127 A Student Pilot For A Feasibility Study of the Theoretical 3S Trial (SPFT3S): Patient Questionnaire and Demographics

Introduction

There is conflicting evidence on the benefit of statins for primary prevention of cardiovascular disease (CVD) in non-diabetics over 75. Emerging evidence shows they may be ineffective, yet current guidance supports their use in those up to 85. The objectives of this study were to assess patients’ understanding of statins, willingness to participate in a theoretical randomised controlled trial (RCT), where they would be randomised to stop their statin and to compare the trial population with national data.

Methods

The survey took place in 8 GP practices with 4 students involved in questionnaire distribution. A patient search identified those over 75 and on a statin. Patients were excluded if they had a history of CVD or diabetes. 36 patients were identified and completed questionnaires, 5 were removed because they reported exclusion criteria. Demographic data was compared to the UK population from the 2011 census.

Results

Of 31 participants, 71% understood why they took statins, most were unconcerned about side effects and only 1 patient stopped statins due to the media. Opinions on the theoretical “stopping statins trial” were varied. 35% of people responded positively. 29% would not want to take part and 36% of people were unsure. Comparison of our trial population against the national population shows that 903,505 people would be eligible for a UK trial.

Conclusions

The purpose of this exercise was to see if patients would be willing to participate in a trial where 50% stopped taking their statin. Approximately a third said yes and only a third said no. As there are nearly a million people in this population, it suggests a fully funded, larger-scale feasibility study of this theoretical randomised control trial is warranted.

126 A Student Pilot for A Feasibility Study of the Theoretical 3S Trial (SPFT3S): GP and Ethics Committee Members Questionnaire

Introduction

Emerging research suggests that statin use for primary prevention in people without diabetes aged 75 and older has no benefit. This study aims to determine the feasibility of the theoretical Stop Statin Study (3S), a double-blind randomised controlled trial carried out in general practice, which would test this hypothesis. 50% of trial patients would stop taking statins for 5 years in an event driven study. The questionnaires aim to identify the attitudes of general practitioners (GPs) and ethics committee members (ECMs) regarding stopping statins for 5 years in patients aged 75 and older without diabetes or history of cardiovascular disease and their willingness to allow patients to participate in the 3S study.

Method

Questionnaires comprised of 6 questions were designed. 4 students distributed the questionnaire and it was completed by 19 GPs based at 8 practices in the North-East of England. 31 ECMs (12 expert and 19 lay) responded by email.

Results

95% of GPs who completed the survey would agree to their patients participating in the theoretical study with 47% of GPs indicating that their willingness to participate in the study is patient dependent. 95% of GPs would also consider stopping statins in this population group if sufficient research had been carried out or if the guidelines were changed. 42% of GPs have a negative attitude to prescribing statins in this population group. All the ECMs would approve the study, citing over-prescribing and polypharmacy as their reason.

Conclusions

The majority of GPs will participate in the theoretical 3S study, if their patients are willing to participate. There is already a negative perception amongst GPs towards the use of statins in elderly people without disease. The 3S study appears to be feasible from the GP and ethics perspective but would require a larger feasibility study.

Episodic temporal generalization: A developmental study

Groups of 5-year-olds, 10-year-olds, and adults completed either an episodic temporal generalization task, in which no stimuli were repeated, or a repeated standard temporal generalization task, in which there was a fixed standard that was repeated on every trial. Significant developmental improvements were found on both tasks. In both tasks, gradients of performance over two different stimulus ranges superimposed well when plotted on the same relative scale. Performance was similar for the adults and 10-year-olds across tasks, but the 5-year-olds performed better on the repeated standard task. These findings suggest that perceptual processes are a source of scalar variability in timing, and that there are developmental changes in levels of such variability.

The measurement of adult blood pressure and management of hypertension before elective surgery: Joint Guidelines from the Association of Anaesthetists of Great Britain and Ireland and the British Hypertension Society

This guideline aims to ensure that patients admitted to hospital for elective surgery are known to have blood pressures below 160 mmHg systolic and 100 mmHg diastolic in primary care. The objective for primary care is to fulfil this criterion before referral to secondary care for elective surgery. The objective for secondary care is to avoid spurious hypertensive measurements. Secondary care should not attempt to diagnose hypertension in patients who are normotensive in primary care. Patients who present to pre-operative assessment clinics without documented primary care blood pressures should proceed to elective surgery if clinic blood pressures are below 180 mmHg systolic and 110 mmHg diastolic.

The place of newer oral anticoagulants in the treatment of patients with non-valvular atrial fibrillation and coronary artery disease

With the arrival of the newer oral anticoagulants (NOACs), we now have a more convenient means of providing anticoagulation for patients with non-valvular atrial fibrillation (AF). Are there any particular considerations for the many patients who also have coronary artery disease? For many patients there is an obvious need to use the newer agents but for others, such as those who simply refuse to consider using a vitamin K antagonist (VKA) such as warfarin, the decision may be more problematical.

Immediate and late benefits of treating very elderly people with hypertension: results from active treatment extension to Hypertension in the Very Elderly randomised controlled trial

OBJECTIVE

To assess if very elderly people with hypertension obtain early benefit from antihypertensive treatment.

DESIGN

One year open label active treatment extension of randomised controlled trial (Hypertension in the Very Elderly Trial (HYVET)).

SETTING

Hospital and general practice based centres mainly in eastern and western Europe, China, and Tunisia.

PARTICIPANTS

People on double blind treatment at the end of HYVET were eligible to enter the extension.

INTERVENTIONS

Participants on active blood pressure lowering treatment continued taking active drug; those on placebo were given active blood pressure lowering treatment. The treatment regimen was as used in the main trial-indapamide SR 1.5 mg (plus perindopril 2-4 mg if required)-with the same target blood pressure of less than 150/80 mm Hg.

MAIN OUTCOME MEASURES

The primary outcome was all stroke; other outcomes included total mortality, cardiovascular mortality, and cardiovascular events.

RESULTS

Of 1882 people eligible for entry to the extension, 1712 (91%) agreed to participate. During the extension period, 1682 patient years were accrued. By six months, the difference in blood pressure between the two groups was 1.2/0.7 mm Hg. Comparing people previously treated with active drug and those previously on placebo, no significant differences were seen for stroke (n = 13; hazard ratio 1.92, 95% confidence interval 0.59 to 6.22) or cardiovascular events (n = 25; 0.78, 0.36 to 1.72). Differences were seen for total mortality (47 deaths; hazard ratio 0.48, 0.26 to 0.87; P = 0.02) and cardiovascular mortality (11 deaths; 0.19, 0.04 to 0.87; P = 0.03).

CONCLUSION

Very elderly patients with hypertension may gain immediate benefit from treatment. Sustained differences in reductions of total mortality and cardiovascular mortality reinforce the benefits and support the need for early and long term treatment. Trial registration Clinical trials NCT00122811.

Barriers to cardiovascular disease risk scoring and primary prevention in Europe

The prevalence and burden of cardiovascular disease (CVD) is high, and it remains the leading cause of death worldwide. Unfortunately, many individuals who are at high risk for CVD are not recognized and/or treated. Therefore, programs are available to ensure individuals at risk for CVD are identified through appropriate risk classification and offered optimal preventative interventions. The use of algorithms to determine a global risk score may help to achieve these goals. Such global risk-scoring algorithms takes into account the synergistic effects between individual risk factors, placing increases in individual risk factors into context relative to the overall disease, allowing for a continuum of disease risk to be expressed, and identifying patients most likely to derive benefit from an intervention. The predictive value of risk scoring such as using the Framingham equation is reasonable, analogous to cervical screening, with area under the receiver operated characteristic curve a little over 70%. However, limitations do exist, and as they are identified adjustments can be made to the global risk-scoring algorithms. Limitations include patient-specific issues, such as variations in lifetime risk level, ethnicity or socio-economic strata, and algorithm-specific issues, such as discrepancies between different algorithms arising from varying risk factors evaluated. The use of currently developed algorithms is low in general practice, in part, because of the belief that the assessment may oversimplify the risk and/or lead to medication overuse. Additional hindrances to the use of risk scoring include government or local health policy, patient compliance issues and lack of time. A thorough, easy-to-use, and standardized tool for risk estimation would allow for improvements in the primary prevention of CVD.

Incremental cholesterol reduction with ezetimibe/simvastatin, atorvastatin and rosuvastatin in UK General Practice (IN-PRACTICE): randomised controlled trial of achievement of Joint British Societies (JBS-2) cholesterol targets

AIM

The aim of this study was to compare ezetimibe/simvastatin combination therapy with intensified statin monotherapy as alternative treatment strategies to achieve the Joint British Societies (JBS)-2 and National Institute for Health and Clinical Excellence low-density-lipoprotein cholesterol (LDL-C) target of < 2 mmol/l for secondary prevention or JBS-2 LDL-C target of < 2 mmol/l for primary prevention in high-risk patients who have failed to reach target with simvastatin 40 mg.

METHODS

This is a prospective, double-blind study conducted in 34 UK primary care centres; 1748 patients with established cardiovascular disease (CVD), diabetes or high risk of CVD who had been taking simvastatin 40 mg for > or = 6 weeks were screened and 786 (45%) with fasting LDL-C > or = 2.0 mmol/l (and < 4.2 mmol/l) at screening and after a further 6-week run-in period on simvastatin 40 mg were randomised to ezetimibe/simvastatin 10/40 mg (as a combination tablet; n = 261), atorvastatin 40 mg (n = 263) or rosuvastatin 5 mg (n = 73) or 10 mg (n = 189) once daily for 6 weeks. Rosuvastatin dose was based on UK prescribing instructions. The primary outcome measure was the proportion of patients achieving LDL-C < 2 mmol/l at the end of the study.

RESULTS

The percentage of patients (adjusted for baseline differences) achieving LDL-C < 2 mmol/l was 69.4% with ezetimibe/simvastatin 10/40 mg, compared with 33.5% for atorvastatin 40 mg [odds ratio 4.5 (95% CI: 3.0-6.8); p < 0.001] and 14.3% for rosuvastatin 5 or 10 mg [odds ratio 13.6 (95% CI: 8.6-21.6); p < 0.001]. Similar results were observed for achievement of total cholesterol < 4.0 mmol/l. All study treatments were well tolerated.

CONCLUSION

Approximately 45% of patients screened had not achieved LDL-C < 2 mmol/l after > or = 12 weeks of treatment with simvastatin 40 mg. In this group, treatment with ezetimibe/simvastatin 10/40 mg achieved target LDL-C levels in a significantly higher proportion of patients during a 6-week period than switching to either atorvastatin 40 mg or rosuvastatin 5-10 mg.

Duration judgements in patients with schizophrenia

BACKGROUND

The ability to encode time cues underlies many cognitive processes. In the light of schizophrenic patients' compromised cognitive abilities in a variety of domains, it is noteworthy that there are numerous reports of these patients displaying impaired timing abilities. However, the timing intervals that patients have been evaluated on in prior studies vary considerably in magnitude (e.g. 1 s, 1 min, 1 h etc.).

METHOD

In order to obviate differences in abilities in chronometric counting and place minimal demands on cognitive processing, we chose tasks that involve making judgements about brief durations of time (< 1 s).

RESULTS

On a temporal generalization task, patients were less accurate than controls at recognizing a standard duration. The performance of patients was also significantly different from controls on a temporal bisection task, in which participants categorized durations as short or long. Although time estimation may be closely intertwined with working memory, patients' working memory as measured by the digit span task did not correlate significantly with their performance on the duration judgement tasks. Moreover, lowered intelligence scores could not completely account for the findings.

CONCLUSIONS

We take these results to suggest that patients with schizophrenia are less accurate at estimating brief time periods. These deficits may reflect dysfunction of biopsychological timing processes.

Children's serial recall errors: implications for theories of short-term memory development

Three experiments examined developmental changes in serial recall of lists of 6 letters, with errors classified as movements, omissions, intrusions, or repetitions. In Experiments 1 and 2, developmental differences between groups of children aged from 7 to 11 years and adults were found in the pattern of serial recall errors. The errors of older participants were more likely to be movements than were those of younger participants, who made more intrusions and omissions. The number of repetition errors did not change with age, and this finding is interpreted in terms of a developmentally invariant postoutput response inhibition process. This interpretation was supported by the findings of Experiment 3, which measured levels of response inhibition in 7-, 9-, and 11-year-olds by comparing recall of lists with and without repeated items. Response inhibition remained developmentally invariant, although older children showed greater response facilitation (improved correct recall of adjacent repeated items). Group differences in the patterns of other errors are accounted for in terms of developmental changes in levels of output forgetting and changes in the efficiency of temporal encoding processes.

Developmental changes in time estimation: comparing childhood and old age

Participants from ages 5 to 99 years completed 2 time estimation tasks: a temporal generalization task and a temporal bisection task. Developmental differences in overall levels of performance were found at both ends of the life span and were more marked on the generalization task than the bisection task. Older adults and children performed at lower levels than young adults, but there were also qualitative differences in the patterns of errors made by the older adults and the children. To capture these findings, the authors propose a new developmental model of temporal generalization and bisection. The model assumes developmental changes across the life span in the noisiness of initial perceptual encoding and across childhood in the extent to which long-term memory of time intervals is distorted.

The effects of Shaker beta-subunits on the human lymphocyte K+ channel Kv1.3

The activation of T-lymphocytes is dependent upon, and accompanied by, an increase in voltage-gated K+ conductance. Kv1.3, a Shaker family K+ channel protein, appears to play an essential role in the activation of peripheral human T cells. Although Kv1.3-mediated K+ currents increase markedly during the activation process in mice, and to a lesser degree in humans, Kv1.3 mRNA levels in these organisms do not, indicating post-transcriptional regulation. In other tissues Shaker K+ channel proteins physically associate with cytoplasmic beta-subunits (Kvbeta1-3). Recently it has been shown that Kvbeta1 and Kvbeta2 are expressed in mouse T cells and that they are up-regulated during mitogen-stimulated activation. In this study, we show that the human Kvbeta subunits substantially increase K+ current amplitudes when coexpressed with their Kv1.3 counterpart, and that unlike in mouse, protein levels of human Kvbeta2 remain constant upon activation. Differences in Kvbeta2 expression between mice and humans may explain the differential K+ conductance increases which accompany T-cell proliferation in these organisms.

Developmental changes in time estimation: comparing childhood and old age

Participants from ages 5 to 99 years completed 2 time estimation tasks: a temporal generalization task and a temporal bisection task. Developmental differences in overall levels of performance were found at both ends of the life span and were more marked on the generalization task than the bisection task. Older adults and children performed at lower levels than young adults, but there were also qualitative differences in the patterns of errors made by the older adults and the children. To capture these findings, the authors propose a new developmental model of temporal generalization and bisection. The model assumes developmental changes across the life span in the noisiness of initial perceptual encoding and across childhood in the extent to which long-term memory of time intervals is distorted.

Molecular diversity of K+ channels

K+ channel principal subunits are by far the largest and most diverse of the ion channels. This diversity originates partly from the large number of genes coding for K+ channel principal subunits, but also from other processes such as alternative splicing, generating multiple mRNA transcripts from a single gene, heteromeric assembly of different principal subunits, as well as possible RNA editing and posttranslational modifications. In this chapter, we attempt to give an overview (mostly in tabular format) of the different genes coding for K+ channel principal and accessory subunits and their genealogical relationships. We discuss the possible correlation of different principal subunits with native K+ channels, the biophysical and pharmacological properties of channels formed when principal subunits are expressed in heterologous expression systems, and their patterns of tissue expression. In addition, we devote a section to describing how diversity of K+ channels can be conferred by heteromultimer formation, accessory subunits, alternative splicing, RNA editing and posttranslational modifications. We trust that this collection of facts will be of use to those attempting to compare the properties of new subunits to the properties of others already known or to those interested in a comparison between native channels and cloned candidates.

Fetal syndromes and the charter: the Winnipeg glue-sniffing case

The relationship between scientific knowledge and legal discourse is raised once again by a recent decision of the Supreme Court of Canada, a case involving a young Aboriginal woman who was pregnant and ordered by the court to remain in a drug treatment program at a health center until the baby was born. Her glue-sniffing habit was deemed dangerous to the normal development of the fetus. The Court held that her solvent-dependency did not justify the original court action, but both the Court and the various interveners disregarded the current state of our knowledge on the fetal syndromes. There is thus a continuing disconnect between the scientific understanding of fetal risk and the development of Constitutional law around women's reproductive rights. This paper reviews the case and follows it through the appellate process; we examine the research literature on fetal syndromes tracking the changes over time. Finally we comment on the interventions by the Winnipeg Child and Family Services, the Women's Health Rights Coalition, by The Canadian Civil Liberties Association, and both The Canadian Abortion Rights Action League and the Women's Legal Education and Action Fund.

A submersible battery-powered flow injection (FI) sensor for the determination of nitrate in estuarine and coastal waters

The design, construction and performance of a remotely deployed submersible flow injection-based nutrient (total oxidized nitrogen) sensor are described. The sensor featured a custom-built microcomputer and a solid-state, flow-through spectrophotometric detector, and the derivatization chemistry was based on in-line copper-cadmium reduction of nitrate to nitrite, and diazotization with N1NED and sulphanilamide. The limit of detection was 0.0014 mg l(-1) NO3-N and the linear range was 0.0014- 0.77 mg l(-1) with a 260 microl sample volume and a 20 mm path length flow cell. Results from submersed deployments in the Tamar estuary and North Sea are also reported.

Role of the proteasome and NF-kappaB in streptococcal cell wall-induced polyarthritis

The transcription factor NF-kappaB activates a number of genes whose protein products are proinflammatory. In quiescent cells, NF-kappaB exists in a latent form and is activated via a signal-dependent proteolytic mechanism in which the inhibitory protein IkappaB is degraded by the ubiquitin-proteasome pathway. Consequently, inhibition of the proteasome suppresses activation of NF-kappaB. This suppression should therefore decrease transcription of many genes encoding proinflammatory proteins and should ultimately have an anti-inflammatory effect. To this end, a series of peptide boronic acid inhibitors of the proteasome, exemplified herein by PS-341, were developed. The proteasome is the large multimeric protease that catalyzes the final proteolytic step of the ubiquitin-proteasome pathway. PS-341, a potent, competitive inhibitor of the proteasome, readily entered cells and inhibited the activation of NF-kappaB and the subsequent transcription of genes that are regulated by NF-kappaB. Significantly, PS-341 displayed similar effects in vivo. Oral administration of PS-341 had anti-inflammatory effects in a model of Streptococcal cell wall-induced polyarthritis and liver inflammation in rats. The attenuation of inflammation in this model was associated with an inhibition of IkappaBalpha degradation and NF-kappaB-dependent gene expression. These experiments clearly demonstrate that the ubiquitin-proteasome pathway and NF-kappaB play important roles in regulating chronic inflammation and that, as predicted, proteasome inhibition has an anti-inflammatory effect.

Reduction in tensile strength of cartilage precedes surface damage under repeated compressive loading in vitro

An experimental protocol for the fatiguing and tensile testing of articular cartilage has been established. Samples were taken from the interpatellar groove of bovine femurs collected post-slaughter, split into two test groups and subjected to a cyclically varying compressive load of approximately 65 N for 64,800 cycles or 97,200 cycles. The cartilage was then removed from the underlying bone and two specimens, one from the indented region and one from an unindented region - the control, were taken from it and prepared for subsequent tensile testing using notched specimens. From data collected during tensile testing, a value of maximum tensile stress was calculated for each sample. The underlying bone was examined for evidence of microdamage using the basic fuchsin method. A decrease in values of maximum tensile stress (p < 0.05) for the indented sample of each paired group of samples loaded for 97,200 cycles was found. In contrast, those fatigued for only 64,800 cycles showed no such difference. Examination of the underlying bone of these specimens revealed no evidence of trabecular failure and crack formation beneath both the indented and control regions. It is postulated that the fatiguing process used in this experiment induces trauma in the cartilage causing a weakening of the interfibril connections which link collagen fibrils in the matrix, leading to a reduction in tensile strength. This weakening occurs, however, without the appearance of fibrillation on the cartilage surface or any evidence of failure in the bony structure which supports it.

Alternative splicing of the human Shaker K+ channel beta 1 gene and functional expression of the beta 2 gene product

Mammalian voltage-activated Shaker K+ channels associate with at least three cytoplasmic proteins: Kv beta 1, Kv beta 2 and Kv beta 3. These beta subunits contain variable N-termini, which can modulate the inactivation of Shaker alpha subunits, but are homologous throughout an aldo-keto reductase core. Human and ferret beta 3 proteins are identical with rat beta 1 throughout the core while beta 2 proteins are not; beta 2 also contains a shorter N-terminus and has no reported physiological role. We report that human beta 1 and beta 3 are derived from the same gene and that beta 2 modulates the inactivation properties of Kv1.4 alpha subunits.

The load sharing classification of spine fractures

STUDY DESIGN

A 3 to 4 year follow-up was performed on a consecutive series of 28 patients who had three-column spinal fractures surgically stabilized by short-segment instrumentation with first generation VSP (Steffee) screws and plates and autograft fusion. The follow-up revealed 10 patients with broken screws.

BACKGROUND DATA

Retrospective examination of preoperative radiographs and computed tomographic axial and sagittal reconstruction images clearly demonstrated that the screw fractures all occurred in patients with a disproportionately greater amount of injury to the vertebral body.

RESULTS

A point system (the load sharing classification) was developed that grades: 1) the amount of damaged vertebral body, 2) the spread of the fragments in the fracture site, and 3) the amount of corrected traumatic kyphosis.

CONCLUSIONS

This point system can be used preoperatively to: 1) predict screw breakage when short segment, posteriorly placed pedicle screw implants are being used, 2) describe any spinal injury for retrospective studies, or 3) select spinal fractures for anterior reconstruction with strut graft, short-segment-type reconstruction.

Surgical management of radiated scalp in patients with recurrent glioma

Patients with malignant brain tumors requiring multiple craniotomies and external beam radiotherapy are at risk of scalp wound breakdown secondary to fibrosis and radiation damage. We present three cases to illustrate the nature of the problem and the surgical approaches to scalp repair. When a bicoronal incision has been used for the initial craniotomy, the plastic repair can be performed with a bipedicle visor scalp flap and split-thickness skin graft to cover the pericranium at the donor site. When a curvilinear (U-shaped or horseshoe) flap has been used for the initial craniotomy, a single-pedicle flap may be rotated to achieve closure without tension. In anticipation of the risk of scalp wound breakdown in patients with malignant brain tumors, the planning of the operative incision for the first craniotomy needs to take into account the long-term viability of the scalp. We recommend linear scalp incisions parallel to the arterial distribution instead of the traditional curvilinear (U-shaped or horseshoe) flaps; linear incisions are less likely to break down, and in the event of breakdown, linear wounds offer better therapeutic surgical options for plastic repair.

Neuropathological changes in transgenic mice carrying copies of a transcriptionally activated Mos protooncogene

In the human proteolipid protein gene, the base sequence of the intronic region 5' to exon 6 was found to be 5'-ctctttcattttcctgcag-3' and not 5'-ctctttt-cattttcctgcag-3' as previously reported.

A role for hydrophobic residues in the voltage-dependent gating of Shaker K+ channels

A leucine heptad repeat is well conserved in voltage-dependent ion channels. Herein we examine the role of the repeat region in Shaker K+ channels through substitution of the leucines in the repeat and through coexpression of normal and truncated products. In contrast to leucine-zipper DNA-binding proteins, we find that the subunit assembly of Shaker does not depend on the leucine heptad repeat. Instead, we report that substitutions of the leucines in the repeat produce large effects on the observed voltage dependence of conductance voltage and prepulse inactivation curves. Our results suggest that the leucines mediate interactions that play an important role in the transduction of charge movement into channel opening and closing.

Molecular cloning of a member of a third class of Shaker-family K+ channel genes in mammals

We report the cloning of RKShIIIA, a cDNA encoding a K+ channel sequence expressed in rat brain. This cDNA encodes K+ channel subunits that express in Xenopus oocytes a slow, 4-aminopyridine- and tetraethylammonium-sensitive, delayed rectifier-type K+ channel activated by large membrane depolarizations. This gene belongs to the Shaker (Sh) family of K+ channel genes, since the predicted protein has the same overall structure and shows significant homology to other members of this family. However, RKShIIIA cannot be assigned to either of the two known classes of Sh-family genes in mammals based on sequence analysis. Notable features of the RKShIIIA protein product include a probable cytoplasmic loop rich in prolines and a stretch very homologous to the Drosophila Shaw protein, both near the amino terminus.

A comparison of magnetic and electrical stimulation of facial nerve at the cerebello-pontine angle in the dog

Magnetic stimulation is a painless, non-invasive technique which allows an alternative method for testing cranial nerves which were previously inaccessible. We compared the latency of muscle responses obtained by electrical stimulation of the facial nerve at the cerebello-pontine angle (CPA) to high intensity transcranial magnetic stimulation (TMS) in 6 dogs. Evoked muscle response from the levator nasolabialis during electrical stimulation had a mean latency of 6.24 +/- 0.42 msec, compared with a mean of latency of 6.13 +/- 0.50 msec obtained by magnetic stimulation. Orbicularis oculi had a mean latency of 3.65 +/- 0.34 msec compared with a mean latency of 3.53 +/- 0.36 msec for magnetic stimulation. This suggests that high intensity TMS results in direct activation of the facial nerve as it exits the brain-stem in dogs. This observation is in accord with previous clinical studies that magnetic stimulation results in activation of the intracranial segment of the facial nerve in man.

Study of appropriate antibiotic therapy in transurethral prostatectomy

Septicaemia is the commonest cause of morbidity and mortality following transurethral prostatectomy. Routine blind antibiotic prophylaxis is not always effective and there is a tendency to over-use potent new and expensive antimicrobials. Attempts to "sterilise" the urine preoperatively are also expensive and disruptive. However, appropriate treatment/prophylaxis can be administered economically using rapidly obtained laboratory results. We describe here a technique of routine direct antibiotic sensitivity testing (DST) of the patient's urine pre-operatively and before catheter removal. Such testing can be performed by junior medical staff in a ward side-room. An appropriate antibiotic may then be administered parenterally 1 h before surgery or catheter removal. A total of 102 consecutive patients underwent TURP and only 1 of those with infected urine became septicaemic. In this instance, an appropriate antibiotic had been incorrectly given orally before removal of the catheter. If the antibiotic sensitivities of a patient's urine are known, and an appropriate antibiotic is given parenterally 1 h pre-operatively or before catheter removal, the incidence of septicaemia following transurethral surgery may be significantly reduced.

Penetrating left ventricular stab wound: a method of control during resuscitation and prior to repair

A 34-year-old man with left ventricular stab wounds, suffered cardiac arrest soon after arriving in the Intensive Care Unit from the Accident and Emergency Department. He had cardiac tamponade without elevation of his central venous pressure; this was because of exsanguination into his left hemithorax. Immediate thoracotomy while still in his bed confirmed tamponade and revealed two large left ventricular stab wounds, one anterior and on posterior; the heart was in ventricular fibrillation. As he had already been anoxic for some time, no effort could be made to repair the stab wounds before resuscitating him. It was necessary to control bleeding from two separate injuries while replacing volume, continuing with intracardiac drugs, internal cardiac massage and internal defibrillation. This was achieved by inserting a Foley catheter into each wound, inflating the balloons, clamping the catheters and having the assistant gently retracting the catheters against each other while the operator continued with the resuscitation. When the circulation was restored, pledgeted horizontal mattress sutures were inserted on either side of each Foley catheter, which was withdrawn immediately before tying the suture. The patient was discharged home 12 days later without any complications.

Single dose intra-rectal metronidazole as prophylaxis against wound infection following emergency appendicectomy

A prospective placebo controlled randomized trial was carried out in 104 patients with a presumptive diagnosis of acute appendicitis. A single dose of 1 g of metronidazole was given intra-rectally 1 h preoperatively. There were 16 wound infections, 15 (out of 50) in the placebo group, 1 (out of 54) in the metronidazole group. This study supports the already accepted value of metronidazole but suggests that a single intra-rectal dose regimen is adequate for prophylaxis.