The introduction of a surgical safety checklist in a tertiary referral obstetric centre

BACKGROUND Surgery-related adverse events remain a significant and often under-reported problem. In a recent study, the introduction of a perioperative checklist by the WHO reduced deaths and complications by 46% and 36% respectively. The authors wished to evaluate the introduction of a surgical safety checklist in a busy obstetric tertiary referral centre by assessing staff attitudes, checklist compliance and effects upon patients. METHODS A questionnaire-based assessment was performed on staff working in obstetric theatres before and after the introduction of the surgical safety checklist. Checklist compliance was assessed at 3&emsp14;months and 1&emsp14;year. Patients were asked questions relating to the performance of the surgical safety checklist in order to evaluate any anxiety caused. RESULTS Non-medical staff were significantly more likely than medical staff to feel familiar with other team members both before (p<0.001) and after (p=0.03) the introduction of the checklist. 69.6% of all staff felt that interprofessional communication had improved following the introduction of the checklist. Compliance with pre- and postoperative checks was 61.2% and 67.6%, respectively, improving to 79.7% and 84.7% after 1&emsp14;year. Although the majority of patients were aware of the checks being performed, this did not provoke anxiety. CONCLUSION Following consultation with staff and patients, the authors managed to institute and sustain the performance of a surgical safety checklist for elective cases in obstetric theatres. While significant progress has been made, the authors recognise that further work is required in order to further evaluate and optimise this process.

Biosynthesis of Stigmasterol in Tomato Fruits

The presence of stigmasterol in tomato fruits was demonstrated. Labeled mevalonic acid was incorporated into this sterol, while sodium acetate was not. The identity of the isolated product was established by rigorous purification to constant specific activity, melting point determinations, and infrared spectrum.

The Biology of Isolated Chromatin: Chromosomes, biologically active in the test tube, provide a powerful tool for the study of gene action

The isolated chromatin of higher organisms possesses several properties characteristic of the same chromatin in life. These include the presence of histone bound to DNA, the state of repression of the genetic material, and the ability to serve as template for the readout of the derepressed portion of the genome by RNA polymerase. The important respect in which isolated chromatin differs from the material in vivo, fragmentation of DNA into pieces shorter (5 x 10(6) to 20 x 10(6) molecular weight) than the original, does not appear to importantly alter such transcription. The study of isolated chromatin has already revealed the material basis of the restriction of template activity; it is the formation of a complex between histone and DNA. Chromatin isolated by the methods now available, together with the basis provided by our present knowledge of chromatin biochemistry and biophysics, should make possible and indeed assure rapid increase in our knowledge of chromosomal structure and of all aspects of the control of gene activity and hence of developmental processes.

Genomic and cDNA clones for maize phosphoenolpyruvate carboxylase and pyruvate,orthophosphate dikinase: Expression of different gene-family members in leaves and roots

We have isolated cDNA clones for the maize leaf enzymes phosphoenolpyruvate (P-ePrv) carboxylase [orthophosphate:oxaloacetate carboxy-lyase (phosphorylating) EC 4.1.1.31] and pyruvate,orthophosphate (Prv,P(i)) dikinase (ATP:pyruvate,orthophosphate phosphotransferase, EC 2.7.9.1) by exploiting the light-inducibility and large size of the mRNAs (3.5 kilobases) that encode the two enzymes. The clones were identified by hybrid-selection and immunoprecipitation assays. From a maize genomic library, two different types of genomic clones were screened with both the P-ePrv carboxylase and the Prv,P(i) dikinase cDNA clones. Information from these genomic clones and genome blots indicates that the P-ePrv carboxylase gene family has at least three members and the Prv,P(i) dikinase family at least two. Transcripts for both enzymes were detected in green leaves, etiolated leaves, and roots. The results show that the P-ePrv carboxylase mRNAs in green leaves and roots are encoded by different genes. Whereas the P-ePrv carboxylase mRNAs in all three tissues appear to be the same size, the Prv,P(i) dikinase mRNA in green leaves is about 0.5 kilobases longer than the Prv,P(i) dikinase mRNAs in etiolated leaves and roots. It is possible that all these Prv,P(i) dikinase transcripts are encoded by one gene, and the size differences may correspond to the presence or absence of a sequence encoding a chloroplast transit peptide.

THE ACTION OF THE PLANT GROWTH HORMONE

1. Sections of Avena coleoptiles are found to show a considerable elongation when suspended in solutions of growth substance. 2. This elongation does not take place in the absence of O(2) and is inhibited by KCN and phenylurethane. 3. The rate of respiration of sections of coleoptiles is increased by the addition of growth substance in concentrations which cause growth. High concentrations of growth substance inhibit growth and also respiration. 4. The increase in respiration is inhibited by KCN and phenylurethane in the concentrations which inhibit normal respiration. These concentrations are the same as those which inhibit growth. 5. From 2, 3, and 4, it seems possible that the increase in respiration caused by growth substance may be an essential part of its action in growth.

THE GROWTH AND RESPIRATION OF THE AVENA COLEOPTILE

1. Transport of the plant growth hormone into the Avena coleoptile as well as the action of the hormone on cell elongation in the coleoptile are shown to depend upon aerobic metabolism. 2. Crystalline auxine, in contrast with impure preparations, affects neither the magnitude nor the respiratory quotient of coleoptile respiration. 3. Increasing age of the coleoptile cell decreases its rate of elongation much more than its rate of respiration. HCN or phenylurethane on the other hand decrease the two processes to the same extent, in spite of the fact that only a small portion of the energy liberated by respiration can be used in the mechanical process of growth. 4. From 2 and 3 it is concluded that processes of a respiratory nature but of relatively small magnitude form one or more integral steps in the chain of reactions by which the plant growth hormone brings about cell elongation.

A novel primate model of delayed wound healing in diabetes: dysregulation of connective tissue growth factor

AIMS/HYPOTHESIS

Chronic non-healing wounds are a common complication of diabetes. Prolonged inflammation and decreased matrix accumulation may contribute. Connective tissue growth factor (CTGF) is induced during normal wound healing, but its regulation in diabetic wounds is unknown. We developed a primate model for the study of in vivo wound healing in baboons with long diabetes duration.

METHODS

Drum implants were placed subcutaneously into thighs of diabetic and non-diabetic control baboons. After 2 and 4 weeks the skin incision sites were removed for measurement of breaking strength and epithelial thickness. Drum implants were removed for analysis of granulation tissue and inflammatory cells, CTGF and tissue inhibitor of matrix metalloproteinase (TIMP-1). Degradation of added CTGF by wound fluid was also examined.

RESULTS

Healed incision site skin was stiffer (less elastic) in diabetic baboons and epithelial remodelling was slower compared with controls. Granulation tissue from diabetic baboons was reduced at 2 and 4 weeks, with increased vessel lumen areas at 4 weeks. Macrophages were reduced while neutrophils persisted in diabetic tissue. In diabetic wound tissue at 4 weeks there was less CTGF induced, as shown by immunohistochemistry, compared with controls. In contrast, immunoreactive fragments of CTGF were significantly increased in whole tissue lysate in diabetic baboons, suggesting that CTGF is redistributed in diabetes from granulation tissue into wound fluid. When recombinant human CTGF was co-incubated with wound fluid, increased CTGF degradation products were observed in both control and diabetic samples.

CONCLUSIONS/INTERPRETATION

This baboon model of wound healing reflects the abnormal microenvironment seen in human diabetic wounds and provides insights into the dysregulation of CTGF in diabetic wounds.

UAB 0210: A phase I/II trial of induction chemotherapy followed by concomitant docetaxel/radiotherapy with subcutaneous amifostine for advanced squamous cell carcinoma of the head and neck (SCCHN)

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Background: Attempts to improve the outcome of locally advanced SCCHN have generally added chemotherapy to radiation, though the optimal manner of integration has been controversial. To impact distant and local control, we utilized neoadjuvant chemotherapy followed by concomitant boost radiation (CBR) with docetaxel as a radiosensitizer. To improve cytoprotection, subcutaneous amifostine was added during radiotherapy. Methods: From April 2003-March 2007 46 patients with stage III or IV newly diagnosed SCCHN were enrolled (30 Caucasian, 16 African-American). Treatment consisted of 3 cycles of neoadjuvant chemotherapy with cisplatin 75 mg/m2 and docetaxel 75 mg/m2 intravenously at 21 day intervals followed by CBR and concurrent dose-escalated weekly docetaxel starting at 20 mg/m2. Standard 2D radiotherapy was used in the majority of patients. Subcutaneous amifostine was administered at 500 mg during each day of radiation. Results: 39 patients were evaluable. The neoadjuvant chemotherapy was well tolerated by the majority of patients and appeared effective; no patient had progressive disease while on therapy. Three patients required a change to carboplatin due to toxicity. Weekly docetaxel during all weeks of CBR was not tolerable due to severe mucositis and the phase I component defined the MTD of concurrent docetaxel as 20 mg/m2 for 4 cycles during CBR. 4 patients (10%) had persistent disease at completion of treatment. Amifostine administration was well tolerated though 4 patients required discontinuation of the drug. The majority of recurrences have been localized at the primary site (6 patients). 3 patients developed isolated pulmonary metastasis. Only 2 patients remain PEG dependent with median follow-up of 24 months. Conclusions: Induction chemotherapy using cisplatin and docetaxel is feasible and easy to administer in the outpatient setting; those patients who had a major radiographic and clinical response did particularly well in follow-up. Weekly docetaxel can be safely and effectively administered during CBR with good local control. Amifostine can be safely administered via the subcutaneous route; the benefit in locally advanced patients is difficult to assess.

No significant financial relationships to disclose.

A phase III comparison of prophylactic cranial irradiation versus observation in patients with locally advanced non-small cell lung cancer: Initial analysis of Radiation Therapy Oncology Group 0214

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Background: The incidence of central nervous system (CNS) metastases is high in patients with locally advanced non-small cell lung cancer. Brain as an only site of relapse appears increasingly common as loco-regional and extra-cranial systemic treatment improves. There is not standard agreement as to how to address this risk. Methods: Patients with stage III NSCLC without progression of disease after loco-regional treatment with surgery and/or radiation therapy with or without chemotherapy were eligible. Participants were randomized to prophylactic cranial irradiation (PCI) or observation and stratified by stage (IIIA or B), histology (non-squamous or squamous) and therapy (surgery or no surgery). PCI was delivered once daily at 2Gy per fraction to 30Gy. The primary endpoint of the study was overall survival (OS). Secondary endpoints were disease free survival (DFS) and the impact of PCI on incidence of CNS metastases, neuropsychological function, and quality of life (QoL). Kaplan- Meier estimation with the log-rank test was used for OS and DFS and the logistic regression model was used for calculating the incidence of CNS metastasis. Results: Total accrual was 356 patients of the targeted 1058 between 9/19/02 and 8/30/07. The study was closed early due to slow accrual. 340 patients were evaluable. One year OS (p=0.86, 75.6 % and 76.9% for PCI and observation) and one year DFS (p=0.11, 56.4% and 51.2% for PCI and observation) were not statistically significantly different. However, CNS metastatic rate at 1 year was statistically significantly different with CNS relapse 7.7% vs. 18% for PCI vs. observation (p=0.004). Logistic regression showed that the patients in the observation arm are 2.52 times more likely to develop CNS metastases than those in the PCI arm (odds ratio=2.52, 95% CI=(1.32–4.80)). Conclusions: PCI in patients without progressive disease after loco-regional therapy for III NSCLC significantly decreases the rate of CNS metastases. This study did not show a statistically significant difference in OS or DFS. Forthcoming analysis of the impact of PCI on neuropsychological function and QoL will influence the recommendations regarding the standard use of PCI.

No significant financial relationships to disclose.

Consensus guidelines for the management of radiation dermatitis and coexisting acne-like rash in patients receiving radiotherapy plus EGFR inhibitors for the treatment of squamous cell carcinoma of the head and neck

BACKGROUND

Radiation dermatitis occurs to some degree in most patients receiving radiotherapy, with or without chemotherapy. Patients with squamous cell carcinoma of the head and neck (SCCHN) who receive radiotherapy in combination with epidermal growth factor receptor (EGFR) inhibitors, such as cetuximab, may develop a characteristic acne-like rash in addition to dermatitis.

DESIGN

An advisory board of 11 experienced radiation oncologists, medical oncologists and dermatologists discussed the management options for skin reactions in patients receiving EGFR inhibitors and radiotherapy for SCCHN. Skin toxicity was categorised according to the National Cancer Institute-Common Terminology Criteria for Adverse Events (version 3) grading.

RESULTS

Both general and grade-specific approaches for the management of dermatitis in this patient group are presented. It was concluded that where EGFR inhibitor-related acne-like rash and dermatitis coexist within irradiated fields, management should be based on the grade of dermatitis: for grade 1 (or no dermatitis), treatment recommendations for EGFR-related acne-like rash outside irradiated fields should be followed; for grades 2 and above, treatment recommendations for dermatitis were proposed.

CONCLUSIONS

This paper presents comprehensive consensus guidelines for the treatment of dermatitis in patients with SCCHN receiving EGFR inhibitors in combination with radiotherapy.

Consensus guidelines for the management of radiation dermatitis and coexisting acne-like rash in patients receiving radiotherapy plus EGFR inhibitors for the treatment of squamous cell carcinoma of the head and neck

BACKGROUND

Radiation dermatitis occurs to some degree in most patients receiving radiotherapy, with or without chemotherapy. Patients with squamous cell carcinoma of the head and neck (SCCHN) who receive radiotherapy in combination with epidermal growth factor receptor (EGFR) inhibitors, such as cetuximab, may develop a characteristic acne-like rash in addition to dermatitis.

DESIGN

An advisory board of 11 experienced radiation oncologists, medical oncologists and dermatologists discussed the management options for skin reactions in patients receiving EGFR inhibitors and radiotherapy for SCCHN. Skin toxicity was categorised according to the National Cancer Institute-Common Terminology Criteria for Adverse Events (version 3) grading.

RESULTS

Both general and grade-specific approaches for the management of dermatitis in this patient group are presented. It was concluded that where EGFR inhibitor-related acne-like rash and dermatitis coexist within irradiated fields, management should be based on the grade of dermatitis: for grade 1 (or no dermatitis), treatment recommendations for EGFR-related acne-like rash outside irradiated fields should be followed; for grades 2 and above, treatment recommendations for dermatitis were proposed.

CONCLUSIONS

This paper presents comprehensive consensus guidelines for the treatment of dermatitis in patients with SCCHN receiving EGFR inhibitors in combination with radiotherapy.

Patterns of practice in radiation therapy for non-small cell lung cancer among members of American Society of Therapeutic Radiology and Oncology

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Purpose: To investigate the dominant pattern of current practice in radiation therapy (RT) for lung cancer among members of American Society of Therapeutic Radiology and Oncology (ASTRO). Methods: A 35-item survey was designed by a panel of 8 board certified radiation oncologists regarding RT for lung cancer. Surveys were sent through email to 3,800 radiation oncologist members on September 10, 2006, with the results collected online on December 10, 2006. Here we report results on radiation decisions for non-small cell lung cancer (NSCLC). Results: The response rate was 19% (n = 727). The respondents saw an average of 8 consults (ranged 1–25) monthly during the survey time (summing up to a total of >60,000 new cases yearly). For stage I peripherally located NSCLC, 33%, 10% and 20% of respondents reported conventional fractionated, hypofractioned and stereotactic RT, respectively. Another 25% of respondents would have offered stereotactic RT if this technique were available at their center. For stage I centrally located tumors, 78% of respondents did not agree with, but 10% selected, stereotactic RT. For stage II and III, 76% of respondents selected 60–70 Gy in 1.8–2 Gy with chemotherapy. With regard to the combined modality approach for stage II and III disease, 76–77% of respondents selected concurrent chemoRT followed by adjuvant chemotherapy, and 11–16% sequential followed by concurrent chemoRT for patients with good performance status. For stage IV NSCLC with remarkable local disease, the consideration of RT ranged from 0 Gy, 3 Gyx10, 3 Gyx15, 2.5 Gyx20, to 2 Gyx30 in 27%, 17%, 8%, 13%, and 21% of respondents, respectively. Conclusions: The dominant pattern of practice for stage II/III disease is concurrent chemoRT, consistent with results of phase III trials. The treatment decisions for stage I and IV disease are diverse, partially due to technology advancement and the lack of large phase III trials.

No significant financial relationships to disclose.

Assessment of the bioequivalence of two oxcarbazepine oral suspensions versus a film-coated tablet in healthy subjects

Oxcarbazepine (trileptal) oral suspension has been reformulated and a study was performed to compare the bioavailability after single doses and at steady state of the current and former oral suspension versus the marketed film-coated tablets and to compare the bioavailability of the current and former oral suspension. The results support the switch from the former oral suspension to the current oral suspension and also from both oral suspensions to the film-coated tablet and vice versa. The study was an open-label, single-center, 3-way crossover trial. Each treatment period consisted of a single dose of 600 mg oxcarbazepine on Day 1, 600 mg oxcarbazepine b.i.d. repeated administration from Day 4 up to including Day 7, and a final dose of 600 mg oxcarbazepine administered on the morning of Day 8. Blood samples were taken on Day 1, Day 7 and Day 8 (pre-dose). Plasma concentrations of the main metabolite of oxcarbazepine (MHD) were determined using a validated HPLC assay. The 2 oral suspensions were compared with the film-coated tablet as reference formulation under fasted conditions. Also the current oral suspension was compared with the former oral suspension. These comparisons were made using data following single dose administration and under steady state conditions. Plasma AUC for single dose and AUC(0-12h) at steady state and plasma Cmax, log-transformed (natural base) were used for the assessment of bioequivalence. The 90% confidence interval (CI) approach was used for testing bioequivalence. Bioequivalence was accepted if CI was contained within the region (0.8, 1.25). At steady state, both the former and the current oral suspensions showed bioequivalence with the film-coated tablet with respect to AUC and Cmax. The current oral suspension was also bioequivalent when compared to the former oral suspension with respect to AUC and Cmax. After single dose, the former oral suspension was bioequivalent when compared to the film-coated tablet with respect to both AUC and Cmax. However, the current oral suspension was bioequivalent to both the film-coated tablet and the former oral suspension with respect to AUC but not to Cmax.

The permissive cue laminin is essential for growth cone turning in vivo

The proper guidance of migrating growth cones relies on the balance of multiple guidance cues in the embryonic environment. In addition to guidance cues, growth cones are in contact with other substrates that may contribute to the pathfinding of neurons. For example, in the developing insect peripheral nervous system, pioneer neurons migrate on and between layers of the basal lamina. Previous studies have demonstrated that one basal lamina molecule, laminin, promotes outgrowth of many classes of neurons in vitro. In this study, the simple grasshopper nervous system was used to investigate the role of laminin in neuronal pathfinding. Laminin expression precedes axonogenesis of the Tibial (Ti1) pioneer neurons in the developing limb bud, and expression continues during outgrowth and guidance of the pioneer neurons. The role of a nidogen-binding motif on laminin was investigated using subunit-specific antibodies and peptides as blocking reagents in vivo. Antibodies and peptides that block the nidogen-binding site on laminin resulted in stalled Ti1 axon migration, predominantly at the precise location where they normally turn ventrally. After prolonged culturing, Ti1 axons remained stalled at the same location. Therefore, although Ti1 axons were capable of outgrowth in the presence of blocking reagents, they were not able to navigate an essential turn. This study indicates that the interaction of the Ti1 growth cone with the nidogen-binding site on laminin is vital for neuronal pathfinding in vivo and suggests that permissive cues may be essential for growth cone steering.