Point of care testing in the perioperative period

The range of point of care tests continues to increase. Point of care testing is frequently undertaken by nonlaboratory personnel and clinicians should understand the tests available and their applicability in clinical practice.

The musculoskeletal manifestations of haemophilia: a review of the imaging findings

Haemophilia is a common hereditary cause of bleeding diathesis and the musculoskeletal system is frequently affected. Repeated episodes of haemarthrosis initiate a cascade towards haemophilic arthropathy, a disabling and deforming joint disease with both degenerative and inflammatory features, which include articular cartilage loss, bone erosions, and synovitis. Haemophilic pseudotumour and intra-muscular haematoma make up the remainder of the musculoskeletal manifestations of this systemic condition. Radiological assessment is vital in the assessment and follow-up of these haemophilic complications and MRI is the reference standard. This article summarises the radiological findings relevant to the diagnosis and monitoring of this complex patient group.

475 DEVELOPING A VIRTUAL CARE HOME SUPPORT FORUM DURING THE COVID-19 PANDEMIC

Introduction

COVID-19 has had a devastating effect on care homes, increasing both morbidity and mortality of residents and staff. Between 2 March and 12 June 2020, COVID-19 was the main cause of death in male care home residents (33.5%) and second for female (26.6%).1 By 1 May 2020, the death rate from all causes in care homes exceeded that in hospital (6,409 versus 6,397).2 Thus, care homes had to rapidly adapt to facilitate safe care of patients and staff.

Method

An expert outreach team visited a number of care homes in Surrey and Sussex to explore COVID-19 issues in care homes. Key themes were identified that informed topics for the Virtual Care Home Forum, where a series of virtual teaching, training and peer support sessions were hosted either live or on-demand, accessible for all care home staff.

Results

12 sessions were held with an average attendance of 25 people, predominantly care home managers and community healthcare professionals. Real time qualitative feedback was collected and an electronic survey was completed at the end of the series which showed 100% felt the sessions had improved their understanding of the topic, 100% felt the knowledge and skills obtained from the sessions would be useful in their job, 87.5% agreed the sessions would impact or change their practise and 100% felt more supported during the pandemic.

Conclusion

It has been an unprecedented year for the NHS, and the care home sector has suffered significantly. In order to provide the best level of care for patients and support for our community colleagues, we must work collaboratively, including provision of education and training. To ensure equal access for all, maintaining user-safety and compliance with government legislation, virtual webinars proved to be an excellent modality. We plan to continue providing training, teaching and support through this means in the future.

Variables associated with survival in patients with invasive bladder cancer with and without surgery

We recorded the survival of 141 patients assessed for radical cystectomy, which included cardiopulmonary exercise testing. The median Kaplan-Meier survival estimates were: 1540 days for the whole cohort; 2200 days after cystectomy scheduled (n = 108); and 843 days without surgery. The mortality hazard remained double that expected for a matched general population, but survival was better in patients scheduled for surgery than those who were not: the mortality hazard ratio (95%CI) after cystectomy was 0.43 (0.26-0.73) the mortality hazard without surgery, p = 0.001. The mortality hazard ratios for the three-variable Bayesian Model Averaging survival model for all 141 patients were: referral for surgery (0.5); haemoglobin concentration (0.98); and efficiency of carbon dioxide output (1.05). Efficiency of carbon dioxide output was the single variable in the postoperative model (n = 108), mortality hazard 1.08 (per unit increase). The ratio of observed to expected peak oxygen consumption associated best with mortality in 33 patients not referred for surgery, hazard ratio 0.001. Our results can inform consultations with patients with invasive bladder cancer and suggest that interventions to increase fitness and haemoglobin may improve survival in patients who do and who do not undergo radical cystectomy.

Effects of spin-dependent interactions on polarization of bright polariton solitons

We report on the spin properties of bright polariton solitons supported by an external pump to compensate losses. We observe robust circularly polarized solitons when a circularly polarized pump is applied, a result attributed to phase synchronization between nondegenerate TE and TM polarized polariton modes at high momenta. For the case of a linearly polarized pump, either σ+ or σ- circularly polarized bright solitons can be switched on in a controlled way by a σ+ or σ- writing beam, respectively. This feature arises directly from the widely differing interaction strengths between co- and cross-circularly polarized polaritons. In the case of orthogonally linearly polarized pump and writing beams, the soliton emission on average is found to be unpolarized, suggesting strong spatial evolution of the soliton polarization. The observed results are in agreement with theory, which predicts stable circularly polarized solitons and unstable linearly polarized solitons.

E-cadherin plays an essential role in collective directional migration of large epithelial sheets

In wound healing and development, large epithelial sheets migrate collectively, in defined directions, and maintain tight cell-cell adhesion. This type of movement ensures an essential function of epithelia, a barrier, which is lost when cells lose connection and move in isolation. Unless wounded, epithelial sheets in cultures normally do not have overall directional migration. Cell migration is mostly studied when cells are in isolation and in the absence of mature cell-cell adhesion; the mechanisms of the migration of epithelial sheets are less well understood. We used small electric fields (EFs) as a directional cue to instigate and guide migration of epithelial sheets. Significantly, cells in monolayer migrated far more efficiently and directionally than cells in isolation or smaller cell clusters. We demonstrated for the first time the group size-dependent directional migratory response in several types of epithelial cells. Gap junctions made a minimal contribution to the directional collective migration. Breaking down calcium-dependent cell-cell adhesion significantly reduced directional sheet migration. Furthermore, E-cadherin blocking antibodies abolished migration of cell sheets. Traction force analysis revealed an important role of forces that cells in the leading rows exert on the substratum. With EF, the traction forces of the leading edge cells coordinated in directional re-orientation. Our study thus identifies a novel mechanism--E-cadherin dependence and coordinated traction forces of leading cells in collective directional migration of large epithelial sheets.

An ensemble of structures of Burkholderia pseudomallei 2,3-bisphosphoglycerate-dependent phosphoglycerate mutase

Burkholderia pseudomallei is a soil-dwelling bacterium endemic to Southeast Asia and Northern Australia. Burkholderia is responsible for melioidosis, a serious infection of the skin. The enzyme 2,3-bisphosphoglycerate-dependent phosphoglycerate mutase (PGAM) catalyzes the interconversion of 3-phosphoglycerate and 2-phosphoglycerate, a key step in the glycolytic pathway. As such it is an extensively studied enzyme and X-ray crystal structures of PGAM enzymes from multiple species have been elucidated. Vanadate is a phosphate mimic that is a powerful tool for studying enzymatic mechanisms in phosphoryl-transfer enzymes such as phosphoglycerate mutase. However, to date no X-ray crystal structures of phosphoglycerate mutase have been solved with vanadate acting as a substrate mimic. Here, two vanadate complexes together with an ensemble of substrate and fragment-bound structures that provide a comprehensive picture of the function of the Burkholderia enzyme are reported.

Vortex lattices in coherently pumped polariton microcavities

We propose a new class of vortex lattices supported by the parametric conversion of polaritons in wide aperture semiconductor microcavities operating in the strong coupling regime and pumped by a coherent beam. We present numerical and analytical results confirming the existence and robustness of the polaritonic vortex lattices in practically relevant settings and discuss their melting scenarios.

Axonal and neuromuscular synaptic phenotypes in Wld(S), SOD1(G93A) and ostes mutant mice identified by fiber-optic confocal microendoscopy

We used live imaging by fiber-optic confocal microendoscopy (CME) of yellow fluorescent protein (YFP) expression in motor neurons to observe and monitor axonal and neuromuscular synaptic phenotypes in mutant mice. First, we visualized slow degeneration of axons and motor nerve terminals at neuromuscular junctions following sciatic nerve injury in Wld(S) mice with slow Wallerian degeneration. Protection of axotomized motor nerve terminals was much weaker in Wld(S) heterozygotes than in homozygotes. We then induced covert modifiers of axonal and synaptic degeneration in heterozygous Wld(S) mice, by N-ethyl-N-nitrosourea (ENU) mutagenesis, and used CME to identify candidate mutants that either enhanced or suppressed axonal or synaptic degeneration. From 219 of the F1 progeny of ENU-mutagenized BALB/c mice and thy1.2-YFP16/Wld(S) mice, CME revealed six phenodeviants with suppression of synaptic degeneration. Inheritance of synaptic protection was confirmed in three of these founders, with evidence of Mendelian inheritance of a dominant mutation in one of them (designated CEMOP_S5). We next applied CME repeatedly to living Wld(S) mice and to SOD1(G93A) mice, an animal model of motor neuron disease, and observed degeneration of identified neuromuscular synapses over a 1-4day period in both of these mutant lines. Finally, we used CME to observe slow axonal regeneration in the ENU-mutant ostes mouse strain. The data show that CME can be used to monitor covert axonal and neuromuscular synaptic pathology and, when combined with mutagenesis, to identify genetic modifiers of its progression in vivo.

Wld S protein requires Nmnat activity and a short N-terminal sequence to protect axons in mice

The slow Wallerian degeneration (Wld^S) protein protects injured axons from degeneration. This unusual chimeric protein fuses a 70–amino acid N-terminal sequence from the Ube4b multiubiquitination factor with the nicotinamide adenine dinucleotide–synthesizing enzyme nicotinamide mononucleotide adenylyl transferase 1. The requirement for these components and the mechanism of Wld^S-mediated neuroprotection remain highly controversial. The Ube4b domain is necessary for the protective phenotype in mice, but precisely which sequence is essential and why are unclear. Binding to the AAA adenosine triphosphatase valosin-containing protein (VCP)/p97 is the only known biochemical property of the Ube4b domain. Using an in vivo approach, we show that removing the VCP-binding sequence abolishes axon protection. Replacing the Wld^S VCP-binding domain with an alternative ataxin-3–derived VCP-binding sequence restores its protective function. Enzyme-dead Wld^S is unable to delay Wallerian degeneration in mice. Thus, neither domain is effective without the function of the other. Wld^S requires both of its components to protect axons from degeneration.

Spinal cholinergic interneurons regulate the excitability of motoneurons during locomotion

To effect movement, motoneurons must respond appropriately to motor commands. Their responsiveness to these inputs, or excitability, is regulated by neuromodulators. Possible sources of modulation include the abundant cholinergic "C boutons" that surround motoneuron somata. In the present study, recordings from motoneurons in spinal cord slices demonstrated that cholinergic activation of m2-type muscarinic receptors increases excitability by reducing the action potential afterhyperpolarization. Analyses of isolated spinal cord preparations in which fictive locomotion was elicited demonstrated that endogenous cholinergic inputs increase motoneuron excitability during locomotion. Anatomical data indicate that C boutons originate from a discrete group of interneurons lateral to the central canal, the medial partition neurons. These results highlight a unique component of spinal motor networks that is critical in ensuring that sufficient output is generated by motoneurons to drive motor behavior.

A case of a periaortic lymphoma presenting with the features of descending thoracic aorta dissection

We report the case of a 68-year-old male in whom an intrathoracic non-Hodgkin's lymphoma was diagnosed late after he presented with the clinical and radiological features of a descending aortic dissection due to penetrating ulcer. An endovascular stent was implanted in the descending aorta. At follow up, a CT scan showed the presence of a mediastinal mass thought to be a periaortic haematoma as a consequence of the endovascular stent implantation. A further CT scan showed an increase in size of the mediastinal mass encasing the whole descending aorta. A biopsy of the mass was performed which was shown to be non-Hodgkin's lymphoma. This is the first report of a penetrating ulcer of the descending aorta due to lymphoma, which probably caused the dissection.

Chondroitinase ABC promotes sprouting of intact and injured spinal systems after spinal cord injury

Chondroitin sulfate proteoglycans (CSPGs) are inhibitory extracellular matrix molecules that are upregulated after CNS injury. Degradation of CSPGs using the enzyme chondroitinase ABC (ChABC) can promote functional recovery after spinal cord injury. However, the mechanisms underlying this recovery are not clear. Here we investigated the effects of ChABC treatment on promoting plasticity within the spinal cord. We found robust sprouting of both injured (corticospinal) and intact (serotonergic) descending projections as well as uninjured primary afferents after a cervical dorsal column injury and ChABC treatment. Sprouting fibers were observed in aberrant locations in degenerating white matter proximal to the injury in regions where CSPGs had been degraded. Corticospinal and serotonergic sprouting fibers were also observed in spinal gray matter at and below the level of the lesion, indicating increased innervation in the terminal regions of descending projections important for locomotion. Spinal-injured animals treated with a vehicle solution showed no significant sprouting. Interestingly, ChABC treatment in uninjured animals did not induce sprouting in any system. Thus, both denervation and CSPG degradation were required to promote sprouting within the spinal cord. We also examined potential detrimental effects of ChABC-induced plasticity. However, although primary afferent sprouting was observed after lumbar dorsal column lesions and ChABC treatment, there was no increased connectivity of nociceptive neurons or development of mechanical allodynia or thermal hyperalgesia. Thus, CSPG digestion promotes robust sprouting of spinal projections in degenerating and denervated areas of the spinal cord; compensatory sprouting of descending systems could be a key mechanism underlying functional recovery.

Postnatal phenotype and localization of spinal cord V1 derived interneurons

Developmental studies identified four classes (V0, V1, V2, V3) of embryonic interneurons in the ventral spinal cord. Very little is known, however, about their adult phenotypes. Therefore, we characterized the location, neurotransmitter phenotype, calcium-buffering protein expression, and axon distributions of V1-derived neurons in the adult mouse spinal cord. In the mature (P20 and older) spinal cord, most V1-derived neurons are located in lateral LVII and in LIX, few in medial LVII, and none in LVIII. Approximately 40% express calbindin and/or parvalbumin, while few express calretinin. Of seven groups of ventral interneurons identified according to calcium-buffering protein expression, two groups (1 and 4) correspond with V1-derived neurons. Group 1 are Renshaw cells and intensely express calbindin and coexpress parvalbumin and calretinin. They represent 9% of the V1 population. Group 4 express only parvalbumin and represent 27% of V1-derived neurons. V1-derived Group 4 neurons receive contacts from primary sensory afferents and are therefore proprioceptive interneurons. The most ventral neurons in this group receive convergent calbindin-IR Renshaw cell inputs. This subgroup resembles Ia inhibitory interneurons (IaINs) and represents 13% of V1-derived neurons. Adult V1-interneuron axons target LIX and LVII and some enter the deep dorsal horn. V1 axons do not cross the midline. V1-derived axonal varicosities were mostly (>80%) glycinergic and a third were GABAergic. None were glutamatergic or cholinergic. In summary, V1 interneurons develop into ipsilaterally projecting, inhibitory interneurons that include Renshaw cells, Ia inhibitory interneurons, and other unidentified proprioceptive interneurons.

Conditional rhythmicity of ventral spinal interneurons defined by expression of the Hb9 homeodomain protein

The properties of mammalian spinal interneurons that underlie rhythmic locomotor networks remain poorly described. Using postnatal transgenic mice in which expression of green fluorescent protein is driven by the promoter for the homeodomain transcription factor Hb9, as well as Hb9-lacZ knock-in mice, we describe a novel population of glutamatergic interneurons located adjacent to the ventral commissure from cervical to midlumbar spinal cord levels. Hb9+ interneurons exhibit strong postinhibitory rebound and demonstrate pronounced membrane potential oscillations in response to chemical stimuli that induce locomotor activity. These data provide a molecular and physiological delineation of a small population of ventral spinal interneurons that exhibit homogeneous electrophysiological features, the properties of which suggest that they are candidate locomotor rhythm-generating interneurons.

Locomotor-Like Rhythms in a Genetically Distinct Cluster of Interneurons in the Mammalian Spinal Cord

Electrophysiological and morphological properties of genetically identified spinal interneurons were examined to elucidate their possible contribution to locomotor-like rhythmic activity in 1- to 4-day-old mice. In the transgenic mice used in our study, the HB9 promotor controlled the expression of the reporter gene enhanced green fluorescent protein (eGFP), giving rise to GFP+ motoneurons and ventral interneurons. However, only motoneurons and a small group of bipolar, GFP+ interneurons expressed the HB9 protein. The HB9+/GFP+ interneurons were clustered close to the medial surface in lamina VIII along segments L1–L3. The correlation between activity pattern in these visually identified interneurons and motoneuron output was examined using simultaneous whole cell and ventral root recordings. Neurochemically induced rhythmic membrane depolarizations in HB9/GFP interneurons were synchronous with ventral root rhythms, indicating that the interneurons received synaptic inputs from rhythm-generating networks. The frequency of excitatory postsynaptic currents significantly increased during ventral root bursts, but there was no change in the frequency of inhibitory postsynaptic currents during the cycle period. These data implied that HB9/GFP interneurons received primarily excitatory inputs from rhythmogenic interneurons. Neurobiotin-filled axon terminals were in close apposition to other neurons in the cluster and to motoneuron dendrites, raising the possibility that HB9/GFP interneurons formed synaptic connections with each other and with motoneurons. The expression of the vesicular glutamate transporter 2 in axon terminals of HB9/GFP interneurons indicated that these were glutamatergic interneurons. Our findings suggest that the visually identified HB9/GFP interneurons are premotor excitatory interneurons and putative constituents of networks generating locomotor rhythms in the mammalian spinal cord.

Ultrastructural changes in exocrine tissues of a DeltaF-508 CFTR mouse model

Cystic fibrosis (CF) is characterized by abnormal secretion from epithelial cells. We wanted to detect changes in the ultrastructural characteristics of cells within a number of exocrine tissues, including the colon, submandibular and parotid salivary glands of DeltaF-508 CFTR animals. Therefore, in the present study a DeltaF-508 CFTR mouse model was compared to control, by applying conventional and complex carbohydrates staining techniques to tissue sections at the electron microscope level. The colon of DeltaF-508 CFTR mice contained thick mucous secretions that harbored many bacteria, along with cytoplasmic fragments and leukocytes. Leukocytes were also seen to infiltrate the cytoplasm of goblet cells. Tissues were taken before, 10 min after isoprenaline, and 30 min after a further injection of methacholine. In the submandibular gland, there is limited secretory activity after isoprenaline treatment, and this increases further with methacholine treatment. Depletion of the secretory granules of acinar cells is observed, following the combined isoprenaline and methacholine treatment, but no significant changes in granule numbers occurred in granular tubule cells. Glycogen, abundant before treatment, is reduced within 10 min of isoprenaline treatment and is completely exhausted by 30 min, especially in the convoluted granular tubule cells. A few secretory granules in acinar and in granular tubule cells of the DeltaF-508 CFTR submandibular glands displayed two electron densities. The secretory responses of the parotid gland cells were similar to those in submandibular gland cells, except that in these DeltaF-508 CFTR cells, secretory granules appeared more polymorphic in structure than those found in control animals.

A case study in using VET qualifications to rejuvenate learning and change in a complex and disparate rural area health service

The Boggabri Health Service is typical of many rural and remote public health facilities. Twenty-four staff, only a third of whom work full-time, service the needs of a population of 1601. Change from a focus on acute care to a model of wellness through redevelopment as a Multi Purpose Service is providing staff with a unique opportunity for continuing professional development, particularly in regard to aged care standards, their core business. Use of flexible delivery and self-directed learning has transformed this facility from ignorance about the value of undertaking vocational education and training (VET) to 80% enrollment in certificate and diploma qualifications, ever a six month period from January 2001. Some twenty-five facilities comprise the New England Area Health Service, of which Boggabri is but one. The learning innovation demonstrated at Boggabri is being duplicated across other facilities. Interest in VET qualifications from staff at all levels is a remarkable renaissance.

Synthesis of adducts with amino acids as potential dosimeters for the biomonitoring of humans exposed to toluenediisocyanate

Toluenediisocyanates (TDI) are important intermediates in the chemical industry. Among the main damages after low levels of TDI exposure are lung sensitization and asthma. Protein adducts of TDI might be involved in the etiology of sensitization reactions. Blood protein adducts are used as dosimeters for modifications of macromolecules in the target organs where the disease develops. The functional groups of cysteine, tyrosine, serine, lysine, tryptophan, histidine, and N-terminal amino acids are potential reaction sites for isocyanates. Especially the N-terminal amino acids, valine, and aspartic acid of hemoglobin and albumin, respectively, are reactive toward electrophilic xenobiotics. To develop methods for the quantitation of protein adducts of 2,4- and 2,6-TDI, we reacted 3-nitro-4-methylphenyl isocyanate (1a) with single amino acids and reduced the nitro group using catalytic hydrogenation or ammonium formate with palladium on carbon yielding N-[(3-amino-4-methylphenyl)carbamoyl]valine (2a), N-[(3-amino-4-methylphenyl)carbamoyl]aspartic acid (8a), N(alpha)-acetyl-N(epsilon)-[(3-amino-4-methylphenyl)carbamoyl]lysine (12a), and N(alpha)-acetyl-O-[(3-amino-4-methylphenyl)carbamoyl]serine (15a). The same reactions were performed with 5-nitro-2-methylphenyl isocyanate (1b) and 3-nitro-2-methylphenyl isocyanate (1c). The valine adducts were boiled in acid to obtain the corresponding hydantoins: 3-(3-amino-4-methylphenyl)-5-isopropylimidazoline-2,4-dione (5a), 3-(5-amino-2-methylphenyl)-5-isopropylimidazoline-2,4-dione (5b), and 3-(3-amino-2-methylphenyl)-5-isopropylimidazoline-2,4-dione (5c). A method for the detection of N-terminal adducts with valine in biological samples was developed. The tripeptide adduct N-[(3-amino-4-methylphenyl)carbamoyl]valyl-glycyl-glycine (19a) was hydrolyzed with acid in the presence of globin and the internal standard N-[(3-amino-4-methylphenyl-d(6))carbamoyl]valyl-glycyl-glycine (19d). The released hydantoins were determined by LC/MS/MS and after derivatization with pentafluoropropionic anhydride by GC/MS. The determination limit was 0.16 pmol/sample. The same N-terminal adduct with valine was found in globin of a TDI-worker and in two women with polyurethane covered breast implants.

Area health services as learning organisations: the rural experience

Staff development units (SDUs) across New South Wales Health are in a state of flux. Traditional models of training may no longer be meeting the continuing professional education needs of staff. This paper outlines how one SDU, the Rural Health Education and Research Centre at Tamworth, with few resources, has successfully negotiated the transformation from delivering ad hoc, face-to-face teaching, to a model encompassing competency-based training, recognition of prior learning, workplace assessment and distance education.

Isocyanate-specific hemoglobin adduct in rats exposed to 4, 4'-methylenediphenyl diisocyanate

4,4'-Methylenediphenyl diisocyanate (MDI) is the most important of the isocyanates used as intermediates in the chemical industry. Among the main types of damage after exposure to low levels of MDI are lung sensitization and asthma. Protein adducts of MDI might be involved in the etiology of sensitization reactions. It is therefore necessary to have sensitive and specific methods for monitoring the isocyanate exposure of workers. To date, urine metabolites or protein adducts have been used as biomarkers in workers exposed to MDI. However, with these methods it is not possible to determine if the biomarkers result from exposure to MDI or to the parent aromatic amine 4,4'-methylenedianiline (MDA). This work presents a procedure for quantitating isocyanate-specific hemoglobin adducts. Blood proteins are used as markers of exposure and possibly as markers of dose size for the modifications of macromolecules in the target organs where the disease develops. For the quantitation of hemoglobin adducts, N(1)-[4-(4-isocyanatobenzyl)phenyl]acetamide (AcMDI) was reacted with the tripeptide valyl-glycyl-glycine and with valine yielding N-[4-(4-acetylaminobenzyl)phenyl]carbamoyl]valyl-glycyl-glycine and N-[4-[4-(acetylaminobenzyl)phenyl]carbamoyl]valine, respectively. N-[4-[4-(Acetylamino-3,5-dideuteriobenzyl)-2, 6-dideuteriophenyl]carbamoyl]valine was synthesized from valine, as was N(1)-[4-(4-isocyanato-3,5-dideuteriobenzyl)-2, 6-dideuteriophenyl]acetamide, for use as an internal standard. These adducts were cleaved in 2 M HCl to yield the corresponding hydantoins, 3-[4-(4-aminobenzyl)phenyl]-5-isopropyl-1, 3-imidazoline-2,4-dione (MDA-Val-Hyd) and 3-[4-(4-amino-3, 5-dideuteriobenzyl)-2,6-dideuteriophenyl]-5-isopropyl-1, 3-imidazoline-2,4-dione, respectively. In globin of rats exposed to MDI, MDA-Val-Hyd could be found in a dose-dependent manner. The adduct was identified by HPLC/MS/MS and quantified by GC/MS after derivatization with heptafluorobutyric anhydride. The amount of MDA-Val-Hyd found after acid hydrolysis of globin at 100 degrees C is about 12 times larger than the sum of N-acetyl-4, 4'-methylenedianiline (AcMDA) and MDA obtained from mild base hydrolysis of hemoglobin. The MDA-Val-Hyd is an isocyanate-specific adduct. MDA and AcMDA released after mild base hydrolyses result most likely from a sulfinamide adduct which is a typical adduct of arylamines. According to these results, higher amounts of isocyanate adducts than arylamine adducts should be expected in workers exposed to isocyanates.

X-ray structural analysis of compensating mutations at the barnase-barstar interface

The crystal structure of the barstar mutants (Y29P) and (Y29D, Y30W) as well as that of the complexes of barstar(Y29P) with wild-type barnase and barnase(H102K) have been determined. These barstar mutants compensate for the dramatic loss of barnase-barstar interaction energy caused by a single mutation of the barnase active site His-102 to a lysine. The latter introduces an uncompensated charge in the pocket at the surface of barstar where Lys-102 is located. The analysis of the structures suggests a mechanism for this compensation based on the solvation of the charge of Lys-102. Additional compensation occurs through the formation of a hydrogen bond.

Refinement and structural analysis of barnase at 1.5 A resolution

The structure of Bacillus amyloliquefaciens ribonuclease (barnase), an extracellular 110-residue enzyme initially solved at 2.0 A resolution, has been refined at 1.5 A using synchrotron radiation and an imaging-plate scanner. Refinement with anisotropic atomic displacement parameters resulted in increased accuracy of the structure. The final model has a crystallographic R factor of 11.5% and an Rfree of 17.4%. The three independent molecules in the asymmetric unit, referred to as A, B and C, allowed detailed analysis of this final model and meaningful comparison with structures of barnase complexed either with nucleotide inhibitors or with its natural intracellular inhibitor, barstar. The analysis of the overall solvent structure revealed a similar number of water molecules associated with each barnase molecule; among these were 16 equivalent buried solvent molecules, the locations of which are discussed in detail and classified on the basis of their structural role. The importance of the water molecules' contribution to the barnase-barstar interaction is also highlighted. The high accuracy of the present analysis revealed the presence of a Zn2+ ion mediating the contacts between pairs of symmetry-related A, B or C molecules; such an ion had previously only been identified for pairs of C molecules.

Bacterial Streak and Bulb Rot of Sweet Onion: II. Epiphytic Survival of Pseudomonas viridiflava in Association with Multiple Weed Hosts

A semiselective agar medium (T-5) was used to sample environment and plant material as a habitat for Pseudomonas viridiflava. Soil, irrigation water, soybean foliage, and foliage from various weeds in an onion-growing area were assayed over a 5-year period. P. viridiflava was recovered only as an epiphytic resident from weed species that included cutleaf evening primrose, dandelion, common fumitory, purple cudweed, spiny sowthistle, Virginia pepperweed, and wild radish. The bacterium apparently overseasons in association with these weeds, because its presence was detected prior to, as well as during, the onion-growing season. Preliminary tests indicated that weed control may suppress bacterial streak and bulb rot levels.

Randomised double blind trial of morphine versus diamorphine for sedation of preterm neonates

AIMS

To compare the safety and effectiveness of morphine and diamorphine for the sedation of ventilated preterm neonates in a double blind, randomised trial.

METHODS

Eighty eight babies were allocated to receive either morphine (n = 44) or diamorphine (n = 44) by bolus infusion (200 or 120 mcg/kg, respectively, over two hours), followed by maintenance infusion (25 or 15 mcg/kg/h, respectively) during the initial phase of their respiratory disease. Serial monitoring of physiological, behavioural, and biochemical variables over the first 24 hours of the infusions was performed. Longer term outcomes were also monitored.

RESULTS

Morphine, but not diamorphine, was associated with a mean (SEM) decrease in mean arterial blood pressure of 2.2 (1.0) mm Hg (p = 0.05) over the initial loading infusion. Physiological (blood pressure variability) and behavioural measures of sedation (clinical assessment and sedation scoring) indicated that the two drug regimens were equally effective after 24 hours, but the sedative effects of diamorphine were evident more quickly than those of morphine. Both regimens significantly reduced plasma adrenaline concentrations over the first 24 hours of the infusions. No significant differences in mortality, ventilator days, chronic lung disease or intracranial lesions were noted.

CONCLUSIONS

Both drug regimens reduce the stress response to ventilation in preterm neonates. However, diamorphine's more rapid onset of sedation and morphine's hypotensive tendency suggest that diamorphine is preferable for the sedation of mechanically ventilated preterm neonates.

Characterization of an amorphous deposit in the lamina propria in oral snuff users in the Sudan as collagen

Histological and ultrastructural features of 25 oral snuff dipper's lesions with distinctive subepithelial hyaline deposits were investigated. Periodic acid-Schiff reaction with and without diastase digestion demonstrated the presence of glycogen and other carbohydrates, but histochemical stains for normal collagen, elastin and fibrin showed a weak variable reactivity of the deposit. Although in 7/25 cases the deposit was in close proximity to labial salivary glands and on occasions ducts were found within the deposit, the presence of mucin was not a consistent feature. Congo red staining and immunohistochemical investigation with an anti-amyloid antibody did not support the previous contention that such deposits were amyloid in nature. Immunohistochemically, collagen antibodies also provided negative results, but ultrastructural features of three biopsies studied suggest that the bulk of this deposit is made up of collagen, as typical cross-striated fibrils were found. The pathogenesis of this deposit could therefore be interpreted as over-production and/or reduced turnover of collagen by resident fibroblasts, which is further altered by the ingredients of toombak. The deposit does not appear to be a secretory product.

Status of total quality management in Australian public health organisations

Research suggests that there is some confusion among quality improvement managers about the differences between quality management and traditional quality assurance. This lack of understanding would appear to be the same among rural and urban health staff, although there is a higher percentage of staff engaged in multidisciplinary activities in the rural health services. Education of staff and commitment from top management would seem to be the factors inhibiting the health industry from incorporating quality management into their cultures.

A pragmatic approach to educating rural health services on quality management

Despite the popularity of Total Quality Management (TQM) with its use of multidisciplinary process improvement teams, little appears to have been achieved in rural health services using this approach. Reviewing the literature suggests few publications. Even traditional Quality Assurance (QA) activities in many of the smaller rural health services are reasonably undeveloped. Against this backdrop, the Rural Health Education and Research Centre successfully marketed and ran several experiential TQM workshops for rural health workers across NSW, resulting in 60 TQM projects being successfully completed. The purpose of this paper is to present the model we use to enable more rural health workers to participate in and benefit from quality management.

Impact of a management assessment centre in developing proficient health managers

There is growing use of management assessment centres within parts of New South Wales Health. The present study examined outcome benefits from managers who participated in the Australasian Management Competencies Assessment Centre, some 123 staff from one rural and one metropolitan area health service. Results confirmed greater use of personal development plans and increased attendance at continuing professional development among participants compared with like managers who had not participated. The paper argues strongly in favour of widespread use of management competencies assessment centres as a way to implement planned cultural change.

Exocytosis from rat submandibular granular tubules during cyclocytidine stimulation shows unusual features, including changes in the granule membrane

Sequential secretory changes in granular tubule cells caused by the secretagogue cyclocytidine (75 mg/kg i.p.) were studied at the ultrastructural level, in perfusion (n = 5 animals) and immersion (n = 8 animals) fixed rat submandibular glands, using the periodic acid-thiocarbohydrazide-silver proteinate technique (PA-TCH-SP). The onset of secretion varied from 45 to 75 minutes after administering the cyclocytidine. During the initial stages of overt secretion, structural changes occurred irregularly in a progressive fashion with: (1) an increase in granule membrane staining with PA-TCH-SP and a parallel alignment of the secretory granules with the adjacent apical plasma membrane, which developed a honeycomb-like appearance; (2) docking of these secretory granules to the apical plasma membrane; (3) early secretion of some secretory granules in a semiclassical exocytotic fashion (but this was rarely witnessed). During stages (1) and (2), the cytochemical characteristics of the membrane of the secretory granules, as well as of the plasma membrane, suggest a priming process is occurring. After these initial preparatory phases, further structural changes occurred in the granule membranes with a gradually progressive formation of microvesicles and granule fusions; secretion continued in an explosive manner with proteinaceous material being transferred to lumina in at least three different ways: (1) by typical exocytosis (but it was infrequent); (2) from granules fused intracellularly into aggregates (compound exocytosis); and (3) some apocrine-type of secretion through bleb formation. The formation of these intracellular aggregations was associated with the microvesicles in the granule membranes and some aggregates became very large. Secretion of their contents into lumina occurred through elongated membrane channels. The material secreted included microvesicular forms that had become interiorised in the granular aggregates, and any cytoplasm that may also have been entrapped.

Intramedullary nail breakage in distal fractures of the tibia

Five cases of tibial intramedullary nail breakage are reported, the reasons discussed, and methods of overcoming this problem put forward.

Analysis and biochemistry of blood folate

Although the analysis of low plasma concentrations of 5-methyltetrahydrofolate by several specific HPLC methods has been reported, considerably fewer routine chromatographic techniques exist for the analysis of specific folate coenzymes in the erythrocyte where a nonspecific bioassay indicates that the vitamin achieves a level 10 times higher than that in plasma. By using three separate folypolyglutamate deconjugation procedures and combining an extraction technique which adequately preserves all native folate coenzymes with an HPLC technique utilizing fluorescence, diode array, and off-line radioassay detection capable of resolving all crucial native folates in their monoglutamyl forms, we were unable to demonstrate levels of 5-methyltetrahydrofolate in whole blood hemolysate beyond what might be expected from the plasma component. While the exact nature of erythrocyte folate could not be ascertained, we provide evidence that a proportion of it may exist at the formyl level of oxidation. The complex pH and enzymatic interrelationship between folate coenzymes at the formyl oxidation level is discussed in terms of our extraction technique and findings, as well as in a broader biological context. This paper also describes a simple acid precipitation technique for measuring plasma 5-methyltetrahydrofolate, as well as providing comprehensive data on the chromatographic behavior of all the folylmonoglutamates in reversed-phase and weak anion-exchange modes, including useful spectral data for optimizing detection parameters and identifying individual coenzymes. 10-Formyltetrahydrofolate and 5-methyltetrahydrofolate are the two most important one-carbon-substituted folate coenzymes. 10-Formyltetrahydrofolate is unavailable commercially, probably due to its instability. We chart the chemical synthesis of this important coenzyme and show that it and what is thought to be 5,10-hydroxymethylenetetrahydrofolate are actually minor products compared to the parent 5,10-methenyltetrahydrofolate and the ultimate reaction product, 5-formyltetrahydrofolate. Since intraerythrocyte folate binds to a specific hemoglobin site, we ascertained the total number of binding sites on hemoglobin (Bmax) and the equilibrium dissociation constant (Kd) for 5-methyltetrahydrofolate, 5-formyltetrahydrofolate, and the antimetabolite methotrexate. Binding affinities were consistent with a low-affinity, low-capacity interaction for all three. It was demonstrated that hemoglobin has a greater affinity for 5-methyltetrahydrofolate than for the other folate derivatives (Kd = 1.2 x 10(-3) M), while rather surprisingly, methotrexate had a higher affinity for hemoglobin than did 5-formyltetrahydrofolate (Kd = 2.5 x 10(-3) and 3.7 x 10(-2) M, respectively.