Specialist alcohol liaison services in general hospitals improve engagement in alcohol rehabilitation and treatment outcome

OBJECTIVE

To examine the impact of providing a specialist addictions trained psychiatric nurse on outcome of alcohol treatment in patients presenting to general medical and surgical wards of a district general hospital. Before introducing the specialist alcohol liaison service, a range of staff including a consultant liaison psychiatrist, junior psychiatrists and community psychiatric nurses trained in liaison psychiatry assessed this patient group.

METHOD

A retrospective review of all alcohol liaison referrals with ICD-10 defined alcohol misuse was performed for one year. Comparison data for the first 100 referrals to the specialist alcohol liaison service were obtained prospectively. Indicators included diagnosis at referral, and engagement in and completion of alcohol rehabilitation.

RESULTS

The rates of completion of a four to six week period of alcohol rehabilitation were significantly better after introduction of the Specialist Alcohol Liaison Service. Of those who commenced alcohol rehabilitation, 88% completed, compared to 40% in the traditional assessment service (p < 0.0001).

CONCLUSION

Specialist addictions trained staff in the assessment and management of alcohol dependent patients in medical and surgical wards produce a better immediate outcome than their non-specialist colleagues. This may have implications for service design.

Structure-based design of caspase-1 inhibitor containing a diphenyl ether sulfonamide

A series of compounds was designed and prepared as inhibitors of interleukin-1beta converting enzyme (ICE), also known as caspase-1. These inhibitors, which employ a diphenyl ether sulfonamide, were designed to improve potency by forming favorable interactions between the diphenyl ether rings and the prime side hydrophobic region. An X-ray crystal structure of a representative member of the diphenyl ether sulfonamide series bound to the active site of caspase-1 was obtained.

Q-switched Alexandrite laser in the treatment of pigmented macules in Laugier-Hunziker syndrome

We report clearance of pigmented macules on the lips of two subjects with Laugier-Hunziker syndrome using the Q-switched Alexandrite laser. Recurrence of two macules was noticed in one case 6 months after treatment and the lesions were successfully retreated. This report evaluates the efficacy and side-effect profile of the Q-switched Alexandrite laser in the treatment of lentigines in this syndrome.

The reliability of case register diagnoses: a birth cohort analysis

BACKGROUND

Few studies assess the reliability of case register diagnoses, despite their widespread use in psychiatric research. This study investigates case register diagnostic reliability in comparison to casenote derived diagnoses in a birth cohort.

METHODS

Diagnostic information from the case register and casenotes of 449 individuals was extracted. The incident and lifetime register diagnoses were compared with those derived from the casenotes.

RESULTS

Inter-rater reliability was good (kappa = 0.71). Agreement between casenote and incident register diagnosis was moderate (kappa = 0.52), as was agreement between casenote and register lifetime diagnosis (kappa = 0.58). Case register diagnoses were insufficiently accurate to stand alone. Case register diagnoses for organic disorder, schizophrenia, alcoholism, learning disability, personality disorder and transient or no psychiatric disorder were reliable enough for the case register to act as a useful screening instrument. The case register was not acceptable, even as a screening instrument, for the diagnoses of neurotic or affective disorders.

CONCLUSIONS

Studies relying only on case register diagnoses may be flawed if diagnoses are not independently verified. National statistics derived from case register data, especially for neurosis and affective disorder, may be unreliable.

Mohs micrographic surgery for the treatment of in situ nail apparatus melanoma: a case report

Nail apparatus melanoma (or subungual melanoma) is rare and accounts for only 1.4% of all cutaneous melanomas in the United Kingdom. We report the use of fixed-tissue Mohs micrographic surgery to treat a biopsy-proven Clark level I in situ nail apparatus melanoma, presenting with diffuse longitudinal melanonychia.

Excision of selected skin tumours using Mohs' micrographic surgery with horizontal paraffin-embedded sections

Histological interpretation of frozen sections made during Mohs' micrographic surgery may be difficult, depending on the morphological and staining characteristics of the tumour and on the nature of the associated inflammatory infiltrate. We have employed an adaptation of micrographic surgery in which horizontal, formalin-fixed, paraffin-embedded sections were used to improve histological assessment in the excision of 18 non-melanoma skin tumours in which frozen sections had been or were likely to be unsatisfactory. We describe our experience of this method in the management of squamous cell carcinomas (11), extramammary Paget's disease (two), microcystic adnexal cell carcinomas (two), dermatofibrosarcoma protuberans (two), and primary cutaneous neuroendocrine carcinoma (Merkel cell carcinoma) (one). The use of horizontal paraffin-embedded sections lengthens the duration of the procedure but facilitates accurate assessment of histological sections in selected tumours.

Treatment of proliferative haemangiomas with the 585 nm pulsed dye laser

Haemangiomas usually develop within the first few weeks of life, most regressing spontaneously before the age of 7 years. Some may ulcerate or compromise a vital function, in which case systemic corticosteroids, surgery or radiotherapy may be helpful. All of these treatment modalities are associated with significant morbidity. Treatment with the 585 nm flashlamp pulsed dye laser is safe and effective in the management of superficial vascular malformations. We report seven patients, under 12 months of age, who presented with proliferative haemangiomas, causing functional impairment. Ulcerated lesions were present in four patients. The patients were treated with the 585 nm pulsed dye laser (fluences 7.0-9.25 J/cm2), at intervals of 4-8 weeks. All of the lesions showed a significant reduction in size, together with improvement in the colour and integrity of the overlying skin. Treatment with the 585 nm pulsed dye laser should be considered in the management of infants with early proliferative haemangiomas, in whom intervention is indicated.

Basal cell carcinoma: rapid techniques using cytokeratin markers to assist treatment by micrographic (Mohs') surgery

In micrographic (Mohs') surgery, routine haematoxylin and eosin stains may present difficulties in interpretation of infiltrative (morphoeic) basal cell carcinoma. To supplement these routine stains rapid immunoperoxidase and immunofluorescence techniques are described using cytokeratin markers Dako LP34, MNF 116 or Novocastra NCL-Pan CK on frozen sections to help in the histological evaluation of these tumours.

Crystal structure of the cysteine protease interleukin-1 beta-converting enzyme: a (p20/p10)2 homodimer

Interleukin-1 beta-converting enzyme (ICE) proteolytically cleaves pro-IL-1 beta to its mature, active form. The crystal structure at 2.5 A resolution of a recombinant human ICE-tetrapeptide chloromethylketone complex reveals that the holoenzyme is a homodimer of catalytic domains, each of which contains a p20 and a p10 subunit. The spatial separation of the C-terminus of p20 and the N-terminus of p10 in each domain suggests two alternative pathways of assembly and activation in vivo. ICE is homologous to the C. elegans cell death gene product, CED-3, and these may represent a novel class of cytoplasmic cysteine proteases that are important in programmed cell death (apoptosis). Conservation among members of the ICE/CED-3 family of the amino acids that form the active site region of ICE supports the hypothesis that they share functional similarities.

Penile melanosis successfully treated with the Q-switched ruby laser

Penile melanosis is an uncommon benign primary pigmentary disorder affecting the penile shaft and/or glans. We report the successful treatment of penile melanosis using the Q-switched ruby laser.

The use of Q-switched Nd:Yag laser for removal of permanent eyeliner tattoo

We present the results of a pilot study of the use of Nd:Yag laser in the removal of permanent eyeliner tattoos. Fourteen eyelids were treated, and in all cases a reduction in pigmentation was achieved although responses were variable. The advantages of such therapy over existing techniques are described. The technique offers a useful reduction of permanent eyeliner pigmentation and is particularly suited to treatment of localized areas of imperfect application or pigment migration.

Micrographically controlled excision (Mohs' surgery) of basal cell carcinoma around the eye. Combined dermatological surgical clearance and oculoplastic surgical repair

Periorbital infiltrative basal cell carcinomas are notoriously difficult to treat, particularly those around the medial canthus. Micrographically controlled excision with horizontal frozen sections (Mohs' surgery) allows for clearance of the tumour with minimal loss of normal tissue. Once the tumour has been completely removed, the defect can be repaired by the oculoplastic surgeon for the best functional and cosmetic result. This is the ideal treatment for tumours with a contiguous growth pattern that are liable to be seriously over or under treated by other modalities. The technique requires special training for both the operator and the Medical Laboratory Scientific Officer (MLSO). It is costly in time and manpower but in selected cases, where recurrent tumour is most dangerous and where tissue conservation is paramount, it may be invaluable. Close collaboration between dermatological and oculoplastic surgeons in such cases probably offers the patient the best treatment and outcome.

Methodology employed for the structure determination of tumour necrosis factor, a case of high non-crystallographic symmetry

The structure of the protein tumour necrosis factor (TNF) was determined from crystals of space group P3(1)21 which contain six copies of the TNF monomer per crystallographic asymmetric unit [Jones, Stuart & Walker (1989). Nature (London), 338, 225-228]. The nature of these crystals (relatively high crystallographic symmetry coupled with multiple copies of the protein in the asymmetric unit) led to some peculiarly challenging problems at several points in the structure determination. In particular, (1) self-rotation function calculations failed to yield clearly interpretable solutions, (2) the analysis of difference Patterson maps for heavy-atom derivatives required the development of a Patterson search program suite GROPAT. The redundancy in the asymmetric unit allowed refinement of poor-quality isomorphous phases at 4 A resolution and phase extension from 4 to 2.9 A resolution using real-space symmetry averaging and solvent flattening in the absence of any isomorphous phase information. Despite further difficulties caused by structural differences between the six independent copies of the monomer the resultant electron density map was of high quality and proved to be easily interpretable.

Amelanotic lentigo malignant melanoma: a case report and review of the literature

A patient with an amelanotic lentigo malignant melanoma is presented which manifested itself initially as an erythematous flare with the subsequent development of nodules. The diagnosis was only made histologically. A computer search of the literature revealed 6 previous cases, and a review of these rare tumours is presented.

Refined structure of the acetazolamide complex of human carbonic anhydrase II at 1.9 A

The binding of acetazolamide to human carbonic anhydrase II (HCA II) has been investigated by X-ray crystallography. The atomic positions of the enzyme inhibitor complex have been refined at 1.9 A resolution using the least squares refinement program package PROLSQ. The crystallographic R-factor is 17.6%. The bound inhibitor is clearly resolved in the active site of the enzyme. The acetazolamide amine group is bound as a fourth ligand to the zinc ion, the other three are all histidine residues. In addition to van der Waals' interactions and the previously described binding of the sulphonamide group, the inhibitor forms a hydrogen bond from the carbonyl oxygen of the acetylamido group to the amino group of Gln 92.

The structure of tumour necrosis factor--implications for biological function

The three-dimensional structure of TNF has been determined at 0.29 nm using the technique of X-ray crystallography. Published data on site-directed mutagenesis and antibody binding may now be assessed in the light of the structure, thus the links between structure and function for TNF may be addressed. TNF is a compact trimer composed of three identical subunits of 157 amino acids. The main-chain topology for a single subunit is essentially a beta-sandwich structure formed by two anti-parallel beta-pleated sheets. This mainchain fold corresponds to the 'jelly roll' motif observed in viral coat proteins such as VP1, VP2 and VP3 of rhinovirus, or the hemagglutinin molecule of influenza. TNF is the first non-viral protein to contain this motif. The subunits associate tightly about a threefold axis interacting through a simple edge-to-face packing of the beta-sandwich to form the solid, conical shaped trimer. A large number of the residues conserved between the amino acid sequences of TNF and lymphotoxin lie within the beta-sandwich or at the threefold axis of the trimer. This implies the presence of the same beta-sandwich motif in the lymphotoxin monomer and preservation of the edge-to-face mode of trimeric association. The detailed three dimensional structure for TNF explains a wide range of observations, including data on antibody binding and site directed mutagenesis. The currently available evidence points to a region of biological importance situated at the interface between two subunits on the lower half of the trimer.

Micrographic (MOHS') surgery in the management of periocular basal cell epitheliomas

The use of fresh tissue micrographic surgery offers distinct advantages over other currently available forms of treatment in the management of primary and recurrent periocular basal cell epitheliomas. The technique is described and the results of a prospective study of 22 patients are presented. The advantages in terms of both surgery of tumour excision and tissue preservation are discussed. We conclude that micrographic surgery has a definite role to play in the management of certain periocular basal cell epitheliomas.

Refined structure of baboon alpha-lactalbumin at 1.7 A resolution. Comparison with C-type lysozyme

The solution of the structure of alpha-lactalbumin from baboon milk (Papio cynocephalus) at 4.5 A resolution using the isomorphous replacement method has been reported previously. Initial refinement on the basis of these low-resolution studies was not successful because of the poor isomorphism of the best heavy-atom derivative. Because of the striking similarity between the structure of lysozyme and alpha-lactalbumin, a more cautious molecular replacement approach was tried to refine the model. Using hen egg-white lysozyme as the starting model, preliminary refinement was performed using heavily constrained least-squares minimization in reciprocal space. The model was further refined using stereochemical restraints at 1.7 A resolution to a conventional crystallographic residual of 0.22 for 1141 protein atoms. In the final model, the root-mean-square deviation from ideality for bond distances is 0.015 A, and for angle distances it is 0.027 A. The refinement was carried out using the human alpha-lactalbumin sequence and "omit maps" calculated during the course of refinement indicated eight possible sequence changes in the baboon alpha-lactalbumin X-ray sequence. During the refinement, a tightly bound calcium ion and 150 water molecules, of which four are internal, have been located. Some of the water molecules were modelled for disordered side-chains. The co-ordination around the calcium is a slightly distorted pentagonal bipyramid. The Ca-O distances vary from 2.2 A to 2.6 A, representing a tight calcium-binding loop in the structure. The calcium-binding fold only superficially resembles the "EF-hand" and presumably has no evolutionary relationship with other EF-hand structures. The overall structure of alpha-lactalbumin is very similar to that of lysozyme. All large deviations occur in the loops where all sequence deletions and insertions are found. The C terminus appears to be rather flexible in alpha-lactalbumin compared to lysozyme. The experimental evidence supports the earlier predictions for the alpha-lactalbumin structure that were based upon the assumption that alpha-lactalbumin and lysozyme have similar three-dimensional structures, with minimal deletions and insertions. A detailed comparison of the two structures shows striking features as well as throwing some light on the evolution of these two proteins from a common precursor.

Structure of tumour necrosis factor

Tumour necrosis factor is a trimeric molecule, each subunit of which consists of an antiparallel beta-sandwich. Individual subunits from the trimer by a novel edge-to-face packing of beta-sheets. A comparison of the subunit fold with that of other proteins reveals a remarkable similarity to the 'jelly-roll' structural motif characteristic of viral coat proteins.

Mouse skin photosensitivity with dihaematoporphyrin ether (DHE) and aluminium sulphonated phthalocyanine (AlSPc): a comparative study

Skin photosensitivity of sun exposed sites is the major side effect of dihaematoporphyrin ether (DHE) photodynamic therapy (PDT). Reports of severe oedema and erythema have generally been anecdotal. We have studied aluminium sulphonated phthalocyanine (AlSPc) as a potential photosensitiser for PDT. In this paper we report our work comparing the skin photosensitivity reactions of DHE and AlSPc. We have studied: (i) the time course of the skin reactions, (ii) the effect of increasing time from administration of photosensitiser to irradiation, (iii) drug-skin reaction dose response. Groups of Skh I female hairless albino mice were given an intravenous bolus dose of either 0.9% saline solution, AlSPc or DHE (Photofrin II). Drug doses ranged from 0.5 to 50 mg/kg. At times ranging from 1 h to 1 month animals were irradiated with a range of doses of solar simulated radiation (SSR). The skin reaction was observed over a 2 week period. DHE reactions were always more severe than those with AlSPc. Peak skin reaction was seen at 3 h for DHE and 6 h for AlSPc. DHE reactions were still visible 2 weeks after irradiation whereas the AlSPc reaction disappeared by 48 h. Irradiation evoked a reaction up to 2 months after administration of DHE but only up to 2 weeks with AlSPc. The mean SSR dose at which a skin reaction was seen decreased with increasing dose of both agents. The rate of decrease was slower with AlSPc than DHE. This study suggests that in PDT, AlSPc will cause much less skin photosensitivity than DHE.

The meaning of "physical fitness"

The understanding of the term "physical fitness" was determined for a randomly selected sample (n = 94) of a population using a self-administered mailed questionnaire. Subjects were asked to state and give a reason for their perceived level of physical fitness, to state their perceived performance level in a number of physical fitness tests (muscular strength, daily physical work capacity, fatness, level of regular physical exercise, exercise speed, and body flexibility), and to rate how well these tests measure physical fitness. The reason most frequently stated for perceived level of physical fitness was the level of habitual physical activity (43%); significantly less frequently (P less than 0.01-0.0001) cited were reasons related to health (23%), physical performance (12%), and obesity (3%). The variation in perceived level of physical fitness was best explained by the variation in imagined regular exercise and fatness (r2 = 0.66, P less than 0.0001) with no significant additional contribution from imagined performance in remaining fitness tests. The measurement of regular exercise was most favored as a test of physical fitness. These results, taken together with evidence of the physical and psychological health benefits of regular exercise, imply that the most appropriate measure of physical fitness for the average person is an assessment of the habitual physical activity level.

Alpha-lactalbumin possesses a novel calcium binding loop

Calcium performs a unique role in biology, achieving biological effects through highly specific interactions with and modulation of target proteins. It has been proposed that calcium-modulated proteins possess a characteristic, evolutionarily related, binding fold, known as the EF-hand. The high-resolution X-ray structure of alpha-lactalbumin reveals a Ca2+ binding fold that resembles an EF-hand only superficially and presumably has no evolutionary relationship with it. However, there is clear homology with the corresponding loop in c-type lysozyme (the 'parent' molecule of alpha-lactalbumin). This study, at 1.7 A resolution, represents one of the most accurate analyses of a calcium binding protein yet reported.

Possible hazards from irradiation with the carbon dioxide laser

Previous investigators, using relatively high irradiance levels, have been unable to demonstrate viable tissue in the plume during carbon dioxide laser vaporization. Our study was undertaken to reinvestigate this possibility, particularly at the lower irradiance levels that are currently in clinical use. Fresh post-mortem skin was injected with a known quantity of bacterial spores and vaporized at different levels of irradiance and energy fluence. The plume and splatter were collected and cultured. Spores were found following the vaporization of five of 13 specimens treated at an irradiance of less than 500 W/cm2, while there were none in the 20 specimens treated at an irradiance of greater than 997 W/cm2. These results show that the widely accepted assumption that the carbon dioxide laser produces a sterile field may be false and that viable particles may be disseminated during vaporization at low irradiance. This may be important when considering the treatment of potentially infectious lesions.

Aerobiology of irradiation with the carbon dioxide laser

The ability of a carbon dioxide laser to scatter debris and aerosolize bacteria from human skin was tested by collecting the aerosols liberated with glass impingers together with a slit sampler. Two sets of tests were done--one to detect dispersal of cells from treatment of rodent ulcers or warts, and the other on pieces of skin obtained from autopsy material, which had been injected with spores. With low power levels a few bacterial particles were collected, together with some whole cells, however, at levels greater than 750 W cm-2 all the cultures were sterile.

Elephantine sarcoidosis presenting as ulcerating lymphoedema

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Acarboxy prothrombin in cord plasma from normal neonates

Acarboxy prothrombin was detected in the plasma of 48 of 128 umbilical cord plasma samples and in all of 65 patients receiving coumadin. None was found in 20 normal adults. Although the prevalence was the same in blacks, whites, and neonates of mixed origin, levels were significantly higher in blacks. There was a negative correlation between the level of acarboxy prothrombin and the prothrombin index. There was no correlation between maternal age, birth weight, gestational age, obstetrical complications, race, socioeconomic status, albumen, or alpha-foetoprotein and the incidence of cord plasma acarboxy prothrombin.

Identification of a heparin activated amidolytic enzyme in carp (Cyprinus carpio) plasma

A heparin activated amidolytic enzyme capable of cleaving synthetic thrombin sensitive chromogenic substrates was identified from the plasma of the carp (Cyprinus carpio). Activation was inhibited by KCl, protamine sulphate and human plasma. Heparin was not required for the continued action of the enzyme. Active enzyme was irreversibly inhibited by DFP. The pH and temperature optima was studied and the enzyme semi purified by Sephadex G100 superfine and Sephadex A50 chromatography. An approximate MW of 62,000 was found. Activity generated by as little as 0.002 units of heparin per ml carp plasma was detected. The trivial name carpamidase is proposed for the enzyme.

Sequence and structure of yeast phosphoglycerate kinase

The structure of yeast phosphoglycerate kinase has been determined with data obtained from amino acid sequence, nucleotide sequence, and X-ray crystallographic studies. The substrate binding sites, as deduced from electron density maps, are compatible with known substrate specificity and the stereochemical requirements for the enzymic reaction. A carboxyl-imidazole interaction appears to be involved in controlling the transition between the open and closed forms of the enzyme.

A rapid chromogenic method for the determination of prothrombin precursor in plasma

A method was described for the quantitation of precursor prothrombin using a chromogenic substrate S2238 and Dispholidus typus venom. Prothrombin precursor was detected in the adsorbed plasma of all 65 patients on coumadin therapy tested, but was absent in 20 controls. The technic offered a rapid and sensitive method for determining if a prolonged prothrombin time is due to vitamin K antagonism or deficiency.