndrome, in order to establish if this could account for the increased frequency of the antigen in that syndrome. Seventy-one of 227 subjects with Down's syndrome (31.3%) were found to be positive for the antigen by haemagglutination, and comparison of these with the HAA-subjects failed to reveal any differences in the ABO blood groups.

Serum and tissue proteins in tuberous sclerosis. I. Serum and red-cell polymorphic systems

5 serum protein polymorphic systems (haptoglobin, alkaline phosphatase, group-specific (Gc) proteins, beta2-glycoprotein 1 and leucine aminopeptidase) and 6 red-cell polymorphisms (adenosine deaminase, adenylate kinase, phosphoglucomutase, glutamic-pyruvic transaminase, phosphogluconate dehydrogenase and acid phosphatase) have been investigated in 54 subjects with tuberous sclerosis. The frequencies of all systems were compared with those of a control sample drawn from a similar mentally retarded population and abnormal distributions were detected in the haptoglobin and Gc system. Quantitative estimation of the serum levels of the Gc protein failed to detect any inter-group differences. Data on the deviations from the Hardy-Weinberg equlibrium, Haldane's Log ratio test between groups, and gene frequencies of both test and control groups are given. It is suggested that selection by mortality is the possible causation for the abnormal distribution of the Gc phenotypes, but the haptoglobin phenotype distribution requires further investigation with care being taken in the selection of control subjects.