Photoacoustic imaging of squirrel monkey cortical responses induced by peripheral mechanical stimulation

Non-human primates (NHPs) are crucial models for studies of neuronal activity. Emerging photoacoustic imaging modalities offer excellent tools for studying NHP brains with high sensitivity and high spatial resolution. In this research, a photoacoustic microscopy (PAM) device was used to provide a label-free quantitative characterization of cerebral hemodynamic changes due to peripheral mechanical stimulation. A 5 × 5 mm area within the somatosensory cortex region of an adult squirrel monkey was imaged. A deep, fully connected neural network was characterized and applied to the PAM images of the cortex to enhance the vessel structures after mechanical stimulation on the forelimb digits. The quality of the PAM images was improved significantly with a neural network while preserving the hemodynamic responses. The functional responses to the mechanical stimulation were characterized based on the improved PAM images. This study demonstrates capability of PAM combined with machine learning for functional imaging of the NHP brain.

MAPK11 (p38β) is a major determinant of cellular radiosensitivity by controlling ionizing radiation-associated senescence: An in vitro study

Background and purpose

MAPKs are among the most relevant signalling pathways involved in coordinating cell responses to different stimuli. This group includes p38MAPKs, constituted by 4 different proteins with a high sequence homology: MAPK14 (p38α), MAPK11 (p38β), MAPK12 (p38γ) and MAPK13 (p38δ). Despite their high similarity, each member shows unique expression patterns and even exclusive functions. Thus, analysing protein-specific functions of MAPK members is necessary to unequivocally uncover the roles of this signalling pathway. Here, we investigate the possible role of MAPK11 in the cell response to ionizing radiation (IR).

Materials and methods

We developed MAPK11/14 knockdown through shRNA and CRISPR interference gene perturbation approaches and analysed the downstream effects on cell responses to ionizing radiation in A549, HCT-116 and MCF-7 cancer cell lines. Specifically, we assessed IR toxicity by clonogenic assays; DNA damage response activity by immunocytochemistry; apoptosis and cell cycle by flow cytometry (Annexin V and propidium iodide, respectively); DNA repair by comet assay; and senescence induction by both X-Gal staining and gene expression of senescence-associated genes by RT-qPCR.

Results

Our findings demonstrate a critical role of MAPK11 in the cellular response to IR by controlling the associated senescent phenotype, and without observable effects on DNA damage response, apoptosis, cell cycle or DNA damage repair.

Conclusion

Our results highlight MAPK11 as a novel mediator of the cellular response to ionizing radiation through the control exerted onto IR-associated senescence.

Patient perspectives on nipple-areola complex micropigmentation during the COVID-19 pandemic

Background

Micropigmentation is a well-recognised option for nipple-areola complex reconstruction, as part of the breast reconstruction pathway for patients following mastectomy. As a part of delayed breast reconstruction, this treatment was put on hold during the COVID-19 pandemic.

Aims

To assess the views of patients regarding micropigmentation in response to the COVID-19 pandemic, and whether their attitudes to seeking out this part of the reconstructive journey had been altered.

Methods

A questionnaire undertaken with 53 patients between August & September 2020 attending the Micropigmentation clinic.

Findings

81.1% of patients reported COVID-19 had not impacted their decision, with a similar proportion happy to proceed with the treatment at the time of questioning.

Conclusions

The results highlight the importance of nipple-areola complex to our patients’ reconstructive journey.

P2717Type-II MI and chronic myocardial injury rates, invasive management and 4 year mortality among consecutive patients undergoing high sensitivity troponin T testing in the emergency department

Background

In emergency departments (EDs), assessment of patients with suspected acute coronary syndromes (ACS) represents a major workload and high sensitivity troponin (HsTn) T and I levels are frequently measured. A minority of patients have final diagnosis of myocardial infarction (MI).

Methods and results

Among 2738 consecutive patients with suspected ACS presenting to ED at Liverpool Hospital, Australia, between March and June 2014, we determined the relative frequencies of 3 patient groups: type-I MI, type-II MI including chronic myocardial injury (CMI), and assessed the use of invasive and pharmacological therapies and 4-year outcomes. Adjudication of MI was according to the 4th universal definition of MI as follows: 1) type-I MI; 2) type-II MI (including acute myocardial injury), and 3) CMI. Of 995 patients (36%) median age 76 years [IQR 65–83]), with at least 2 HsTnT measurements and one >14ng/l, 727 (73%) had chronic myocardial injury, 171 (17%) had type-II MI; and 97 (9.7%) had type-I MI. Patients with type-I MI (mean age 63 years) were younger than those with type-II MI or chronic myocardial injury by 12 and 14 years respectively. The main triggering factors for type-II MI/acute injury included: sepsis (21.1%), acute heart failure (18.3%), tachyarrhythmia (16.9%), anaemia (8.6%) and a combination of factors (16%). In-hospital angiography (62% had PCI) rates were 95% for patients with type-I MI, 24% (7% PCI) for those with type-II MI and 3.4% for CMI. Mortality at 4 years was 55% for type-II MI, 44% for CMI and 18% for type-1 MI (P<0.001; Figure), though after Cox modelling adjusting for age, gender, renal function and COPD, compared to type 1 MI, type-II MI (hazard ratio 1.61 [95% CIs 0.90–2.86]; p=0.106) and CMI (hazard ratio 1.01 [95% CIs 0.59–1.74]; p=0.963) were not independently associated with increased late mortality, largely because patients with type 1 MI were a decade younger.

Conclusion

Among unselected patients undergoing HsTnT testing in EDs, type-II MI including acute myocardial injury was more common than type-I MI. Chronic myocardial injury, which occurred in 3 of 4 patients. While patients with type-II MI acute myocardial injury had higher late mortality rates than type-I MI, though after multivariable analyses mortality rates were not different.

Cortical control of intraspinal microstimulation: Toward a new approach for restoration of function after spinal cord injury

Approximately 6 million people in the United States are currently living with paralysis in which 23% of the cases are related to spinal cord injury (SCI). Miniaturized closed-loop neural interfaces have the potential for restoring function and mobility lost to debilitating neural injuries such as SCI by leveraging recent advancements in bioelectronics and a better understanding of the processes that underlie functional and anatomical reorganization in an injured nervous system. This paper describes our current progress toward developing a miniaturized brain-machine-spinal cord interface (BMSI) that converts in real time the neural command signals recorded from the cortical motor regions to electrical stimuli delivered to the spinal cord below the injury level. Using a combination of custom integrated circuit (IC) technology for corticospinal interfacing and field-programmable gate array (FPGA)-based technology for embedded signal processing, we demonstrate proof-of-concept of distinct muscle pattern activation via intraspinal microstimulation (ISMS) controlled in real time by intracortical neural spikes in an anesthetized laboratory rat.

Radiography and Scintigraphy in the Assessment of Early Gonarthrosis

The radiographic and scintigraphic appearances in early gonarthrosis were compared in 62 knees. Early femorotibial osteoarthrosis was found to be confined to one compartment (medial or lateral) of the joint. However, concomitant patellofemoral osteoarthrosis was common. 99Tcm-MDP scintigraphy was consistently positive when the joint space (femorotibial and patellofemoral) was reduced by 75 per cent or more. Joint space narrowing by as much as 50 per cent could be observed in a scintigraphically normal knee. The inconsistency between the radiologic and scintigraphic findings in the earliest stages of gonarthrosis points to the importance of appropriate radiographic technique.

Towards a miniaturized brain-machine-spinal cord interface (BMSI) for restoration of function after spinal cord injury

Nearly 6 million people in the United States are currently living with paralysis in which 23% of the cases are related to spinal cord injury (SCI). Miniaturized closed-loop neural interfaces have the potential for restoring function and mobility lost to debilitating neural injuries such as SCI by leveraging recent advancements in bioelectronics and a better understanding of the processes that underlie functional and anatomical reorganization in an injured nervous system. This paper describes our current progress towards developing a miniaturized brain-machine-spinal cord interface (BMSI) that is envisioned to convert in real time the neural command signals recorded from the brain to electrical stimuli delivered to the spinal cord below the injury level. Specifically, the paper reports on a corticospinal interface integrated circuit (IC) as a core building block for such a BMSI that is capable of low-noise recording of extracellular neural spikes from the cerebral cortex as well as muscle activation using intraspinal microstimulation (ISMS) in a rat with contusion injury to the thoracic spinal cord. The paper further presents results from a neurobiological study conducted in both normal and SCI rats to investigate the effect of various ISMS parameters on movement thresholds in the rat hindlimb. Coupled with proper signal-processing algorithms in the future for the transformation between the cortically recorded data and ISMS parameters, such a BMSI has the potential to facilitate functional recovery after an SCI by re-establishing corticospinal communication channels lost due to the injury.

The impact of type 2 diabetes and obesity on the long-term outcomes of more than 85 000 liver transplant recipients in the US

BACKGROUND

Type 2 diabetes is known to negatively impact the outcome of chronic liver disease.

AIM

To evaluate the impact of diabetes on the outcomes of liver transplants (LT).

METHODS

Study cohort included adults (>18 years) who received LT in the US between 1994 and 2013 (The Scientific Registry of Transplant Recipients). Pre- and post-transplant diabetes was recorded in patients with mortality follow-up.

RESULTS

We included 85 194 liver transplant recipients. Of those, 11.2% had history of pre-transplant diabetes. The most common indications for liver transplant were hepatitis C (36.4%), alcohol-related liver disease (20.6%), primary liver malignancy of unspecified aetiology (14.7%), cryptogenic cirrhosis (8.0%), hepatitis B (4.6%) and non-alcoholic steatohepatitis (3.9%). A total of 96.5% transplants were from deceased donors, and 7.9% donors had history of diabetes. During an average 6.5 years of follow-up, 31.3% recipients died and 8.8% had a graft failure. In multivariate survival analysis [at least 5 years of cohort follow-up (N = 35 870)], after adjustment for age, ethnicity, insurance type, history of chronic diseases, HCV infection and noncompliance, independent predictors of recipient mortality included the presence of pre-transplant diabetes [adjusted hazard ratio (95%CI) = 1.21 (1.12-1.30)] and developing diabetes post-transplant [1.06 (1.02-1.11)]. Donor's history of diabetes was also independently associated with higher mortality [1.10 (1.02-1.19)]. Furthermore, donor's history of diabetes was also associated with an increased the risk of liver graft failure [1.35 (1.24-1.47)].

CONCLUSIONS

Presence of type 2 diabetes pre- and post-transplant, as well as presence of type 2 diabetes in the donors, are all associated with an increased risk of adverse post-transplant outcomes.

Novel setting for addressing tobacco-related disparities: a survey of community welfare organization smoking policies, practices and attitudes

Research in the United States and Australia acknowledges the potential of non-government social and community service organizations (SCSOs) for reaching socially disadvantaged smokers. This study aimed to describe SCSO smoking policies and practices, and attitudes of senior staff towards smoking and cessation. It also investigated factors associated with positive tobacco control attitudes. In 2009, a cross-sectional telephone survey was undertaken of senior staff in Australian SCSOs, 149 respondents representing 93 organizations completed the survey (response rate=65%; 93/142). Most service clients (60%) remained in programs for 6 months plus, and 77% attended at least weekly. Although 93% of respondents indicated they had an organizational smoking policy, it often did not include the provision of smoking cessation support. Most respondents indicated that client smoking status was not recorded on case notes (78%). Attitudes were mostly positive towards tobacco control in SCSOs, with a mean (standard deviation) score of 8.3 (2.9) of a possible 13. The practice of assessing clients' interest in quitting was the only statistically significant factor associated with high tobacco control attitude scores. The results suggest that SCSOs are appropriate settings for reaching socially disadvantaged smokers with cessation support. Although generally receptive to tobacco control, organizations require further support to integrate smoking cessation support into usual care. In particular, education, training and support for staff to enable them to help their clients quit smoking is important.

Dynamics of extracellular release of Aspergillus fumigatus DNAand galactomannan during growth in blood and serum

Aspergillus fumigatus is the major cause of invasive aspergillosis (IA),a disease associated with high rates of morbidity and mortality in patientsundergoing treatment for haematological malignancies. This study investigated A. fumigatus growth in vitro and in a murine model of IA inorder to provide insights into the dynamics of extracellular DNA and galactomannan (GM)release and their relevance to early diagnosis of IA. Following inoculationof whole blood with 20 A. fumigatus conidia ml−1,DNA that corresponded to the inoculum could be detected by PCR but GM wasnot detected in plasma separated from the blood sample, indicating that thefungus did not grow in whole blood. The quantities of DNA detected by PCR,and GM, were proportional to the amount of fungal biomass present in vitro. Fungal DNA could be detected in the sera of mice experimentally infectedwith A. fumigatus with maximum detection in cyclophosphamide-treatedmice.

Exercise affects tissue lymphocyte apoptosis via redox-sensitive and Fas-dependent signaling pathways

Intensive and exhaustive exercise induces an activation of blood T-lymphocytes, which seems to be terminated by apoptotic processes in the postexercise period. Here, we report that exercise-induced T-lymphocyte apoptosis is a systemic phenomenon occurring in various lymphoid and nonlymphoid tissues. The apoptosis rate could be related to exercise intensity and type. Although in some tissues, such as the spleen and Peyer's patches, an early start of apoptosis (1-3 h postexercise) could be detected, a delayed apoptosis (24 h postexercise) was observed in lung, bone marrow, and lymph nodes. Further analysis showed a similar apoptosis distribution among lymphocyte subpopulations. We tested whether components of the extrinsic or the intrinsic apoptotic pathways or both were involved in these processes. Elevated levels of lipid peroxidation-product malondialdehyde (MDA), indicating an increased production of reactive oxygen species (ROS), were found after exercise in Peyer's patches, lung, and spleen, but not in lymph nodes. Application of N-acetyl-cysteine (NAC) prevented exercise-induced T-cell apoptosis completely in spleen and bone marrow, partially in lung and Peyer's patches, while it was ineffective in lymph nodes. Additionally, exercise addressed the Fas-mediated apoptosis. The percentage of Fas-receptor (Fas+) and Fas-ligand positive (FasL+) lymphocytes was enhanced in Peyer's patches after exercise. Moreover, FasL+ T cells were increased in the lung, while in lymph nodes Fas+ cells were increased. The critical role of Fas signaling in exercise-induced apoptosis was supported by using Fas-deficient MRL/lpr-mice. In Fas-deficient mice, exercise-induced T-lymphocyte apoptosis was prevented in spleen, lung, bone marrow, and lymph nodes, but not in Peyer's patches. These data demonstrate that exercise-induced lymphocyte apoptosis is a transient systemic process with tissue-type specific apoptosis-inducing mechanisms, whose relevance for the adaptive immune competence remains to be shown.

Intrathecal ziconotide and baclofen provide pain relief in seven patients with neuropathic pain and spasticity: case reports

Seven cases of combination of intrathecal (IT) ziconotide and baclofen therapy in patients with refractory neuropathic pain and spasticity were reviewed. Five of the seven adult patients were receiving IT baclofen treatment when ziconotide was initiated. All five patients had experienced at least one previous failed IT treatment regimen. Pain intensity scores improved by a mean of 50.3% with the use of ziconotide-baclofen therapy. Mean time to onset of pain relief was 15 weeks, at a mean ziconotide dose of 3.7 microg/day. Within this group of patients, adverse events were observed in one patient, but they were not considered to be ziconotide related and subsequently resolved. The remaining two patients were receiving ziconotide treatment when baclofen was initiated. Pain intensity scores improved by 75% and 30%, respectively. Pain relief was evident at two weeks and one week, with corresponding ziconotide doses of 2.4 microg/day and 14.4 microg/day, respectively. One patient in this group reported adverse events, but all resolved during continued treatment with the study drugs. Treatment regimens varied between patients in these case series; each regimen used a different titration strategy and different concentrations of ziconotide and baclofen. Combination IT ziconotide and baclofen therapy may be a treatment option for patients with neuropathic pain and spasticity. Future studies are warranted to determine the optimal dosing and titration schedules for ziconotide-baclofen usage.

Motivation to change in recent onset and long-standing bulimia nervosa: are there differences?

REASON FOR THE STUDY: Little is known about how motivation to change evolves over the course of an eating disorder. The present study compared 'stage of change' and motivation, confidence and readiness to change in two groups of patients with bulimia nervosa (BN), adolescents with a short duration of illness and adults with a long duration of illness.

METHOD

Patients completed the Severity of eating disorder symptomatology scale, Hospital Anxiety and Depression Scale and measures of stage of change and motivation, readiness and confidence to change their bulimic symptomatology at pre-treatment.

MAIN FINDINGS

Short- and long duration groups did not differ in illness severity, comorbidity, stage of change, motivation, readiness, and confidence to change. There were, however, some differences between groups in terms of the relationship between motivational measures, illness severity, duration and comorbidity.

CONCLUSIONS

There seem to be more similarities than differences between adolescents with short duration of illness and those with well-established BN in terms of their motivation to change.

Measuring memory impairment in community-based patients with schizophrenia. Case-control study

BACKGROUND

The majority of memory impairment studies in schizophrenia are cohort studies using laboratory-based tests, which make it difficult to estimate the true extent and relevance of memory impairment in patients with schizophrenia in the community.

AIMS

To examine the extent of memory impairment in community-based patients with schizophrenia using a clinically relevant test.

METHOD

All patients with schizophrenia (n=190) in one catchment area were identified, of whom 133 were potentially eligible for the study; 73 patients volunteered to take part. They were assessed using the Rivermead Behavioural Memory Test (RBMT), the National Adult Reading Test, the Positive and Negative Syndrome Scale, the Health of the Nation Outcome Scales and the Scales and the Office for National Statistics Classification of Occupation. Their performance on the memory test was compared with that of matched controls (n=71).

RESULTS

Patients as a group performed significantly worse (P<0.001) than controls on the RBMT. Using the RBMT normative scores, 81% of patients were found to have impaired memory compared with 28% of controls.

CONCLUSIONS

Using a clinically relevant test, the majority of community-based patients with schizophrenia may have memory impairment.

Randomized controlled trial of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: the POPMACT study

BACKGROUND

We carried out a large randomized trial of a brief form of cognitive therapy, manual-assisted cognitive behaviour therapy (MACT) versus treatment as usual (TAU) for deliberate self-harm.

METHOD

Patients presenting with recurrent deliberate self-harm in five centres were randomized to either MACT or (TAU) and followed up over 1 year. MACT patients received a booklet based on cognitive behaviour therapy (CBT) principles and were offered up to five plus two booster sessions of CBT from a therapist in the first 3 months of the study. Ratings of parasuicide risk, anxiety, depression, social functioning and global function, positive and negative thinking, and quality of life were measured at baseline and after 6 and 12 months.

RESULTS

Four hundred and eighty patients were randomized. Sixty per cent of the MACT group had both the booklet and CBT sessions. There were seven suicides, five in the TAU group. The main outcome measure, the proportion of those repeating deliberate self-harm in the 12 months of the study, showed no significant difference between those treated with MACT (39%) and treatment as usual (46%) (OR 0.78, 95% CI 0.53 to 1.14, P=0.20).

CONCLUSION

Brief cognitive behaviour therapy is of limited efficacy in reducing self-harm repetition, but the findings taken in conjunctin with the economic evaluation (Byford et al. 2003) indicate superiority of MACT over TAU in terms of cost and effectiveness combined.

Genetic screening for Alzheimer's disease: what factors predict intentions to take a test?

The authors investigated factors that predict intention to take a genetic test for Alzheimer's disease (AD). The 449 men and women were surveyed in two groups: (a) those told that a positive result meant a 90% chance of developing AD (increased certainty) and (b) those told that a positive result meant a 50% chance of developing AD (decreased certainty). Participants completed measures of the Theory of Planned Behavior (TPB), anticipated regret, risk perception, likelihood of taking a genetic test for cancer, and AD risk factors. Just over 50% of the variance in intentions was related to TPB variables, likelihood of taking a genetic test for cancer, number of people the participants knew who had AD, experimental condition, and anticipated regret. The subjective norm was the strongest predictor of intention in the increased certainty group, whereas positive belief was the strongest predictor in the decreased certainty group.

Evidence for the validity of a patient-based instrument for assessment of outcome after revision hip replacement

The Oxford hip score (OHS) is a patient-based instrument for assessment of outcome which is often used after total hip replacement, and the EuroQol 5D (EQ5D) is a patient-based generic questionnaire for health assessment. In an analysis of the outcome at one year of 609 revision hip replacements (RHRs), we compared the OHS and EQ5D scores, postoperative patient satisfaction and change in pain. About 25% of the operations were repeat RHRs. At one year, 57% of patients were very pleased with their operation. The correlation between preoperative and postoperative scores and change scores for the OHS and EQ5D was high. For both instruments the effect sizes were large, but the greater effect size of the OHS suggests that it is particularly sensitive to improvements after RHR. The effect scores of the OHS declined with the number of previous RHRs, while those for the EQ5D seemed less sensitive. Our results confirm the value of the OHS in assessing outcome after RHR.

Evidence for the validity of a patient-based instrument for assessment of outcome after revision hip replacement

The Oxford hip score (OHS) is a patient-based instrument for assessment of outcome which is often used after total hip replacement, and the EuroQol 5D (EQ5D) is a patient-based generic questionnaire for health assessment. In an analysis of the outcome at one year of 609 revision hip replacements (RHRs), we compared the OHS and EQ5D scores, postoperative patient satisfaction and change in pain. About 25% of the operations were repeat RHRs. At one year, 57% of patients were very pleased with their operation. The correlation between preoperative and postoperative scores and change scores for the OHS and EQ5D was high. For both instruments the effect sizes were large, but the greater effect size of the OHS suggests that it is particularly sensitive to improvements after RHR. The effect scores of the OHS declined with the number of previous RHRs, while those for the EQ5D seemed less sensitive. Our results confirm the value of the OHS in assessing outcome after RHR.

Buying in: IDN reaps GPO benefits

The impact of switching to group purchasing contracts on a hospital's supply expenses is often a subject of speculation, but is rarely actually measured. Scott Frost relates how one hospital system isolated the financial impact of joining a national GPO.

HIV dynamics and T-cell immunity after three structured treatment interruptions in chronic HIV-1 infection

OBJECTIVE

To evaluate whether controlled re-exposures to autologous HIV-1 could boost HIV-specific immunity and limit virus replication in patients with chronic HIV-1 infection.

PATIENTS AND DESIGN

Subjects with at least 2 years virus suppression during antiretroviral therapy and a CD4 : CD8 ratio > 1 were randomly assigned to interrupt highly active antiretroviral treatment (HAART) three times (n = 12) or to continue their previous HAART (n = 14).

RESULTS

In 10/12 interrupter patients a rebound of HIV-1 RNA was detected in all three structured treatment interruptions (STI). Plasma virus doubling time was shorter during the first STI than in the second and third STI, corresponding to an average 13% reduction in viral basic reproductive rate. However, the mean time before plasma viral load rose to > 50 copies/ml was significantly shorter in the second and third STI. The average frequency of HIV-specific CD8 T cells in the interrupter patients at the end of the third STI cycle was significantly higher compared with the baseline and the end of the first STI. A substantial increase in HIV-specific CD8 T cell frequencies was found in four interrupter patients, whereas there were no changes in all 14 non-interrupter individuals. A weak p24-specific T helper response developed in 5/12 interrupter patients compared with no response in non-interruptors, but these responses were transient and disappeared rapidly.

CONCLUSION

The increase in the control of viral replication, and positive effects of STI on immune responses in this population should encourage the further development of HIV-specific immune-based therapeutic strategies.

Shared care: a qualitative study of GPs' and hospital doctors' views on prescribing specialist medicines

BACKGROUND

Shared care schemes have mainly centred on chronic diseases, such as asthma and diabetes. However, with increasing government emphasis on primary and secondary care integration and the effects of budget restraints, general practitioners (GPs) have been asked to take on the prescribing of specialist medicines.

AIM

To elicit the views and experiences of GPs and hospital doctors about existing arrangements for shared care applied to the prescribing of specialist medicines. To identify a set of quality indicators for prescribing specialist medicines at the interface between primary and secondary care.

DESIGN OF STUDY

A qualitative study based on semi-structured interviews.

SETTING

Forty-eight GPs and 13 hospital doctors in the former South Thames region.

METHOD

The interviews focused on how far experiences with shared care compare with the arrangements currently in place for prescribing specialist medicines and identified the barriers to facilitators of effective shared care.

RESULTS

A number of key themes were identified and these formed the basis for eight quality indicators relating to the prescribing of specialist medicines where treatment is shared between primary and secondary care. The themes centred around issues of clinical responsibility, 'cost-shifting', availability of medicines, GP satisfaction, and the nature of the prescribing relationship.

CONCLUSION

Overall, GPs appeared dissatisfied with arrangements for prescribing specialist medicines, while hospital doctors were generally satisfied. The quality indicators will form the basis of a more extensive quantitative survey of GPs' perceptions of the arrangements for prescribing specialist medicines.

The efficacy of femoral nerve block in pain reduction for outpatient hamstring anterior cruciate ligament reconstruction: a double-blind, prospective, randomized trial

The purpose of this study was to assess the efficacy of intraoperative femoral nerve block (FNB) in the reduction of postoperative pain following anterior cruciate ligament (ACL) hamstring reconstruction. Patients undergoing primary ACL reconstruction with hamstring tendon graft under general anesthetic who had signed an informed consent were included in the study. Patients were stratified to 4 surgeons and randomized to FNB with 0.25% bupivacaine or placebo of normal saline injected into the femoral nerve sheath before reversal of the general anesthetic. All patients received an intra-articular injection of bupivacaine at the beginning of their operative procedure. A single technique that included the use of a peripheral nerve stimulator was used for all FNBs. All patients were discharged on the day of surgery and given prescriptions for Tylenol 3. The Short-Form McGill Pain Questionnaire (SF-MPQ), a visual analog scale (VAS) for pain, and a medication diary recording Tylenol 3 usage were completed by patients in the recovery room, on the night of surgery, and on postoperative days 1, 2, and 3. There were complete data for 61 patients (FNB, 29; placebo, 32). An analysis of variance (ANOVA) test of the data showed no significant difference between the FNB and placebo group for pain reduction over the combined study period for both the SF-MPQ and VAS. However, the ANOVA does suggest that, on the night of surgery, there was a significant reduction in pain as measured with the VAS in the FNB group. A Student t test performed on the night of surgery data (SF-MPQ, P = .131; VAS, P = .0114; Tylenol 3, P = .076) showed a statistically significant difference between the FNB (39.4+/-21.0 mm) and placebo (56.8+/-24.6 mm) measured by VAS. Because this represented a difference of only 1.74 cm on a 10-cm VAS, it is unlikely to be clinically relevant. No difference was found in the amount of analgesic required on any day postoperatively. In conclusion, FNB may reduce pain on the night of surgery. However, this may not be clinically significant. FNB is not recommended at this time for use in outpatient ACL reconstruction with hamstring graft.

Phylogenetic analysis of GBV-C/hepatitis G virus

Comparison of 33 epidemiologically distinct GBV-C/hepatitis G virus complete genome sequences suggests the existence of four major phylogenetic groupings that are equally divergent from the chimpanzee isolate GBV-C(tro) and have distinct geographical distributions. These four groupings are not consistently reproduced by analysis of the virus 5'-noncoding region (5'-NCR), or of individual genes or subgenomic fragments with the exception of the E2 gene as a whole or of 200-600 nucleotide fragments from its 3' half. This region is upstream of a proposed anti-sense reading frame and contains conserved potential RNA secondary structures that may be capable of directing the internal initiation of translation. Phylogenetic analysis of this region from certain South African isolates is consistent with previous analysis of the 5'-NCR suggesting that these belong to a fifth group. The geographical distribution of virus variants is consistent with a long evolutionary history that may parallel that of pre-historic human migrations, implying that the long-term evolution of this RNA virus is extremely slow.

Health care support workers in the critical care setting

The 1999/2000 winter demands on the NHS have once again highlighted deficits in UK critical care provision (Daily Telegraph, 2000; London Evening Standard, 2000) Recent years have seen the development of the role of health care support workers in the NHS; some critical care units now employ health care support workers This research examined the views of critical care unit staff on the introduction of health care support workers into the critical care unit It is concluded that the role is viable within the setting of this study A framework is outlined that could form the basis for a critical care health care support worker training programme

Physical activity and stages of change in fifth and sixth graders

The Stage of Change (SC) paradigm was adapted to assess readiness to be or stay physically active among fifth and sixth graders. Students completed a four-item SC survey, the Past Year Leisure Time Physical Activity Questionnaire, and the Modifiable Physical Activity Questionnaire for Adolescents. Precontemplation, contemplation, and preparation stages were grouped as "pre-action" (PRE), and action and maintenance as "post-action" (AX) stages. Nearly 40% of all students were in PRE, compared to 60% of students in AX stages. Twenty-two percent of all students were in the sedentary precontemplation or contemplation stages. Significantly more boys were in maintenance than girls, and more girls than boys were in contemplation. Students averaged 14-21 hours/week of television, video, or computer work, and 1.6 hours/week of physical activity outside of school. Interventions may be targeted at a specific SC to enable a child to move forward along the SC continuum toward an active lifestyle.

Exploring the expanded role of nurses in critical care

This paper reports on a small research study that explored the perceptions of staff in an intensive/coronary/high-dependency care unit on the expanded role of nurses in critical care. The research was undertaken in two phases. In the first phase, focus groups and interviews of nursing and medical staff were used as methods to explore their perceptions. Data were analysed by thematic content analysis and generated four categories: specialized skills; maintaining competence; how far nurses can go; and training and education. Using verbatim examples from the participants, these categories are described. In summary, it was found that both doctors and nurses were in favour of nursing role developments, and for the nurses this was driven by their desire to meet the patients' needs. In a smaller second phase, a questionnaire was developed based on information gained in the first phase. It was utilized to seek the views of all the nursing staff on specific role-expansion activities. Findings revealed substantial support for developing the role of critical care nurses in a number of activities: cannulation; venepuncture; ordering blood tests and X-rays; performing physiotherapy; inserting arterial lines; performing elective cardioversion; thrombolysis treatment and intubation. This research study has yielded important information. However, it is recognized that, whilst these roles may be new to this particular critical care unit, there are many other units where they may already be common practice. Whenever new roles are developed, it is important to evaluate their effectiveness in measurable terms and regular audit is advisable. Further research is therefore recommended on both the development and evaluation of new roles in critical care.

Nicotine concentration, smoke pH and whole tobacco aqueous pH of some cigar brands and types popular in the United States

The present study examined characteristics relating to nicotine delivery of 17 cigar brands, which included small cigars, cigarillos, and large premium cigar brands. The cigars selected for analysis were intended to represent the range of cigar products currently available and in popular use. In addition to cigar characteristics previously studied such as size, nicotine content, and pH of their tobacco, the present study examined smoke pH on a puff-by-puff basis. The tobacco content of the cigars ranged in weight from 0.53 to 21.5 g. There was considerable variation in total nicotine content, which ranged from 5.9 to 335.2 mg per cigar. The aqueous pH of the tobacco from the cigars also varied widely with values ranging from 5.7 to 7.8. The smoke pH values of the smallest cigars was generally acidic, changed little across puffs, and more closely resembled the profiles previously reported for typical cigarettes. Interestingly, the smoke pH of smaller cigars and cigarillos became acidic after the first third of the cigar was consumed and then remained acidic thereafter, whereas larger cigars became acidic during the first third, then became quite alkaline during the last third. Because of wide variations in nicotine content of the tobacco across brands and of similarly wide variations in smoke pH, cigar size is not an accurate predictor of the nicotine delivery capacity of a particular cigar brand, although, in general, larger cigars are capable of providing larger total nicotine delivery with extraordinarily high delivery levels being possible from many of the large premium cigars. These results demonstrated that the popular cigars in this study contained enough nicotine for the development of dependence when smoking as few as one or two of the larger cigars per day.