Therapeutic radiographer prescribing practices in the United Kingdom: Questionnaire survey

INTRODUCTION

Non-medical professionals in the United Kingdom (UK) have been granted prescribing rights to improve patient care quality and cost-effectiveness. There is limited evidence on how therapeutic radiographer prescribers have impacted medicine management or patient services.

METHODS

An online survey was conducted amongst non-medical prescribing therapeutic radiographers in the UK between 2019 and 2022. The study teams initially analysed the individual data sets, subsequently combined, and secondary analysis was performed to provide a UK perspective, to understand the services provided and identify areas for improvement. Data was analysed using descriptive statistics from Microsoft Excel® and SPSS®.

RESULTS

74 non-medical prescribing therapeutic radiographers who were predominantly over 40 years old and in full-time work participated. The main job categories were consultant radiographers (n = 23, 31.1%) and advanced practice practitioners (n = 18, 24.3%). Many use their prescribing qualifications (87.5%, n = 62), issuing a mean of 15 independent and seven items by supplementary and prescribing per week. Most received assessment and diagnostic skills training before prescribing courses (91.6%, n = 67). Respondents prescribed from a median of six areas, with the highest being in GI (82%), skin (68%), infections (58%), urinary tract disorders (55%) and ear, nose, and oropharynx conditions (54%).

CONCLUSION

This study presents the first report on therapeutic radiographers prescribing in the UK, offering insights into current practices and highlighting the success of non-medical prescribing. Therapeutic radiographers' roles continue to expand into advanced practice and medicine-prescribing responsibilities, contributing to holistic and patient-centred care.

IMPLICATIONS FOR PRACTICE

The results are relevant for nations grappling with oncology workforce shortages and contemplating similar roles for therapeutic radiographers. The study can be a valuable resource for policymakers and healthcare organisations worldwide.

Loss of functionally important and regionally endemic species from streams forced into intermittency by global warming

Climate change is altering hydrological cycles globally, and in Mediterranean (med-) climate regions it is causing the drying of river flow regimes, including the loss of perennial flows. Water regime exerts a strong influence over stream assemblages, which have developed over geological timeframes with the extant flow regime. Consequently, sudden drying in formerly perennial streams is expected to have large, negative impacts on stream fauna. We compared contemporary (2016/17) macroinvertebrate assemblages of formerly perennial streams that became intermittently flowing (since the early 2000s) to assemblages recorded in the same streams by a study conducted pre-drying (1981/82) in the med-climate region of southwestern Australia (the Wungong Brook catchment, SWA), using a multiple before-after, control-impact design. Assemblage composition in the stream reaches that remained perennial changed very little between the studies. In contrast, recent intermittency had a profound effect on species composition in streams impacted by drying, including the extirpation of nearly all Gondwanan relictual insect species. New species arriving at intermittent streams tended to be widespread, resilient species including desert-adapted taxa. Intermittent streams also had distinct species assemblages, due in part to differences in their hydroperiods, allowing the establishment of distinct winter and summer assemblages in streams with longer-lived pools. The remaining perennial stream is the only refuge for ancient Gondwanan relict species and the only place in the Wungong Brook catchment where many of these species still persist. The fauna of SWA upland streams is becoming homogenised with that of the wider Western Australian landscape, as drought-tolerant, widespread species replace local endemics. Flow regime drying caused large, in situ alterations to stream assemblage composition and demonstrates the threat posed to relictual stream faunas in regions where climates are drying.

"We're Still Struggling a Bit to Actually Figure Out What That Means for Government": An Exploration of the Policy Capacity Required to Oversee Robot Technologies in Australia and New Zealand Care Services

Many countries are experiencing a “care crisis” driven by increasing demand for care services alongside difficulties in recruiting and retaining an appropriate care workforce. One of the solutions offered to this is the use of robotic technologies. While there are several positives produced by robots, they are not without challenges and have the potential to be misused. History shows disruptive technologies require appropriate policy capacity for these to be effectively stewarded so that we can secure the positive gains of these without encountering potential harms. In this paper, we explore the types of policy capacity needed to oversee robotic technologies. Drawing on interviews with 35 key stakeholders involved with the implementation of robots in Australian and New Zealand care services, we identify the capabilities required at the individual, organisational, and systemic levels across the analytical, operational, and political domains. We found the respondents perceived a lack of policy capacity to oversee robotics in the government. However, these gaps are less in respect to technological skills and abilities and more in respect to the system’s impacts and effects of these technologies. We conclude by outlining a summary of the capabilities required to oversee robots in complex care systems.

Life-history traits are poor predictors of species responses to flow regime change in headwater streams

Recent climate change is altering the timing, duration and volume of river and stream flows globally, and in many regions, perennially flowing rivers and streams are drying and switching to intermittent flows. Profound impacts on aquatic biota are becoming apparent, due in part to the strong influence of flow regime on the evolution of life history. We made predictions of life-history responses for 13 common aquatic invertebrate species (four caddisflies, five mayflies, two stoneflies, a dragonfly and an amphipod), to recent flow regime change in Australian mediterranean climate streams, based on historic studies in the same streams. Size distributions, phenology, voltinism and synchrony were compared, revealing five main responses. More than half of the species were restricted to perennially flowing streams and were absent from those that had switched to intermittent flows (including all four caddisfly species). These formerly common species are at risk of extinction as climate change progresses. Two mayfly species had divergent responses in voltinism and synchrony, and one relied on drought micro-refuges to persist. One stonefly species changed development timing to suit the new flow regime, and the amphipod species retreated to subterranean refuges. Two formerly common species were not detected at all during 2016-2017. In addition, a new mayfly species and a caddisfly species proliferated under new flow regimes, because they had life histories suited to brief hydroperiods. Importantly, previous life history rarely predicted species' actual responses to climate-driven flow regime change, raising doubts about the veracity of predictions based on species traits. This is because a species' potential for flexible phenology or growth rate is not necessarily indicated by life-history traits.

Exploring views and experiences of how infections are detected and managed in practice by nurses, care workers and manager's in nursing homes in England and Sweden: a survey protocol

INTRODUCTION

In order to avoid unnecessary hospital admission and associated complications, there is an urgent need to improve the early detection of infection in nursing home residents. Monitoring signs and symptoms with checklists or aids called decision support tools may help nursing home staff to detect infection in residents, particularly during the current COVID-19 pandemic.We plan to conduct a survey exploring views and experiences of how infections are detected and managed in practice by nurses, care workers and managers in nursing homes in England and Sweden.

METHODS AND ANALYSIS

An international cross-sectional descriptive survey, using a pretested questionnaire, will be used to explore nurses, care workers and managers views and experiences of how infections are detected and managed in practice in nursing homes. Data will be analysed descriptively and univariate associations between personal and organisational factors explored. This will help identify important factors related to awareness, knowledge, attitudes, belief and skills likely to affect future implementation of a decision support tool for the early detection of infection in nursing home residents.

ETHICS AND DISSEMINATION

This study was approved using the self-certification process at the University of Surrey and Linköping University ethics committee (Approval 2018/514-32) in 2018. Study findings will be disseminated through community/stakeholder/service user engagement events in each country, publication in academic peer-reviewed journals and conference presentations. A LAY summary will be provided to participants who indicate they would like to receive this information.This is the first stage of a plan of work to revise and evaluate the Early Detection of Infection Scale (EDIS) tool and its effect on managing infections and reducing unplanned hospital admissions in nursing home residents. Implementation of the EDIS tool may have important implications for the healthcare economy; this will be explored in cost-benefit analyses as the work progresses.

The extension of internal humidity levels beyond the soil surface facilitates mound expansion in Macrotermes

Termites in the genus Macrotermes construct large-scale soil mounds above their nests. The classic explanation for how termites coordinate their labour to build the mound, based on a putative cement pheromone, has recently been called into question. Here, we present evidence for an alternate interpretation based on sensing humidity. The high humidity characteristic of the mound's internal environment extends a short distance into the low-humidity external world, in a 'bubble' that can be disrupted by external factors like wind. Termites transport more soil mass into on-mound reservoirs when shielded from water loss through evaporation, and into experimental arenas when relative humidity is held at a high value. These results suggest that the interface between internal and external conditions may serve as a template for mound expansion, with workers moving freely within a zone of high humidity and depositing soil at its edge. Such deposition of additional moist soil will increase local humidity, in a feedback loop allowing the 'interior' zone to progress further outward and lead to mound expansion.

Surface curvature guides early construction activity in mound-building termites

Termite colonies construct towering, complex mounds, in a classic example of distributed agents coordinating their activity via interaction with a shared environment. The traditional explanation for how this coordination occurs focuses on the idea of a 'cement pheromone', a chemical signal left with deposited soil that triggers further deposition. Recent research has called this idea into question, pointing to a more complicated behavioural response to cues perceived with multiple senses. In this work, we explored the role of topological cues in affecting early construction activity in Macrotermes. We created artificial surfaces with a known range of curvatures, coated them with nest soil, placed groups of major workers on them and evaluated soil displacement as a function of location at the end of 1 h. Each point on the surface has a given curvature, inclination and absolute height; to disambiguate these factors, we conducted experiments with the surface in different orientations. Soil displacement activity is consistently correlated with surface curvature, and not with inclination nor height. Early exploration activity is also correlated with curvature, to a lesser degree. Topographical cues provide a long-term physical memory of building activity in a manner that ephemeral pheromone labelling cannot. Elucidating the roles of these and other cues for group coordination may help provide organizing principles for swarm robotics and other artificial systems. This article is part of the theme issue 'Liquid brains, solid brains: How distributed cognitive architectures process information'.

Fast, accurate, small-scale 3D scene capture using a low-cost depth sensor

Commercially available depth sensing devices are primarily designed for domains that are either macroscopic, or static. We develop a solution for fast microscale 3D reconstruction, using off-the-shelf components. By the addition of lenses, precise calibration of camera internals and positioning, and development of bespoke software, we turn an infrared depth sensor designed for human-scale motion and object detection into a device with mm-level accuracy capable of recording at up to 30Hz.

Systems science and systems thinking for public health: a systematic review of the field

OBJECTIVES

This paper reports on findings from a systematic review designed to investigate the state of systems science research in public health. The objectives were to: (1) explore how systems methodologies are being applied within public health and (2) identify fruitful areas of activity.

DESIGN

A systematic review was conducted from existing literature that draws on or uses systems science (in its various forms) and relates to key public health areas of action and concern, including tobacco, alcohol, obesity and the social determinants of health.

DATA ANALYSIS

117 articles were included in the review. An inductive qualitative content analysis was used for data extraction. The following were systematically extracted from the articles: approach, methodology, transparency, strengths and weaknesses. These were then organised according to theme (ie, commonalities between studies within each category), in order to provide an overview of the state of the field as a whole. The assessment of data quality was intrinsic to the goals of the review itself, and therefore, was carried out as part of the analysis.

RESULTS

4 categories of research were identified from the review, ranging from editorial and commentary pieces to complex system dynamic modelling. Our analysis of each of these categories of research highlighted areas of potential for systems science to strengthen public health efforts, while also revealing a number of limitations in the dynamic systems modelling being carried out in public health.

CONCLUSIONS

There is a great deal of interest in how the application of systems concepts and approach might aid public health. Our analysis suggests that soft systems modelling techniques are likely to be the most useful addition to public health, and align well with current debate around knowledge transfer and policy. However, the full range of systems methodologies is yet to be engaged with by public health researchers.

The views of patients with diabetes about nurse prescribing

AIMS

To explore the views of patients with diabetes about nurse prescribing and the perceived advantages and disadvantages.

METHODS

Patients were recruited from the case-loads of seven nurse prescribers in six National Health Service sites in England. Sites reflected the key settings in which nurses typically prescribe for patients with diabetes within primary care. Forty-one interviews were undertaken by trained qualitative researchers. Interviews addressed opinions and experiences of nurse prescribing; audiotapes were transcribed, coded, and themes identified.

RESULTS

Patients were confident in nurse prescribing. Distinctions were made between the role of the nurse and that of the doctor, and views varied with regard to the extent patients felt nurses should work autonomously. Confidence in nurse prescribing was inspired by nurses' specialist knowledge and experience, a mutual trusting relationship, a thorough consultation, and experience of the benefits of nurse prescribing. Communication between nurses and doctors about patient care, awareness by nurses of their area of competence, training and experience, specialist diabetes knowledge and access to training updates were considered important for safe prescribing. Patterns of attendance had changed in some cases, with patients tending to see doctors less often. Access to medicines was improved for patients during non-routine/emergency situations.

CONCLUSIONS

Nurse prescribing is acceptable to patients and can increase the efficiency of diabetes service in primary care. Workforce planners need to include the services of nurse prescribers alongside those of doctors.

Nurse-led care in dermatology: a review of the literature

BACKGROUND

Nurses play lead roles in the delivery of care in dermatology. While a number of primary studies have been conducted evaluating nurse-led care in dermatology, review and synthesis of the findings from these studies has not been undertaken.

OBJECTIVES

To systematically identify, summarize and critically appraise the current evidence regarding the impact and effectiveness of nurse-led care in dermatology.

METHODS

Systematic searches were done of CINAHL, MEDLINE, British Nursing Index and the Royal College of Nursing Library Catalogue from 1990 until March 2005. The searches were not restricted to the U.K., and were supplemented by an extensive hand search of the literature through references identified from retrieved articles and by contact with experts in the field.

RESULTS

A total of 14 relevant publications were identified (and included findings from both primary and secondary care), of which five were descriptions of nursing activities, five were evaluations of nurse interventions and four were patient evaluations of nurse-led care. The evidence emerging from the literature indicates that nurses are treating a number of dermatological conditions, primarily using treatment protocols, across a broad range of clinical settings. However, there is a lack of confidence among nurses working in primary care (predominantly practice nurses) to treat some of these conditions (including scalp scaling in psoriasis and infected eczema). Although the importance of education is recognized, the educational needs of these nurses are frequently unmet. The benefits of nurse interventions on service delivery include a reduction in the severity of condition and more effective use of topical therapies. Patients report faster access to treatment, a reduction in referrals to the GP or dermatologist, and an increase in knowledge of their condition.

CONCLUSIONS

Nurses frequently play lead roles in the diverse range of models of care that exist in dermatology. Although findings of the review are generally positive, there are methodological weaknesses and under-researched issues, e.g. cost effectiveness of nurse-led care, and extended independent and supplementary nurse prescribing in dermatology, that point to the need for further rigorous evaluation.

Modeling the consequences of bioterrorism response

Military medicine is playing important roles in preparing for the possibility of a covert biological attack on the United States. The objective of this work was to develop a spreadsheet tool that allows planners to compare the consequences of different speeds of response to a covert bioterrorist attack using the metric of preventable deaths. Our model simulates the number of patients to be treated and the number of deaths by day. It allows planners to vary their assumptions, such as the biological agent used, treatment efficacy, and speed of providing initial treatment. Responding to an attack on a city would involve many steps, such as determining the agent used, determining the time and location of the attack and the affected population, obtaining and delivering antibiotics, and providing treatment. Our model is a useful tool for planning the necessary size and timing of bioterrorism response.

Decreased DMPK transcript levels in myotonic dystrophy 1 type IIA muscle fibers

Myotonic dystrophy 1 is caused by the expansion of a CTG trinucleotide repeat on chromosome 19q13.3. The repeat lies in the 3' untranslated region of the myotonic dystrophy protein kinase gene (DMPK), and it has been hypothesised that the expansion alters the expression levels of DMPK and/or its neighbouring genes, DMWD and SIX5. Published data remain controversial, partly due to the mixed cell populations found in most tissues examined. We have microdissected human skeletal muscle biopsies from myotonic dystrophy 1 patients and controls and analysed gene expression at this locus for type I and type IIA fibres, using quantitative real-time reverse transcription-polymerase chain reaction. Levels of DMPK expression were specifically decreased in the type IIA fibres of myotonic dystrophy patients, below the levels found in controls. This suggests that DMPK expression is altered in this disease, suggesting significant pathological consequences.

Identification of Serhl, a new member of the serine hydrolase family induced by passive stretch of skeletal muscle in vivo

In response to extended periods of stretch, skeletal muscle typically exhibits cell hypertrophy associated with sustained increases in mRNA and protein synthesis. Several soluble hypertrophic agonists have been identified, yet relatively little is known as to how mechanical load is converted into intracellular signals regulating gene expression or how increased cell size is maintained. In skeletal muscle, hypertrophy is generally regarded as a beneficial adaptive response to increased workload. In some cases, however, hypertrophy can be detrimental as seen in long-term cardiac hypertrophy. Skeletal muscle wasting (atrophy) is a feature of both inherited and acquired muscle disease and normal aging. Elucidating the molecular regulation of cell size is a fundamental step toward comprehending the complex molecular systems underlying muscle hypertrophy and atrophy. Subtractive hybridization between passively stretched and control murine skeletal muscle tissue identified an mRNA that undergoes increased expression in response to passive stretch. Encoded within the mRNA is an open reading frame of 311 amino acids containing a highly conserved type 1 peroxisomal targeting signal and a serine lipase active center. The sequence shows identity to a family of serine hydrolases and thus is named serine hydrolase-like (Serhl). The predicted three-dimensional structure displays a core alpha/beta-hydrolase fold and catalytic triad characteristic of several hydrolytic enzymes. Endogenous Serhl protein immunolocalizes to perinuclear vesicles as does Serhl-FLAG fusion protein transiently expressed in muscle cells in vitro. Overexpression of Serhl-FLAG has no effect on muscle cell phenotype in vitro. Serhl's expression patterns and its response to passive stretch suggest that it may play a role in normal peroxisome function and skeletal muscle growth in response to mechanical stimuli.

Fibrin monomer and fibrinopeptide B act additively to increase DNA synthesis in smooth muscle cells cultured from human saphenous vein

PURPOSE

We investigated the hypothesis that fibrinogen increased DNA synthesis (and cell proliferation) of smooth muscle cells (SMCs) cultured from human saphenous vein and that the increased DNA synthesis was attenuated when cells were cultured on polymeric collagen.

METHODS

SMCs were cultured from human saphenous vein on plastic, fibronectin, monomeric, and polymeric collagen. Fibrinogen products were prepared by proteolytic digestion. DNA synthesis was measured by bromodeoxyuridine incorporation into DNA, cell proliferation by cell counting, cyclic adenosine monophosphate by enzyme-linked immunosorbent assay, and fibrinopeptide B labeled with iodine 125 used for binding studies.

RESULTS

Fibrin monomer (0.003-0.1 micromol/L) stimulated a concentration-dependent increase in DNA synthesis of up to 10-fold, which could be inhibited by the peptide Bbeta15-42. The stimulation of DNA synthesis was highest for cells cultured on plastic and lowest for cells cultured on type I collagen polymer. Much higher concentrations of fibrinogen (0.3-1 micromol/L) were required to effect similar increases in DNA synthesis. Fibrinogen had a particular effect to augment DNA synthesis, up to 14-fold, when cells were cultured on monomeric type I collagen. This augmented DNA synthesis was inhibited by a neutralizing antibody to urokinase-type plasminogen activator. Incubation of cells cultured on collagen monomer with fibrinogen resulted in production of fibrinopeptide B. Fibrinopeptide B (5 micromol/L) increased DNA synthesis by fourfold and had additive effects with fibrin monomer to increase DNA synthesis. Iodinated tyrosine fibrinopeptide B bound to SMCs (dissociation constant 0.6 micromol/L).

CONCLUSION

Cultured human saphenous vein SMCs appear to have high-affinity receptors for fibrin monomer and fibrinopeptide B, the engagement of which stimulates DNA synthesis. These mechanisms may be pertinent to the association between fibrinogen and vein graft stenosis in vivo.

A mammalian radial spokehead-like gene, RSHL1, at the myotonic dystrophy-1 locus

Ciliary function is essential for normal cellular activity in all species from simple protozoa upwards. In humans, ciliary dysmotility or complete immobility have been identified in autosomal recessive multisystemic diseases characterized by recurrent respiratory tract infections and male subfertility due to impaired sperm mobility. Linkage to human chromosome 19q13.3 has been published for some families but no candidate genes have been identified. We report the first identification of a mammalian homolog of a radial spokehead-like protein, with high homology to proteins of sea urchins and the protozoan Chlamydomonas reinhardtii, at the myotonic dystrophy-1 locus (chromosome19q13.3). In the lower organisms, these proteins are important in normal ciliary or flagellar action, including that of sea urchin spermatozoa. Expression of the mammalian homolog was detected in the adult testis. We suggest that this gene, which we have called Radial Spokehead-Like 1 (RSHL1), is a candidate gene for familial primary ciliary dyskinesia.

Chlamydia pneumoniae does not influence atherosclerotic plaque behavior in patients with established carotid artery stenosis

BACKGROUND AND PURPOSE

Research for infectious agents in the etiology of atherosclerosis has identified Chlamydia pneumoniae as a possible candidate. While there is evidence of an association between presence of this microorganism and atherosclerosis, it is unclear whether infection has a genuinely etiologic role in this disease, whether its presence influences clinical outcomes, and, if so, at which stages of disease this occurs. We have approached this issue in patients with advanced carotid artery atherosclerosis using molecular biological detection methods and clinically relevant indicators of pathology in carotid artery atheroma to determine whether the presence of C pneumoniae correlates with plaque instability.

METHODS

C pneumoniae was detected with the use of a sensitive nested polymerase chain reaction. Preoperative embolization and preoperative infarcts were recorded with the use of transcranial Doppler insonation of the middle cerebral artery and cerebral CT, respectively.

RESULTS

C pneumoniae DNA was detected in 25.5% of a cohort of 98 symptomatic patients. There was no significant difference in plaque stability as measured by embolization rates between the chlamydial-positive and -negative specimens. There was also no correlation between the number of ipsilateral hemispheric infarcts in the territory of the middle cerebral artery and chlamydial status.

CONCLUSIONS

This study confirms that C pneumoniae is a common finding in atherosclerotic plaques of the carotid artery but suggests that the presence of the infectious organism has little detectable impact on plaque instability when measured by clinically significant markers. This raises important questions for the rationale of antibiotic therapy in atherosclerosis.

Independent regulation of the myotonic dystrophy 1 locus genes postnatally and during adult skeletal muscle regeneration

Myotonic dystrophy is caused by a CTG(n) expansion in the 3'-untranslated region of a serine/threonine protein kinase gene (DMPK), which is flanked by two other genes, DMWD and SIX5. One hypothesis to explain the wide-ranging effects of this expansion is that, as the mutation expands, it alters the expression of one or more of these genes. The effects may vary in different tissues and developmental stages, but it has been difficult to develop these hypotheses as the normal postnatal developmental expression patterns of these genes have not been adequately investigated. We have developed accurate transcript quantification based on fluorescent real-time reverse transcription-polymerase chain reaction (TaqMan) to develop gene expression profiles during postnatal development in C57Bl/10 mice. Our results show extensive independent postnatal regulation of the myotonic dystrophy-locus genes in selected tissues and demonstrate which are the most highly expressed of the genes in each tissue. All three genes at the locus are expressed in the adult lens, questioning a previous model of cataractogenesis mediated solely by effects on Six5 expression. Additionally, using an in vivo model, we have shown that Dmpk levels decrease during the early stages of muscle regeneration. Our data provide a framework for investigation of tissue-specific pathological mechanisms in this disorder.

Identification of Ankrd2, a novel skeletal muscle gene coding for a stretch-responsive ankyrin-repeat protein

Mechanically induced hypertrophy of skeletal muscles involves shifts in gene expression leading to increases in the synthesis of specific proteins. Full characterization of the regulation of muscle hypertrophy is a prerequisite for the development of novel therapies aimed at treating muscle wasting (atrophy) in human aging and disease. Using suppression subtractive hybridization, cDNAs corresponding to mRNAs that increase in relative abundance in response to mechanical stretch of mouse skeletal muscles in vivo were identified. A novel 1100-bp transcript was detected exclusively in skeletal muscle. This exhibited a fourfold increase in expression after 7 days of stretch. The transcript had an open reading frame of 328 amino acids encoding an ATP/GTP binding domain, a nuclear localization signal, two PEST protein-destabilization motifs, and a 132-amino-acid ankyrin-repeat region. We have named this gene ankyrin-repeat domain 2 (stretch-responsive muscle) (Ankrd2). We hypothesize that Ankrd2 plays an important role in skeletal muscle hypertrophy.

Simultaneous analysis of expression of the three myotonic dystrophy locus genes in adult skeletal muscle samples: the CTG expansion correlates inversely with DMPK and 59 expression levels, but not DMAHP levels

The causative mutation in the majority of cases of myotonic dystrophy has been shown to be the expansion of a CTG trinucleotide repeat, but the mechanism(s) by which this repeat leads to the very complex symptomatology in this disorder remains controversial. We have developed a highly sensitive and quantifiable assay, based on competitive RT-PCR, to test the hypothesis that the expansion disrupts the expression of the genes in its immediate vicinity, DMPK, 59 and DMAHP. In order to avoid cell culture-induced artifacts we performed these experiments using adult skeletal muscle biopsy samples and analysed total cytoplasmic poly(A)+mRNA levels for each gene simultaneously, as this is more physiologically relevant than allele-specific levels. There was considerable overlap between the expression levels of the three genes in myotonic dystrophy patient samples and samples from control individuals. However, in the myotonic dystrophy samples we detected a strong inverse correlation between the repeat size and the levels of expression of DMPK and 59. This is the first report of a possible effect of the CTG expansion on gene 59. Our results indicate that whilst a simple dosage model of gene expression in the presence of the mutation is unlikely to be sufficient in itself to explain the complex molecular pathology in this disease, the repeat expansion may be a significant modifier of the expression of these two genes.

A clinical pathway for the secondary diagnosis of alcohol misuse: implications for the orthopaedic patient

This article presents the process of developing a method of routine identification, assessment, intervention, and follow-up for the trauma patient with a concomitant diagnosis of alcohol misuse. A clinical pathway approach to addressing the needs of the alcohol misuser is outlined, and an alternative method that adapts this approach to other settings is also presented. Ever mindful of decreasing lengths of stay and reimbursement predicated on diagnosis-related groups, this pathway is tailored to overlay onto an existing clinical path of care so as not to increase length of stay nor duplicate services.

Chlamydia pneumoniae and vascular disease

BACKGROUND

There is an increasing body of evidence linking the human pathogen Chlamydia pneumoniae with atherosclerosis.

METHODS

A Medline-based review of the literature was carried out.

RESULTS AND CONCLUSION

Seroepidemiological studies have revealed the possibility that evidence of infection with C. pneumoniae and atherosclerotic disease are related. Studies on human tissue have demonstrated that evidence of the organism can be found in human atherosclerotic tissue by both direct and indirect methods significantly more often than in control vascular tissue. Using animal models it is possible to show that C. pneumoniae can be disseminated haematogenously following pulmonary infection and that it shows a tropism for atherosclerotic tissue. In vitro work has demonstrated that the organism is capable of infecting, surviving and multiplying in cells of the human vascular wall, and that it can provoke a cell-mediated cytokine response which has implications both locally and systemically. Two clinical trials of macrolide antibiotics have demonstrated that they confer increased cardiovascular protection in patients following myocardial infarction. Adequately powered trials are needed to establish the therapeutic role of antibiotics in peripheral arterial disease.

Human saphenous vein endothelial cells express a tetrodotoxin-resistant, voltage-gated sodium current

Whole-cell patch-clamp electrophysiological investigation of endothelial cells cultured from human saphenous vein (HSVECs) has identified a voltage-gated Na+ current with a mean peak magnitude of -595 +/- 49 pA (n = 75). This current was inhibited by tetrodotoxin (TTX) in a concentration-dependent manner, with an IC50 value of 4.7 microM, suggesting that it was of the TTX-resistant subtype. An antibody directed against the highly conserved intracellular linker region between domains III and IV of known Na+ channel alpha-subunits was able to retard current inactivation when applied intracellularly. This antibody identified a 245-kDa protein from membrane lysates on Western blotting and positively immunolabeled both cultured HSVECs and intact venous endothelium. HSVECs were also shown by reverse transcription-polymerase chain reaction to contain transcripts of the hH1 sodium channel gene. The expression of Na+ channels by HSVECs was shown using electrophysiology and cell-based enzyme-linked immunosorbent assay to be dependent on the concentration and source of human serum. Together, these results suggest that TTX-resistant Na+ channels of the hH1 isoform are expressed in human saphenous vein endothelium and that the presence of these channels is controlled by a serum factor.

Over expression of the murine myotonic dystrophy protein kinase in the mouse myogenic C2C12 cell line leads to inhibition of terminal differentiation

Myotonic dystrophy (DM) is an autosomal dominant human disorder, caused by the abnormal expansion of a CTG trinucleotide repeat in the 3' untranslated region of a protein kinase gene (DMPK). Muscle symptoms are a common feature of the disorder and in the adult onset cases there are increased patterns of muscle fibre degeneration and regeneration. In the congenitally affected infants there is a failure of muscle maturation, with the histological presence of numerous immature fibres. However, the pathological mechanism in both forms of the disease is unclear. We report that over-expression of the murine dmpk gene, in a murine myogenic cell line, leads to markedly reduced levels of fusion to the terminally differentiated state. These findings complement recently published data using a heterologous expression/cell system and may have implications for the understanding of the disease process in this disorder.

Microsatellite instability in early sporadic breast cancer

We have studied the incidence of microsatellite instability at three trinucleotide repeats and seven dinucleotide repeats from five chromosomal regions, in a group of 30 mammographically detected 'early' invasive breast cancers and correlated its occurrence with clinicopathological parameters. The myotonic dystrophy (DM-1) trinucleotide repeat was analysed in 48 additional cases. In 4 out of 78 (5%) paired tumour-normal DNA samples we found evidence of somatic microsatellite instability at DM-1: a novel allele of a different size was seen in the tumour DNA which was not present in the normal DNA sample. All four tumours that showed evidence of instability were from the core group of 30 cases (13%) and were well or moderately differentiated, oestrogen receptor-positive, infiltrating ductal carcinomas. Two of these tumours were unstable at nine of ten loci studied, both trinucleotide and dinucleotide repeats. DNA prepared from different normal tissues showed no evidence of instability, for all four instability cases. These data indicate that microsatellite instability is specific to the tumour DNA and is an early event in the genesis of some sporadic breast cancers.

Cloning of the human SIX1 gene and its assignment to chromosome 14

The recently described murine homeobox genes, Six1 and Six2, which are expressed during development in limb tendons, have also been shown to be expressed in skeletal and smooth muscle, respectively. We have cloned and sequenced a human SIX1 cDNA and shown by Northern blotting that it is expressed in adult skeletal muscle. The cDNA sequence and predicted protein sequence of SIX1 and Six1 are highly homologous, with 98% similarity over the entire predicted amino acid sequence. SIX1 was mapped to human chromosome 14 using a rodent/human somatic cell hybrid panel.

Tools to incorporate some psychological and organizational issues during the development of computer-based systems

The organization, findings and outcomes of a joint industrial/academic project are described. The principal goal of the project was to develop and test some tools through which people involved in system development can incorporate explicit consideration of certain key psychological and organizational issues. Five tools developed for this purpose are outlined. These are concerned with the design of work organization, job design, the allocation of tasks between humans and computers, usability and task analysis. The use of the tools is described in a 'live' system development project in a large company. The authors briefly review the extent to which these tools meet a set of pre-specified requirements, compare their approach with those of Mumford (1986) and Lim et al. (1992), and make explicit what claims they are making of these tools.

A novel homeodomain-encoding gene is associated with a large CpG island interrupted by the myotonic dystrophy unstable (CTG)n repeat

Myotonic dystrophy (DM) is associated with a (CTG)n trinucleotide repeat expansion in the 3'-untranslated region of a protein kinase-encoding gene, DMPK, which maps to chromosome 19q13.3. Characterisation of the expression of this gene in patient tissues has thus far generated conflicting data on alterations in the steady state levels of DMPK mRNA, and on the final DMPK protein levels in the presence of the expansion. The DM region of chromosome 19 is gene rich, and it is possible that the repeat expansion may lead to dysfunction of a number of transcription units in the vicinity, perhaps as a consequence of chromatin disruption. We have searched for genes associated with a CpG island at the 3' end of DMPK. Sequencing of this region shows that the island extends over 3.5 kb and is interrupted by the (CTG)n repeat. Comparison of genomic sequences downstream (centromeric) of the repeat in human and mouse identified regions of significant homology. These correspond to exons of a gene predicted to encode a homeodomain protein. RT-PCR analysis shows that this gene, which we have called DM locus-associated homeodomain protein (DMAHP), is expressed in a number of human tissues, including skeletal muscle, heart and brain.

Comparison of CTG repeat length expansion and clinical progression of myotonic dystrophy over a five year period

Myotonic dystrophy (DM) is associated with an underlying CTG trinucleotide repeat expansion at a locus on chromosome 19q13.3. We have determined the repeat length in 23 DM patients with varying clinical severity of symptoms and various sizes of repeat amplification. We confirm that as in previous studies there is no strong correlation between repeat length and clinical symptoms but find that the repeat length in peripheral blood cells of patients increases over a time span of five years indicating continuing mitotic instability of the repeat throughout life. Repeat length progression does not appear to be indicative of clinical progression but age probably is. The degree of expansion correlates with the initial repeat size and 50% of the patients with continuing expansions showed clinical progression of their disease symptoms over the five year study period.

Direct molecular analysis of myotonic dystrophy in the German population: important considerations in genetic counselling

Myotonic dystrophy (DM) is associated with the expansion and instability of a trinucleotide (CTG) repeat at the DM locus on chromosome 19. Direct genomic analysis in the German population was carried out on 18 DM families, six families with equivocal diagnosis, 69 subjects with equivocal clinical diagnosis, and 100 controls using the polymerase chain reaction (PCR) and a refined Southern protocol. In the majority of the cases molecular analysis confirmed the clinical diagnosis. These included seven cases of congenital DM (CDM) with widely differing gene expansions and instabilities. In most DM families the expanded fragment became larger in successive generations, but we also identified four families with contractions and two families that showed stability of the enlarged fragment during transmission. In four clinically defined DM patients we were unable to detect enlarged CTG repeats. Sequencing of each exon of the DM gene in two of these patients failed to show any mutations. Our cases have important implications for genetic counselling of DM families, highlighting both the diagnostic value of direct genomic analysis and its limitations.

Myotonic disorders and periodic paralysis

The myotonias are a diverse set of diseases, variable in presentation, often difficult to diagnose and, until now, treated with only a limited degree of success. Recent genetic advances have pinpointed many of the mutations that underlie these disorders and have demonstrated that there may be different causative genetic mutations underlying the same phenotype. This chapter summarizes the genetic data currently available for these disorders and attempts to link these to their clinical features. In some instances this is conceptually relatively straightforward but in others, particularly DM, the manner in which the mutation leads to the observed phenotype is very unclear and can be used as a paradigm for some of the more puzzling aspects of modern human genetics. Some suggestions are put forward on how the unusual mutation seen in DM can lead to highly variable symptoms between individual patients, and how the mutation can be transmitted unstably through a pedigree.

Sequence variation in the gp135 gene of Maedi visna virus strain EV1

We have used the PCR and HIRT DNA obtained from MVV-infected tissue culture cells as a template to generate a number of independently derived clones representing overlapping fragments of the gp135 region (env) of Maedi visna virus (MVV) strain EV1. Sequencing these clones revealed that homology between selected regions of gp135 ranged from 93.2% to 99.8%. Four hypervariable regions and one large highly conserved region have been identified. These data provide information on the variability of EV1 env, which extends and complements the data previously available on env variability between geographically distinct isolates of MVV.

The biology of maedi-visna virus--an overview

This review aims to summarize the current understanding of the biology of maedi-visna virus (MVV), the prototype virus of the family lentivirinae. The paper provides a short overview of the historical background to the discovery of MVV. Detailed descriptions of the structure and organization of the MVV genome and of the virion encoded polypeptides are given and the MVV life cycle in vitro and in vivo are compared and contrasted and the tropism of the virus discussed. The clinical consequences of infection are considered and the mode of transmission, immune response to the virus and possible mechanisms of pathogenesis are discussed.

Use of recombinant gp135 to study epitope-specific antibody responses to maedi visna virus

The envelope glycoprotein gp135 of the ovine lentivirus maedi visna virus (MVV) is the main target for neutralising antibody in vivo, however little is known about the specific regions of gp135 which elicit this neutralising response. We have used the polymerase chain reaction (PCR) to generate overlapping fragments of the gp135 gene which have been expressed as fusion proteins in the yeast Ty-VLP system. These fusion proteins have been used to analyse the antibody response to gp135 in MVV infected sheep and we are able to identify at least three distinct regions of gp135 to which antibodies are directed. The approach described in this paper provides a rapid and simple method of generating overlapping fusion proteins with which to carry out epitope mapping studies.

The detection of problem analytes in a single proficiency test challenge in the absence of the Health Care Financing Administration rule violations

The Clinical Laboratory Improvement Act of 1988 (CLIA 88) has dramatically changed proficiency testing (PT) practices having mandated (1) satisfactory PT for certain analytes as a condition of laboratory operation, (2) fixed PT limits for many of these "regulated" analytes, and (3) an increased number of PT specimens (n = 5) for each testing cycle. For many of these analytes, the fixed limits are much broader than the previously employed Standard Deviation Index (SDI) criteria. Paradoxically, there may be less incentive to identify and evaluate analytically significant outliers to improve the analytical process. Previously described "control rules" to evaluate these PT results are unworkable as they consider only two or three results. We used Monte Carlo simulations of Kodak Ektachem analyzers participating in PT to determine optimal control rules for the identification of PT results that are inconsistent with those from other laboratories using the same methods. The analysis of three representative analytes, potassium, creatine kinase, and iron was simulated with varying intrainstrument and interinstrument standard deviations (si and sg, respectively) obtained from the College of American Pathologists (Northfield, Ill) Quality Assurance Services data and Proficiency Test data, respectively. Analytical errors were simulated in each of the analytes and evaluated in terms of multiples of the interlaboratory SDI. Simple control rules for detecting systematic and random error were evaluated with power function graphs, graphs of probability of error detected vs magnitude of error. Based on the simulation results, we recommend screening all analytes for the occurrence of two or more observations exceeding the same +/- 1 SDI limit. For any analyte satisfying this condition, the mean of the observations should be calculated. For analytes with sg/si ratios between 1.0 and 1.5, a significant systematic error is signaled by the mean exceeding 1.0 SDI. Significant random error is signaled by one observation exceeding the +/- 3-SDI limit or the range of the observations exceeding 4 SDIs. For analytes with higher sg/si, significant systematic or random error is signaled by violation of the screening rule (having at least two observations exceeding the same +/- 1 SDI limit). Random error can also be signaled by one observation exceeding the +/- 1.5-SDI limit or the range of the observations exceeding 3 SDIs. We present a practical approach to the workup of apparent PT errors.