Making waves: nurse-led urgent community response

Anyone in England over 18 whose health or wellbeing suddenly deteriorates at home will have access to an urgent community response (UCR) team within 2 hours by April 2022. Community nursing services are providing the core service model to provide these crisis response services. Nurse leads from three UCR accelerator sites (Kirklees, Warrington and Bromley) elaborate on how they are making waves of change for the better, using their clinical skills and building key relationships with other health services. Acutely unwell patients are being seen by practitioners with advanced assessment skills, which keeps eight out of 10 patients at home safe, avoiding hospital admission.

Gene exchange drives the ecological success of a multi-host bacterial pathogen

The capacity for some pathogens to jump into different host-species populations is a major threat to public health and food security. Staphylococcus aureus is a multi-host bacterial pathogen responsible for important human and livestock diseases. Here, using a population-genomic approach, we identify humans as a major hub for ancient and recent S. aureus host-switching events linked to the emergence of endemic livestock strains, and cows as the main animal reservoir for the emergence of human epidemic clones. Such host-species transitions are associated with horizontal acquisition of genetic elements from host-specific gene pools conferring traits required for survival in the new host-niche. Importantly, genes associated with antimicrobial resistance are unevenly distributed among human and animal hosts, reflecting distinct antibiotic usage practices in medicine and agriculture. In addition to gene acquisition, genetic diversification has occurred in pathways associated with nutrient acquisition, implying metabolic remodelling after a host switch in response to distinct nutrient availability. For example, S. aureus from dairy cattle exhibit enhanced utilization of lactose-a major source of carbohydrate in bovine milk. Overall, our findings highlight the influence of human activities on the multi-host ecology of a major bacterial pathogen, underpinned by horizontal gene transfer and core genome diversification.

Examining the role of protein structural dynamics in drug resistance in Mycobacterium tuberculosis

2D-IR spectroscopy reveals a role for protein structural dynamics in antimicrobial-resistance.

Antimicrobial resistance represents a growing global health problem. The emergence of novel resistance mechanisms necessitates the development of alternative approaches to investigate the molecular fundamentals of resistance, leading ultimately to new strategies for counteracting them. To gain deeper insight into antibiotic–target interactions, the binding of the frontline anti-tuberculosis drug isoniazid (INH) to a target enzyme, InhA, from Mycobacterium tuberculosis was studied using ultrafast two-dimensional infrared (2D-IR) spectroscopy and molecular simulations. Comparing wild-type InhA with a series of single point mutations, it was found that binding of the INH–NAD inhibitor to susceptible forms of the enzyme increased the vibrational coupling between residues located in the Rossmann fold co-factor binding site of InhA and suppressed dynamic fluctuations of the enzyme structure. The effect correlated with biochemical assay data, being reduced in the INH-resistant S94A mutant and absent in the biochemically-inactive P193A control. Molecular dynamics simulations and calculations of inter–residue couplings indicate that the changes in coupling and dynamics are not localised to the co-factor binding site, but permeate much of the protein. We thus propose that the resistant S94A mutation circumvents subtle changes in global structural dynamics caused by INH upon binding to the wild-type enzyme that may impact upon the formation of important protein–protein complexes in the fatty acid synthase pathway of M. tuberculosis.

Functional electrical stimulation to the affected lower limb and recovery after cerebral infarction

Functional electrical stimulation (FES) may improve recovery after stroke. We studied its effects in 38 postcerebral infarct patients. Twenty were randomly assigned to receive FES producing ankle dorsiflexion on the affected side and physical therapy. The remaining 18 received physical therapy only. Subjects were evaluated prior to commencing therapy, at its completion after 4 weeks, and again 4 weeks later using functional and electrophysiological measures. Functional deficit in most patients improved (p < 0.01). Although no significant differences were observed when those treated with FES and those not treated were compared at 4 and 8 weeks, there was significant improvement in the rate of recovery using an ambulation score (p < 0.05), and there was a similar trend in the Barthel Index for FES-treated patients (p < 0.1). Our results indicate that FES may confer additional benefit in acute stroke rehabilitation. Further studies are needed to delineate how best to use it.

Public awareness of cancer in Britain: a population-based survey of adults

Objective:

To assess public awareness of cancer warning signs, anticipated delay and perceived barriers to seeking medical advice in the British population.

Methods:

We carried out a population-based survey using face-to-face, computer-assisted interviews to administer the cancer awareness measure (CAM), a newly developed, validated measure of cancer awareness. The sample included 2216 adults (970 males and 1246 females) recruited as part of the Office for National Statistics Opinions Survey using stratified probability sampling.

Results:

Awareness of cancer warning signs was low when open-ended (recall) questions were used and higher with closed (recognition) questions; but on either measure, awareness was lower in those who were male, younger, and from lower socio-economic status (SES) groups or ethnic minorities. The most commonly endorsed barriers to help seeking were difficulty making an appointment, worry about wasting the doctor's time and worry about what would be found. Emotional barriers were more prominent in lower SES groups and practical barriers (e.g. too busy) more prominent in higher SES groups. Anticipated delay was lower in ethnic minority and lower SES groups. In multivariate analysis, higher symptom awareness was associated with lower anticipated delay, and more barriers with greater anticipated delay.

Conclusions:

A combination of public education about symptoms and empowerment to seek medical advice, as well as support at primary care level, could enhance early presentation and improve cancer outcomes.

Assessing socioeconomic status in adolescents: the validity of a home affluence scale

STUDY OBJECTIVE

To examine the completion rate, internal reliability, and external validity of a home affluence scale based on adolescents' reports of material circumstances in the home as a measure of family socioeconomic status.

DESIGN

Cross sectional survey.

SETTING

Data were collected from a school based study in seven schools in the north of England Cheshire over a five month period from September 1999 to January 2000.

PARTICIPANTS

1824 students (1248 girls, 567 boys) aged 13-15 years who were attending normal classes in Years 9 and 10 in 7 schools on the days of data collection.

MAIN RESULTS

Comparatively poor completion rates were found for questions on parental education and occupation while material deprivation items had much higher completion rates. There was evidence that students with poorer material circumstances were less able to report parental education and occupation whereas material based questions showed less bias. A home affluence scale composed of material items was found to have adequate internal reliability and good external validity.

CONCLUSIONS

A home affluence scale based on material markers provides a useful alternative in assessing family affluence in adolescents. Additionally, it prevents exclusion of those less materially well off adolescents who fail to complete conventional socioeconomic status items.

Does this patient have an abnormal systolic murmur?

Our objective was to review the available evidence of the precision and accuracy of the clinical examination for abnormal systolic murmurs. We conducted a MEDLINE search, manually reviewed all reference lists, and contacted authors of published studies. Each study was independently reviewed by 2 observers and graded for methodologic quality. We found that most studies were conducted using cardiologist examiners. In the clinical setting, the reliability of detecting systolic murmurs was fair (kappa, 0.30-0.48). The most useful findings for ruling in aortic stenosis are a slow rate of rise of the carotid pulse (positive likelihood ratio, 2.8-130), mid to late peak intensity of the murmur (positive likelihood ratio, 8.0-101), and decreased intensity of the second heart sound (positive likelihood ratio, 3.1-50). The most useful finding for ruling out aortic stenosis is the absence of murmur radiation to the right carotid artery (negative likelihood ratio, 0.05-0.10). Smaller, lower-quality studies indicate that cardiologists can accurately rule in and rule out mitral regurgitation, tricuspid regurgitation, hypertrophic cardiomyopathy, and echocardiographic mitral valve prolapse. We conclude that the clinical examination by cardiologists is accurate for detecting various causes of abnormal systolic murmurs. Studies of the clinical examination by noncardiologists are needed.

Mirror movements in the alien hand syndrome. Case report

The alien hand syndrome has been associated with different descriptions of abnormal motor behavior. We report on two patients with transient left hemiparesis who remained with limb apraxia and were particularly impaired by a variety of involuntary skilled movements of their apractic limb. After the report and a review of the literature, we discuss the presence of one type of abnormal movement observed in this syndrome. These movements resemble the mirror movements seen in the normal development of motor control and in some pathologic conditions later. Their appearance in the alien hand syndrome seems to demand both intrahemispheric and interhemispheric motor pathway damage.