Training during the COVID-19 pandemic: the experience of public health registrars in the London and Kent, Surrey, Sussex training programme

BACKGROUND

Public Health registrars (SpRs) were an important component of the workforce that contributed to the COVID-19 response. This study explores their contribution and the impact the early stages of the pandemic had on their learning and training.

METHODS

Data were collected from SpRs in the London and Kent, Surrey, Sussex training programme between July and September 2020 through a mixture of questionnaires and semi-structured interviews. A thematic analysis of interview transcripts was undertaken to identify themes.

RESULTS

35/128 SpRs responded to the survey and 11 were interviewed. SpRs were placed across a range of organizations and made a significant contribution to the COVID-19 response. Overall, SpRs learned important skills but working on the response may for some have impacted negatively on training. A number of facilitators and barriers to learning were identified.

CONCLUSION

The study findings highlight the opportunities for learning created by the pandemic. However, changing projects and the desire of SpRs to contribute to the response meant the impacts on training were mixed. Future deployment of SpRs should consider the balance of responsibility and pace when delegating work, as well as the need to supervise effectively and support remote working to maintain good mental wellbeing.

Anaphylaxis with Associated Fibrinolysis, Reversed with Tranexamic Acid and Demonstrated by Thrombelastography

In the surgical setting, fibrinolysis can be a serious complication of anaphylaxis. We present four cases of anaphylaxis that were associated with fibrinolysis during anaesthesia, and the use of the thrombelastograph to demonstrate this haemostatic defect and its correction using tranexamic acid.

Salmonella enterica serovar Enteritidis phage type 4 outbreak associated with eggs in a large prison, London 2009: an investigation using cohort and case/non-case study methodology

In September 2009, an outbreak of Salmonella enterica serovar Enteritidis affected 327 of 1419 inmates at a London prison. We applied a cohort design using aggregated data from the kitchen about portions of food distributed, aligned this with individual food histories from 124 cases (18 confirmed, 106 probable) and deduced the exposures of those remaining well. Results showed that prisoners eating egg cress rolls were 26 times more likely to be ill [risk ratio 25.7, 95% confidence interval (CI) 15.5-42.8, P<0.001]. In a case/non-case multivariable analysis the adjusted odds ratio for egg cress rolls was 41.1 (95% CI 10.3-249.7, P<0.001). The epidemiological investigation was strengthened by environmental and microbiological investigations. This paper outlines an approach to investigations in large complex settings where aggregate data for exposures may be available, and led to the development of guidelines for the management of future gastrointestinal outbreaks in prison settings.

Carbon monoxide from neighbouring restaurants: the need for an integrated multi-agency response

BACKGROUND

Carbon monoxide (CO) is a colourless, odourless toxic gas produced during incomplete combustion of carbon-based fuels. Most CO incidents reported to the UK Health Protection Agency (HPA) are due to faulty gas appliances, and legislation exists to ensure gas appliances are properly installed.

METHODS

We present three CO poisoning incidents of unusual origin reported to the HPA. In each, residents living above restaurants were poisoned after workers left charcoal smouldering overnight in specialist or traditional ovens whilst ventilation systems were turned off. This led to production of CO, which travelled through floorboards and built up to dangerous concentrations in the flats.

RESULTS

Working with local authorities, these incidents were investigated and resolved, and work was conducted to prevent further occurrences.

CONCLUSIONS

The novel nature of these CO incidents led to delays in recognition and subsequent remedial action. Although previously undescribed, it is likely that due to the number of residences built above restaurants and the rising popularity of traditional cooking methods, similar incidents may be occurring and could increase in frequency. Multi-agency response and reporting mechanisms could be strengthened. Awareness raising in professional groups and the public on the importance of correct ventilation of such appliances is vital.

Surveillance of an infectious syphilis outbreak in south London, UK: a comparison of reporting systems

Rising heterosexual syphilis in south London in 2002 prompted Local Enhanced Syphilis Surveillance (LESS) in five of the 10 genitourinary medicine clinics. LESS reported a fall in heterosexual infectious syphilis in 2004 that was corroborated by the National Enhanced Syphilis Surveillance (NESS). However, mandatory clinic Korner Codes 60 (KC60) coding did not support the reported fall; therefore database discrepancies were evaluated. Three databases (KC60, NESS and LESS) were compared in 2004 at selected clinics using clinical notes as the reference. Six clinics participated in NESS. Four clinics participated in both LESS and NESS and three of these clinics were visited. Only 48% (79 of 163) of KC60 infectious syphilis cases were heterosexual, 36% (58 of 163) were men who have sex with men and the rest were incorrectly coded. The NESS and LESS databases captured 80% and 68% of the confirmed heterosexual syphilis cases, respectively. Despite the inaccuracy in mandatory KC60 returns, this surveillance system captured additional heterosexual syphilis cases.

Shear instability of fluid interfaces: stability analysis

We examine the linear stability of fluid interfaces subjected to a shear flow. Our main object is to generalize previous work to an arbitrary Atwood number, and to allow for surface tension and weak compressibility. The motivation derives from instances in astrophysical systems where mixing across material interfaces driven by shear flows may significantly affect the dynamical evolution of these systems.

Quality of care and outcomes of adults with asthma treated by specialists and generalists in managed care

BACKGROUND

The growth of managed health care in the United States has been accompanied by controls on access to specialty physician services. We examined the relationship of physician specialty to treatment and outcomes of patients with asthma in managed care plans.

METHODS

We conducted a mail survey of adult asthma patients who were enrolled in 12 managed care organizations and had at least 2 contacts for asthma (International Classification of Diseases, Ninth Revision, Clinical Modification code 493.x) during the previous 24 months; we also surveyed their treating physicians. This report concerns 1954 patients and their 1078 corresponding physicians. Treatment indicators included use of corticosteroid inhalers, use of peak flow meters, allergy evaluation, discussion of triggers, and patient self-management knowledge. Outcome measures included canceled activities, hospitalization or emergency department visits, asthma attacks, workdays lost, asthma symptoms, physical and mental health, overall satisfaction with asthma care, and satisfaction with communication with physicians and nurses.

RESULTS

Significant differences were noted for patients of specialists and experienced generalists compared with those of generalist physicians. Peak flow meter possession was reported by 41.9% of patients of generalists, 51.7% of patients of experienced generalists, and 53.8% of patients of pulmonologists or allergists. Compared with patients of generalists, outcomes were significantly better for patients of allergists with regard to canceled activities, hospitalizations and emergency department visits for asthma, quality of care ratings, and physical functioning. Patients of pulmonologists were more likely to rate improvement in symptoms as very good or excellent.

CONCLUSIONS

In a managed health care setting, physicians' specialty training and self-reported expertise in treating asthma were related to better patient-reported care and outcomes.

Factors associated with time to first hip fracture

OBJECTIVE

To examine the relationship between risk factors associated with first hip fracture ever and its time to first fracture.

METHODS

Data were from the Longitudinal Study on Aging. Of the 7,527 participants, 334 sustained a first hip fracture between 1984 and 1991.

RESULTS

Results from the Cox proportional hazards model indicate the time to first fracture was inversely related to the number of risk factors involved. The risk factors significantly associated with first fracture were increasing age, female, Caucasian race, history of falls, insufficient exercise, infrequent church attendance (a likely proxy for outside the home activities), hospitalization in the year before the study, and low body mass index.

CONCLUSION

As the number of risk factors increases, the estimated time to fracture becomes shorter; thus, the window of opportunity for prevention is smaller. To reduce the incidence of first hip fracture and to prolong the time to first fracture, interventions should focus on modifiable risk factors identified: increasing exercise, increasing outside-the-home activities, and improving or maintaining body mass index.

Self-reported preclinical disability identifies older women with early declines in performance and early disease

There appears to be a preclinical stage of physical disability which precedes onset of task difficulty (disability) in those who develop disability progressively as a result of chronic disease. Such a stage provides a basis for identifying older adults at risk of becoming disabled. This cross-sectional study evaluated whether a preclinical stage of physical function identified by self-report is associated with decrements in objective physical performance measures or increases in disease; that is, whether these measures, in those with preclinical disability, are intermediate between individuals who report no difficulty and no preclinical changes and those who report difficulty. The Women's Health and Aging Study II, an observational study of 436 women 70-80 years of age who were among the two-thirds least disabled living in the community. Participants were sampled from the HCFA Medicare eligibility lists and were determined eligible if they reported no difficulty, or difficulty in only one of four domains of physical function: mobility, upper extremity, IADL and ADL tasks. At the first follow-up (18 months after baseline), participants completed questionnaires on physical functioning for tasks in each of these domains, with possible answer options for each task: they had (1) difficulty (disabled); (2) no difficulty and no modification of task performance (High Function); or (3) no difficulty but reported modification and/or change in frequency of task performance (a self-report measure of preclinical disability predictive of incident difficulty). At the same visit, standardized, objective measures of function and disease were obtained, including measured walk; chair stands; strength: hip flexion, knee extension, ankle dorsiflexion, and grip; balance: function reach, single leg stand, tandem stand; joint exam: hip pain on passive motion and knee pain or tenderness; spirometry; ankle:arm blood pressure ratio; visual function: acuity, contrast sensitivity, stereopsis; and graded treadmill exercise test. Data were analyzed from the first follow-up examination. Physical performance decreased, and disease frequency increased, in association with decreasing self-reported mobility function (in walking one-half mile and climbing 10 steps), across three self-report categories: High Function, Preclinical Disability (Task Modification but No Difficulty) and Disability (Difficulty). These findings pertained for measures of walking speed, balance, strength, and knee and hip osteoarthritis. Self-reported level of function predicted differences in ranges as well as means for walking speed, balance and strength. These findings indicate a physiologic basis for self-reported function, including preclinical disability, specifically that different levels of disease severity, impairments and physical performance are concurrently associated with different categories of self-reported function. They also suggest new avenues for screening and intervention to prevent disability.

An outbreak of hepatitis A among young men associated with having sex in public venues

An increase in hepatitis A virus (HAV) infection was noted among young men in the former Thames regions during 1997. A retrospective case-control study, using a standardised questionnaire at interview, was conducted in the area most affected (London and East Sussex) to investigate the hypothesis that this increase was mainly among homosexual men and to establish the risk factors associated with transmission. Forty-eight cases and 161 controls completed questionnaires. Forty-one cases (85%) described their sexuality as homosexual (p < 0.0001). Cases were more likely than controls to have eaten shellfish (Odds Ratio (OR) 2.4; 95% Confidence Interval (CI) 1.16, 5.04) during the two months before onset of illness. Cases had more sexual partners (p = 0.015), and more casual sexual partners (p = 0.007) than controls. Cases were more likely to have had sex in a gay sauna (OR 3.5; 95% CI 1.53, 8.30), or in a gay club, pub or disco (OR 2.9; 95 CI 1.29, 6.63) than controls. After adjusting for confounding factors, cases were more likely to have eaten shellfish (adjusted [adj] OR 3.0; 95% CI 1.33, 6.59) and to have had sex in a gay sauna (adj OR 3.9; 95% CI 1.42, 10.59). Public health messages need to inform homosexual men about recognised risk factors such as eating shellfish and travel abroad to endemic areas, as well as sexual risks. Homosexual men can benefit from hepatitis A vaccine. We would suggest that in an outbreak situation men who have multiple anonymous partners and have sex in public venues should be targeted as a priority for health education and immunisation.

Improving influenza immunisation coverage in 2000-2001: a baseline survey, review of the evidence and sharing of best practice

In May 2000 a new government target of 70% uptake in people aged 65 and over was introduced for influenza immunisation, with a minimum of 60% uptake in 2000-2001. A postal survey of influenza immunisation coverage in over 75 year olds during 1999-2000 was undertaken in our district's general practices. The evidence on interventions which improve coverage was compared to local practice. General Practitioners and their Primary Care Groups/Trust received feedback on their performance, and best practice was shared. The findings were used to inform the immunisation campaign for 2000-01. The survey response rate was 74%. The district coverage was 50%, ranging from 7% to 97% between practices. Practices achieving high coverage rates combined good patient identification with personalised patient invitation and well-organised clinics. The work that went on in the district achieved an overall influenza immunisation coverage of 62% in 2000-01.

Characterization of Alzheimer's beta -secretase protein BACE. A pepsin family member with unusual properties

The cerebral deposition of amyloid beta-peptide is an early and critical feature of Alzheimer's disease. Amyloid beta-peptide is released from the amyloid precursor protein by the sequential action of two proteases, beta-secretase and gamma-secretase, and these proteases are prime targets for therapeutic intervention. We have recently cloned a novel aspartic protease, BACE, with all the known properties of beta-secretase. Here we demonstrate that BACE is an N-glycosylated integral membrane protein that undergoes constitutive N-terminal processing in the Golgi apparatus. We have used a secreted Fc fusion-form of BACE (BACE-IgG) that contains the entire ectodomain for a detailed analysis of posttranslational modifications. This molecule starts at Glu(46) and contains four N-glycosylation sites (Asn(153), Asn(172), Asn(223), and Asn(354)). The six Cys residues in the ectodomain form three intramolecular disulfide linkages (Cys(216)-Cys(420), Cys(278)-Cys(443), and Cys(330)-Cys(380)). Despite the conservation of the active site residues and the 30-37% amino acid homology with known aspartic proteases, the disulfide motif is fundamentally different from that of other aspartic proteases. This difference may affect the substrate specificity of the enzyme. Taken together, both the presence of a transmembrane domain and the unusual disulfide bond structure lead us to conclude that BACE is an atypical pepsin family member.

A comparison of folding techniques in the chemical synthesis of the epidermal growth factor-like domain in neu differentiation factor alpha/beta

The 52-residue alpha/beta chimera of the epidermal growth factor-like domain in neu differentiation factor (NDFealpha/beta) has been synthesized and folded to form a three disulfide bridge (Cys182-Cys196, Cys190-Cys210, Cys212-Cys221) containing peptide. We investigated two general strategies for the formation of the intramolecular disulfide bridges including, the single-step approach, which used fully deprotected and reduced peptide, and a sequential approach that relied on orthogonal cysteine protection in which specific pairs are excluded from the first oxidation step. Because there are 15 possible disulfide bridge arrangements in a peptide with six cysteines, the one-step approach may not always provide the desired disulfide pairing. Here, we compare the single-step approach with a systematic evaluation of the sequential approach. We employed the acetamidomethyl group to protect each pair of cysteines involved in disulfide bridges, i.e. Cys182 to Cys196, Cys190 to Cys210 and Cys212 to Cys221. This reduced the number of possible disulfide patterns from 15 to three in the first folding step. We compared the efficiencies of folding for each protected pair using RP-HPLC, mapped the disulfide connectivity of the predominant product and then formed the final disulfide from the partially folded intermediate via 12 oxidation. Only the peptide having the Cys182-Cys196 pair blocked with acetamidomethyl forms the desired disulfide isomer (Cys190-Cys210/Cys212-Cys221) as a single homogeneous product. By optimizing both approaches, as well as other steps in the synthesis, we can now rapidly provide large-scale syntheses of NDFealpha/beta and other novel EGF-like peptides.

Disulfide assignment of the C-terminal cysteine knot of agouti-related protein (AGRP) by direct sequencing analysis

We have assigned the disulfide structure of Md-65 agouti-related protein (Md65-AGRP) using differential reduction and alkylation followed by direct sequencing analysis. The mature human AGRP is a single polypeptide chain of 112 amino acid residues, consisting of an N-terminal acidic region and a unique C-terminal cysteine-rich domain. The C-terminal domain, a 48 amino acid peptide named Md65-AGRP, was expressed in Escherichia coil cells and refolded under different conditions from the mature recombinant protein. The disulfide bonds in the cystine knot structure of Md65-AGRP were partially reduced using tris(2-carboxyethyl) phosphine (TCEP) under acidic conditions, followed by alkylation with N-ethylmaleimide (NEM). The procedure generated several isoforms with varying degrees of NEM alkylation. The multiple forms of Md65-AGRP generated by partial reduction and NEM modification were then completely reduced and carboxymethylated to identify unreactive disulfide bonds. Differentially labeled Md65-AGRP were directly sequenced and analyzed by MALDI mass spectrometry. The results confirmed that Md65-AGRP contained the same disulfide structure as that of Md5-AGRP reported previously [Bures, E. J., Hui, J. O., Young, Y. et al. (1998) Biochemistry 37, 12172-12177].

Use of complementary therapies by patients attending musculoskeletal clinics

Patients with musculoskeletal disorders commonly seek treatment outside orthodox medicine (complementary therapy). In patients attending hospital clinics we investigated the prevalence of such behaviour and the reasons for it. Patients attending rheumatology and orthopaedic clinics who agreed to participate were interviewed on the same day by means of a structured questionnaire in three sections: the first section about demographic characteristics; the second about the nature and duration of the complaint, the length of any treatment and whether the patient was satisfied with conventional treatment; and the third about the use of complementary medicine, the types of therapy that had been considered and the reasoning behind these decisions. The data were examined by univariate and bivariate analysis as well as logistic regression multivariate analysis. 166 patients were interviewed (99% response rate) and the predominant diagnosis was rheumatoid arthritis (22.3%). 109 patients (63%) were satisfied with conventional medical treatment; 63 (38%) had considered the use of complementary therapies, and 47 (28%) had tried such a therapy. 26 of the 47 who had used complementary therapy said they had gained some benefit. Acupuncture, homoeopathy, osteopathy and herbal medicine were the most popular types of treatment to be considered. Patients of female gender (P = 0.009) and patients who had expressed dissatisfaction with current therapies (P = 0.01) were most likely to have considered complementary medicine. These results indicate substantial use of complementary therapy in patients attending musculoskeletal disease clinics. The reasons for dissatisfaction with orthodox treatment deserve further investigation, as does the effectiveness of complementary treatments, which must be demonstrated before they are integrated with orthodox medical practice.

Human leptin receptor. Determination of disulfide structure and N-glycosylation sites of the extracellular domain

The leptin receptor (OB-R) is a member of the class I cytokine receptor family and mediates the weight regulatory effects of its ligand through interaction with cytoplasmic kinases. The extracellular domain of this receptor is comprised of two immunoglobulin-like and cytokine-receptor homology domains each and type III fibronectin domains. The extracellular domain of human leptin receptor was expressed in and purified from Chinese hamster ovary cells and was found to contain extensive N-glycosylation (approximately 36% of the total protein). The purified protein had a molecular weight of approximately 145,000 and exhibited ligand binding ability as evidenced by formation of ligand-receptor complex, followed by chemical cross-linking. The determined disulfide motif of the soluble leptin receptor contained several distinct cystine knots as well as 10 free cysteines. The N-glycosylation analysis revealed that Asn624 of the WSXWS motif (residues 622-626) within the C-terminal cytokine receptor homology domain was glycosylated, indicating that this region is solvent-exposed. On the other hand, the N-terminal WSXWS motif was not glycosylated.

Determination of disulfide structure in agouti-related protein (AGRP) by stepwise reduction and alkylation

The agouti-related protein gene (Agrp) plays an important role in body weight regulation. The mature human protein is a single polypeptide chain of 112 amino acid residues, consisting of an N-terminal acidic region and a unique C-terminal cysteine-rich domain. The disulfide structure of recombinant human AGRP was determined by chemical methods using partial reduction with tris(2-carboxyethyl)phosphine under acidic conditions, followed by direct alkylation with N-ethylmaleimide or fluorescein-5-maleimide. Partial reduction and alkylation provided several forms of AGRP that were modified in a stepwise fashion. The resulting proteins were characterized by peptide mapping, sequence analysis, and mass spectrometry, showing that AGRP contained a highly reducible disulfide bond, C85-C109, followed by less reactive ones, C90-C97, C74-C88, C67-C82, and C81-C99, respectively. The chemically defined disulfide connectivity of the recombinant human AGRP was homologous to that of omega-agatoxin IVB except for an additional disulfide bond, C85-C109.

Studies of two-species Bose-Einstein condesation

We describe our recent progress on the investigation of two-species Bose-Einstein condensation. From a theoretical analysis we show that there is a new rich phenomenology associated with two-species Bose-Einstein condensates which does not exist in a single-species condensate. We then describe results of a numerical model of the evaporative cooling process of a trapped two-species gas.

Outcome after hemiarthroplasty for femoral neck fractures in the elderly

A prospective outcome study was performed on 270 patients, 65 years of age and older, who sustained a femoral neck fracture and underwent hemiarthroplasty. The treatment compared was the use of a noncemented unipolar versus either a cemented or a press fit bipolar prosthesis. The outcome variables assessed included the occurrence of a postoperative complication, length and cost of hospitalization, and function in various quality of life measurements. Patients who underwent bipolar hemiarthroplasty with either a cemented or a press fit prosthesis had better pain relief and function than patients who had a noncemented unipolar prosthesis at a minimum of 24 months after surgery. However, the mean hospitalization cost for patients who had a bipolar prosthesis was $12,290 compared with $8876 for a unipolar prosthesis.

Living related small bowel transplantation: anaesthesia and peri-operative care

The peri-operative management of the only surviving case, to date, of living-related small bowel transplantation is described. The anaesthetic technique was chosen to optimize hepato-splanchnic blood flow. Peri-operative splanchnic blood flow was measured and alterations in flow with changes in inotropic agents and volume loading monitored. There appears to be a role for the use of dopexamine and aggressive volume loading.

Propofol neuroprotection in a rat model of ischaemia reperfusion injury

This study was designed to test the hypothesis that propofol, which possesses antioxidant properties, would produce greater protection than isoflurane in cerebral ischaemia reperfusion injury, at dose levels that produced similar affects on brain electrical activity. Twenty Sprague-Dawley rats were anaesthetized using isoflurane 1.5% in air/oxygen, and mechanically ventilated to a PaCO2 of 4.5 kPa. Following 90 min of middle cerebral artery occlusion using an intraluminal filament, rats were given, in random order, either propofol 1 mg kg-1 min-1 or isoflurane 3% (both of which have been shown to reliably produce EEG burst suppression). After a further 30 min, reperfusion was induced by withdrawing the filament. Animals were killed following 240 min of reperfusion. Rats in the propofol group showed a 21% reduction in mean hemispheric infarct volume when compared with the isoflurane group (P < 0.0001). These data suggest that propofol may act by mechanisms in addition to CMRO2 depression, and provide a basis for further studies of propofol neuroprotection.

A longitudinal examination of functional recovery among older people with subcapital hip fractures

OBJECTIVE

Few studies have examined the time-dependent change in functional recovery along with the factors that affect the change among older hip fracture patients. The focus of this study is to examine the predictors of functional recovery in community-dwelling older people with subcapital fractures using longitudinal data analysis methods.

DESIGN

A 1-year prospective study. Information was obtained through structured interviews following surgery and at 2, 6, and 12 months after hospital discharge and from medical chart review.

SETTING AND PATIENTS

The sample consisted of 312 community-dwelling older adults, admitted to one of the seven Baltimore area hospitals with a subcapital fracture, who received either internal fixation or hemiarthroplasty.

RESULTS

The longitudinal data analysis using mixed-effects regression indicates that time and prefracture physical activities of daily living (PADL) had a significant association with PADL functional recovery over the course of 1 year. Among those 85 years and older, those who were disoriented after surgery had poorer PADL functional recovery over time than those who were not disoriented. Also, recovery in instrumental activities of daily living (IADL) was associated significantly with time, prefracture IADL function, unsteady gait prefracture, hospital length of stay, and discharge to an institution. The type of surgical procedure performed was not associated significantly with either PADL or IADL functional recovery.

CONCLUSIONS

The factors that are related to functional recovery in this study shed light on the complexity of the recovery process in hip fracture patients. The rate of recovery in postsurgical PADL and IADL function is not constant over time; postsurgical IADL function among disoriented patients (without dementia) continues to deteriorate over time compared with the nondisoriented group; this difference in trends of deterioration on IADL function is most profound in the oldest-old aged group, those 85 and older. The types of surgical procedure performed was not significantly associated with postsurgical functional recovery.

Continuing education for medical professionals: a reflective model

The Royal Colleges and their Faculties have moved continuing professional development up the agenda of doctors in the UK. The low educational value and failure to change professional practice of much continuing medical education has led to criticism of its emphasis on formal, didactic teaching and academic knowledge. The ubiquitous scientific or technical bias in medical education makes questionable assumptions about the nature of professional knowledge, how professionals learn, and the linkage of theory and practice in professional work. Given its narrow conception of professional knowledge, it is hardly surprising that the effectiveness of continuing medical education has proven difficult to evaluate. These points of criticism suggest that a more systematic and coherent approach to continuing education is required. The adoption of the concept of continuing professional development, which draws on learning by reflective practice, marks an important step in this direction. Continuing professional development emphasises self-directed learning, professional self-awareness, learning developed in context, multidisciplinary and multilevel collaboration, the learning needs of individuals and their organisations, and an inquiry-based concept of professionalism. It also involves a widening of accountability to patients, the community, managers and policymakers, and a form of evaluation which is internal, participatory and collaborative rather than external and scientific in character.

Effects of desflurane and isoflurane on splanchnic microcirculation during major surgery

Isoflurane has been considered the agent of choice where preservation of splanchnic blood flow is required. Liver blood flow and the hepatic artery buffer response are maintained better in the presence of isoflurane than with other volatile anaesthetic agents. The effects of desflurane have not been assessed in humans. Therefore, we have compared the effects of isoflurane and desflurane anaesthesia on small bowel and hepatic microcirculatory flow during major surgery using laser Doppler flowmetry in a prospective, randomized, single-blind, crossover study. Patients were allocated randomly to receive desflurane or isoflurane (1 MAC) in oxygen-enriched air. Steady-state jejunal and liver blood flow in segment III were assessed by laser Doppler flowmetry. Volatile anaesthetics were then interchanged, and measurements repeated at steady state. Desflurane anaesthesia at 1 MAC was associated with significantly greater gut blood flow than 1 MAC of isoflurane. These differences could not be explained by systemic haemodynamic differences. The similarity in total hepatic flow between groups implies an intact hepatic artery buffer response with desflurane and isoflurane.

Continuing medical education: the question of evaluation

This paper examines the question of evaluation which has been largely neglected in the credit-based systems of continuing medical education adopted by the Medical Royal Colleges. These systems are seen to encourage a training model of continuing education and a scientific model of evaluation as measurement. By contrast, humanistic evaluation is interpretative and differs not only in its criteria and methods, but also in its underpinning curricular ideologies and values. This model has closer links with concepts of education and professional practice associated with continuing professional development. Decisions about who should conduct the evaluation, what is to be evaluated, how it should be carried out, and about the goals and purposes of evaluation are outlined, noting that they presuppose an ideological view of the relationship of professional knowledge, values and practice. In a concluding discussion of evaluation and the control of professional knowledge, it is argued that the narrow, professional control of evaluation, buttressed by the quality assurance and monitoring mechanisms of the Colleges, is inappropriate, given the increasingly diverse accountabilities which affect medical professionals.

Glial cell line-derived neurotrophic factor: selective reduction of the intermolecular disulfide linkage and characterization of its disulfide structure

Glial cell line-derived neurotrophic factor is a protein known to enhance the survival of dopaminergic neurons against several neurotoxins. It has been shown to have therapeutic potential in the treatment of Parkinson's disease and other neurodegenerative diseases. We have determined the inter- and intramolecular disulfide linkages of the dimeric molecule by a combination of direct peptide analysis and peptide analysis after either partial reduction or partial oxidation of the protein. Under an acidic condition, the interchain disulfide bond was selectively cleaved with tris(2-carboxyethyl)phosphine, revealing that Cys101 was involved in the intermolecular disulfide linkage. Three other disulfides, Cys68-Cys131, Cys72-Cys133, and Cys41-Cys102, were identified as intramolecular linkages. The determined disulfide structure is highly homologous to that of transforming growth factor beta 2. Since one intramolecular disulfide points through a ring consisting of eight amino acid residues based on the similarity with transforming growth factor beta 2, the disulfide-linked peptides were not purified by conventional methods. Only the peptides from an N-terminal region (residues -1 to 37) were liberated by proteolytic treatment with trypsin or endoproteinase Lys-C, resulting in a stable cystine-knot protein.

Continuing education for public health medicine--is it just another paper exercise?

In 1993 the Conference of Royal Colleges and their Faculties called for its members to develop formalized continuing medical education (CME) programmes. Most colleges have adopted a narrow definition of CME and a mechanistic approach to monitoring participation. The Faculty of Public Health Medicine has responded differently by initiating a broader model of continuing professional development (CPD) which emphasizes the individual nature of continuing education. This paper explores the rationale behind this decision. Recent systematic reviews of the effectiveness of CME have demonstrated the need for relevance in any continuing education activity. This means relevance not only to learning needs but also to current work and the applicability of the knowledge. However, the effectiveness of traditional CME for all doctors and particularly public health physicians remains to be established. Thus the Faculty has moved towards a wider context of learning in the form of CPD incorporating an evaluative approach and aspects of adult learning theory. There remains a need for the links between audit and continuing education to be strengthened.

The predictors of surgical procedure and the effects on functional recovery in elderly with subcapital fractures

BACKGROUND

It has been demonstrated that the majority of hip fracture patients do not regain their prefracture level of functioning and usually decline in function following fracture. Little is known about the effectiveness of surgical procedure performed (hemiarthroplasty vs internal fixation) on functional recovery of subcapital fracture patients. This study examines the factors related to the type of the surgical procedure chosen and the effect of this selection on physical activities of daily living (PADL) and instrumental activities of daily living (IADL).

METHODS

The sample consists of 312 patients with subcapital fractures age 65 and older admitted from the community to one of seven Baltimore area hospitals between 1984 and 1986. Baseline information was obtained during hospitalization through structured interviews with both patients and their significant others (proxy). The follow-up interviews were administered to proxies at two months, six months, and one year after discharge from hospital. Information on disease diagnoses, fracture severity, and surgical procedures performed was obtained from medical charts.

RESULTS

Patients with a displaced fracture were seven times more likely to receive a hemiarthroplasty (OR = 7.0, 95% CI 3.7-13.1). During the short-term recovery (2 months after surgery), patients who received hemiarthroplasty were doing better in transferring, meal preparation, and shopping than those who received internal fixation. For the long-term functional recovery (one year), the overall PADL and IADL functions were not statistically significantly different between the two surgical procedures performed.

CONCLUSIONS

The severity of fracture was found to be the most important determinant of surgical procedure. Patients with a subcapital fracture who received hemiarthroplasty tended to have a better functional recovery in the short term. Further study of other benefits of using as hemiarthroplasty is needed.

Use of recombinant human erythropoietin to facilitate liver transplantation in a Jehovah's Witness

A 46-yr-old woman with rapidly progressing primary biliary cirrhosis presented for liver transplantation. The use of preoperative recombinant human erythropoietin enabled this to be achieved without prohibited blood products. Perioperative management of this patient and general principles of management of Jehovah's Witnesses undergoing major surgery are discussed.

Prevention of falls in the elderly

The purpose of these symposium presentations was to examine the role of physical activity as a means of preventing hip fractures through the prevention of falls. Risk factor identification is necessary to develop preventive strategies. Risk factors related to physical activity and other risk factors for falls were identified. Intervention studies aimed at reducing, preventing or delaying falls were identified and discussed. A literature search from 1976-1994, identified 52 studies examining risk factors for falls, recurrent falls and/or falls resulting in injury. Nine intervention studies were identified with the primary outcome of falls. Physical activity-related risk factors for falls include limitations in general functioning, such as ambulation and mobility problems, difficulty or dependence in activities of daily living, and exposures to the risks of falling as indicated by the nature and frequency of daily activities. Impairments in gait and balance as well as neuromuscular and musculoskeletal impairments frequently underlie changes in physical activity in old age. Reduced activity level may occur as a result of these impairments, leading to further declines in physical functioning and an increased risk of falls. A relatively high level of activity in old age is also associated with risk of falls. Other risk factors for falls, such as cognitive impairment, visual deficits and medication use, may combine with physical activity-related risk factors to increase the risk of falls. Intervention studies directed at nursing home populations did not prevent falls but had other statistically and clinically significant outcomes. Studies among the community dwelling that targeted potential or current risk factors and included an exercise component reported a significant reduction in falls, prevented the onset of new disabilities and reduced baseline risk factors. Prevention of falls and subsequent injuries in the institutionalized population remains a challenge. Further development of interventions for community-dwelling elders that facilitate maintenance of physical activity without unduly increasing the risk of falls is also critical. The potential for maintenance of benefits gained from all fall interventions needs further examination.

New horizons in ICU sedation: exploring non-sedative effects of ICU sedation

Sedative drugs are widely used in intensive care, primarily in ventilated patients. The common actions and side-effects of these agents are widely recognised. However, recent evidence suggests that opiates and other sedative agents that are used in this situation also have important, but not widely appreciated, effects on metabolism, physiological signalling and disease mechanisms. Some of these effects are an extension of their expected therapeutic actions; these are being elucidated as the biological consequences of stress, and its suppression is now being clarified. An example is the central effects of benzodiazepines and opioids on metabolism and immune function. In other instances these drugs have important peripheral actions, with immunomodulatory or metabolic roles. Furthermore, some drugs may modify disease processes--an example being the antioxidant effect of propofol. Finally, basic cellular mechanisms, such as immediate early gene expression and transcription factor activation, may involve processes that may be susceptible to modification by sedative agents. Such secondary effects of sedative agents need to be investigated for three reasons. First, they provide explanations for some phenomena observed during their use. Second, some of the undesirable side-effects may be avoided by judicious use of drugs in certain clinical situations. Finally, there is the prospect that we may be able to harness some actions for novel therapeutic purposes.

Immunoglobulin-A detection and the investigation of clinical toxoplasmosis

Current serological methods for the investigation of Toxoplasma gondii infection are unreliable for the diagnosis of congenital disease, reactivated infection associated with the acquired immune deficiency syndrome (AIDS), or the determination of the date of onset of infection. An enzyme-linked immunosorbent assay (ELISA) and an immunosorbent agglutination assay (ISAGA) were developed for the detection of toxoplasma-specific immunoglobulin-A (IgA) and used to investigate patients in these three categories. The IgA ISAGA and IgA ELISA were found to be reproducible and specific tests. The IgA ISAGA demonstrated enhanced sensitivity. Measurement of IgA in patients with toxoplasma-associated lymphadenopathy of known duration and AIDS patients with toxoplasma infection was of limited value. Detection of specific IgA by ISAGA was more sensitive than conventional methods for the diagnosis of congenital toxoplasmosis. We recommend the investigation of infant sera with IgA ISAGA. IgA estimation is not indicated in other clinical situations.

Endotoxin, septic shock and acute lung injury: neutrophils, macrophages and inflammatory mediators

The treatment of septic shock remains a major problem in surgical practice. Current research on the pathogenesis of the sepsis syndrome focuses on the effects of the lipopolysaccharide constituents of bacterial endotoxin. Evidence suggests that endotoxin induces a whole-body inflammatory response that in turn mediates organ damage, eventually leading to multiorgan failure. The first organ in which failure is usually apparent is the lung, with the appearance of non-cardiogenic pulmonary oedema as part of the adult respiratory distress syndrome. Inflammatory cells involved in lung injury include neutrophils and macrophages, which release mediators such as elastase, oxygen radicals and cytokines. This review summarizes current experimental work on how endotoxin leads to lung injury, based on its effects in animals and patients. Present knowledge suggests that future treatment of septic shock might involve inhibiting the body's inflammatory response to endotoxin. Possible ways of doing this are discussed.

Transmission of toxoplasmosis by bone marrow transplant associated with Campath-1G

A 12-year-old boy in third remission acute lymphoblastic leukaemia was given a mismatched transplant from his mother. He suffered prolonged neutropenia and pyrexia which was only finally diagnosed as toxoplasmosis using molecular biology methods and by his response to appropriate treatment. This was probably transmitted by bone marrow transplant since maternal immune T cells were removed by the use of Campath-1G and treatment with cyclosporin A probably prevented his IgM immune response and impeded the diagnosis.