Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

OPTN/SRTR 2020 Annual Data Report: Intestine

Despite small increases in additions to the intestine transplant wait- list, total waitlist numbers, overall intestine transplant rates, and overall transplants performed from 2019 to 2020, the trend over the last decade is still toward less intestine transplant activity. Waitlist mortality continues to fall for pediatric populations and is relatively stable for adults. While 1- year graft survival continues to improve, there has been no noticeable improvement in 3- and 5-year graft survival. Immunosuppression practices continue to favor use of an induction agent followed by tacrolimus-based regimens. Patient survival at 5 years is currently identical for isolated intestines and liver-inclusive allograft recipients.

Mobile telephone delivered contingency management for encouraging adherence to supervised methadone consumption: feasibility study for an RCT of clinical and cost-effectiveness (TIES)

BACKGROUND

Prescription methadone or buprenorphine enables people with opioid use disorder to stop heroin use safely while avoiding withdrawal. To ensure methadone is taken as prescribed and to prevent diversion onto the illicit market, people starting methadone take their daily dose under a pharmacist's supervision. Many patients miss their daily methadone dose risking withdrawal, craving for heroin and overdose due to loss of heroin tolerance. Contingency management (CM) can improve medication adherence, but remote delivery using technology may be resource-light and cost-effective. We developed an innovative way to deliver CM by mobile telephone. Software monitors patients' attendance and supervised methadone consumption through an internet self-login at the pharmacy and sends reinforcing text messages to patients' mobile telephones. A linked system sends medication adherence reports to prescribers and provides early warning alerts of missed doses. A pre-paid debit card system provides financial incentives.

METHODS

A cluster randomised controlled trial design was used to test the feasibility of conducting a future trial of mobile telephone CM to encourage adherence to supervised methadone in community pharmacies. Each cluster (drug service/3 allied pharmacies) was randomly allocated to provide patient's presenting for a new episode of opiate agonist treatment (OAT) with either (a) mobile telephone text message CM, (b) mobile telephone text message reminders, or (c) no text messages. We assessed acceptability of the interventions, recruitment, and follow-up procedures.

RESULTS

Four drug clinics were approached and three recruited. Thirty-three pharmacists were approached and 9 recruited. Over 3 months, 173 individuals were screened and 10 enrolled. Few patients presented for OAT and high numbers were excluded due to receiving buprenorphine or not attending participating pharmacies. There was 96% consistency in recording medication adherence by self-login vs. pharmacy records. In focus groups, CM participants were positive about using self-login, the text messages, and debit card. Prescribers found weekly reporting, time saving, and allowed closer monitoring of patients. Pharmacists reported that the tablet device was easy to host.

CONCLUSION

Mobile telephone CM worked well, but a planned future trial will use modified eligibility criteria (existing OAT patients who regularly miss their methadone/buprenorphine doses) and increase the number of participating pharmacies.

TRIAL REGISTRATION

The trial is retrospectively registered, ISRCTN 58958179 .

OPTN/SRTR 2018 Annual Data Report: Intestine

Despite medical and surgical advances in treatment of intestinal failure, intestine transplant still plays an important role. However, the number of new patients added to the intestine transplant waiting list has decreased over the past decade, reaching a low of 135 in 2018. The number of intestine donors also decreased, reaching a low of 106 in 2018, and the number of intestine transplants performed declined to its lowest level, 104, of which 59% were intestine-liver transplants. Graft failure has plateaued over the past decade. Patient survival for transplants in 2011-2013 varied by age and transplant type. Patient survival was lowest for adult intestine-liver recipients (1-and 5-year survival 66.7% and 49.1%, respectively) and highest for pediatric intestine recipients (1-and 5-year survival 89.1% and 76.4%, respectively).

OPTN/SRTR 2017 Annual Data Report: Intestine

Despite improvements in medical and surgical treatment of intestinal failure, intestine transplant continues to play an important role. In 2017, 109 intestine transplants were performed, 62 in adults and 47 in children, reflecting the changed age distribution over the past decade of candidates waitlisted for intestine and intestine-liver transplant from largely pediatric to increasing proportions of adults. In 2017, 56.0% of candidates on the intestine list at any time during the year were aged younger than 18 years, with a decrease over time in those aged younger than 6 years and an increase in those aged 6-17 years. Adults accounted for 44.0% of candidates on the list at any time during the year, with an increase since 2013 in those aged 18-34 years and a decrease in those aged 35 years or older. By age, the pretransplant mortality rate was highest for adult candidates at 7.9 per 100 waitlist-years and lowest for pediatric candidates at 3.7 per 100 waitlist-years. Patient survival varied by age and type of transplant, and was lowest for adult intestine-liver recipients (1- and 5-year survival 66.7% and 42.6%, respectively) and highest for pediatric intestine recipients (1- and 5-year survival 86.2% and 75.4%, respectively).

Positive reinforcement targeting abstinence in substance misuse (PRAISe): Study protocol for a Cluster RCT & process evaluation of contingency management

There are approximately 256,000 heroin and other opiate users in England of whom 155,000 are in treatment for heroin (or opiate) addiction. The majority of people in treatment receive opiate substitution treatment (OST) (methadone and buprenorphine). However, OST suffers from high attrition and persistent heroin use even whilst in treatment. Contingency management (CM) is a psychological intervention based on the principles of operant conditioning. It is delivered as an adjunct to existing evidence based treatments to amplify patient benefit and involves the systematic application of positive reinforcement (financial or material incentives) to promote behaviours consistent with treatment goals. With an international evidence base for CM, NICE recommended that CM be implemented in UK drug treatment settings alongside OST to target attendance and the reduction of illicit drug use. While there was a growing evidence base for CM, there had been no examination of its delivery in UK NHS addiction services. The PRAISe trial evaluates the feasibility, acceptability, clinical and cost effectiveness of CM in UK addiction services. It is a cluster randomised controlled effectiveness trial of CM (praise and financial incentives) targeted at either abstinence from opiates or attendance at treatment sessions versus no CM among individuals receiving OST. The trial includes an economic evaluation which explores the relative costs and cost effectiveness of the two CM intervention strategies compared to TAU and an embedded process evaluation to identify contextual factors and causal mechanisms associated with variations in outcome. This study will inform UK drug treatment policy and practice. Trial registration ISRCTN 01591254.

OPTN/SRTR 2016 Annual Data Report: Intestine

Despite improvements in medical and surgical treatment of intestinal failure, intestine transplant continues to play an important role. In 2016, a total of 147 intestine transplants were performed, 80 intestine-without-liver and 67 intestine-liver. Over the past decade, the age distribution of candidates waitlisted for intestine and intestine-liver transplant shifted from primarily pediatric to increasing proportions of adults. In 2016, 58.2% of candidates on the intestine list at any time during the year were aged younger than 18 years, with a decrease over time in those aged younger than 6 years and an increase in those aged 6-17 years. Adults accounted for 41.9% of candidates on the list at any time during the year, with a stable proportion of those aged 18-34 years and a decrease in those aged 35 years or older. By age, pretransplant mortality rate was highest for adult candidates at 11.7 per 100 waitlist years and lowest for children aged younger than 6 years at 2.2 per 100 waitlist years. For intestine transplants with or without a liver in 2009-2011, 1- and 5-year graft survival was 72.0% and 54.1%, respectively, for recipients aged younger than 18 years, and 70.5% and 44.1%, respectively, for recipients aged 18 years or older.

Emergence of dalbavancin non-susceptible, vancomycin-intermediate Staphylococcus aureus (VISA) after treatment of MRSA central line-associated bloodstream infection with a dalbavancin- and vancomycin-containing regimen

OBJECTIVES

Dalbavancin is a long-acting lipoglycopeptide with activity against gram-positives, including methicillin-resistant Staphylococcus aureus (MRSA). The potential for lipoglycopeptides, with half-lives greater than 1 week, to select for resistance is unknown. Here we explore a case of MRSA central line-associated bloodstream infection in which dalbavancin and vancomycin non-susceptibility emerged in a urine isolate collected after the patient was treated with vancomycin and dalbavancin sequentially.

METHODS

Isolates from blood and urine underwent susceptibility testing, and whole genome sequencing (WGS). The blood isolate was subjected to successive passage in vitro in the presence of escalating dalbavancin concentrations and the emergent isolate was subjected to repeat susceptibility testing and WGS.

RESULTS

The blood isolate was fully susceptible to vancomycin; however, MICs of the urine isolate to dalbavancin, vancomycin, telavancin, and daptomycin were at least fourfold higher than the blood-derived strain. Both strains were indistinguishable by spa and variable number tandem repeat (VNTR) typing, and WGS revealed only seven variants, indicating clonality. Four variants affected genes, including a 3bp in-frame deletion in yvqF, a gene which has been implicated in glycopeptide resistance. Vancomycin and dalbavancin non-susceptibility emerged in the blood isolate after successive passage in vitro in the presence of dalbavancin, and WGS identified a single non-synonymous variant in yvqF.

CONCLUSIONS

This is the first case in which VISA has emerged in the context of a dalbavancin-containing regimen. The selection for cross-resistance to vancomycin in vitro by dalbavancin exposure alone is troubling. Clinicians should be aware of the possibility for emergence of dalbavancin non-susceptibility and glycopeptide cross-resistance arising following therapy.

Long-term decline in grassland productivity driven by increasing dryness

Increasing aridity and drought severity forecast for many land areas could reduce the land carbon (C) sink. However, with limited long-term direct measures, it is difficult to distinguish direct drying effects from counter effects of CO₂ enrichment and nitrogen (N) deposition. Here, we document a >50% decline in production of a native C₃ grassland over four decades and assign the forcing and timing to increasing aridity and specifically to declining late-summer rainfall. Analysis of C and N stable isotopes in biomass suggests that enhanced water use efficiency via CO₂ enrichment may have slightly ameliorated the productivity decline but that changes in N had no effects. Identical declines in a long-term snow-addition experiment definitively identified increasing late-summer dryness as the cause. Our results demonstrate lasting consequences of recent climate change on grassland production and underscore the importance of understanding past climate–ecosystem coupling to predicting future responses to changing climate.

How primary production is influenced by climatic forcing has not been tested in most ecosystems. Here, the authors study a four-decade record of grassland production and find a sustained decline in above-ground net primary production attributable to increased aridity from declining late-summer rainfall.

Child involvement in the paediatric consultation: a qualitative study of children and carers' views

BACKGROUND

This study aimed to investigate child and carers' attitudes towards child involvement in paediatric consultations.

METHODS

Semi-structured qualitative interviews explored child and carers' attitudes towards child involvement at different stages of the paediatric consultation process. Twenty families (21 children, 17 mothers and 5 fathers) were interviewed following a paediatric (index) consultation in two UK paediatric inpatient and outpatient departments.

RESULTS

All but one family felt the child should be involved at some stage of the consultation process but the desired extent and nature of involvement depended on child, family and illness characteristics, as well as on the stages of the consultation. During history gathering, some parents and children felt it was the decision and responsibility of the parent to facilitate communication between the child and the doctor. Others expected the doctor to decide when and how to facilitate this process. At diagnosis the desired amount of information given to the child increased with increasing maturity in the child. Some felt making a diagnosis should be a collaborative process; others felt it was solely the domain of the doctor. In discussing and making a treatment plan, some children wanted to be given the choice of being involved and some wanted their parents to be responsible for implementing the plan. Some families with a seriously ill child, however, wanted the burden of involvement in the management plan taken away from them.

CONCLUSIONS

Families vary in their views about involvement of children in paediatric consultations in a way that may be unique to each child, family and illness. Moreover, different views were expressed about involvement in each stage of the consultative process and in management of the child's health. The challenge for doctors is to determine the level of involvement and information exchange favoured by a particular parent and child. Good practice recommendations emerging from the analysis are described.

NMR and spin relaxation in systems with magnetic nanoparticles: effects of size and molecular motion

To better understand the specifics of nuclear magnetic resonance and spin relaxation in systems with magnetic nanoparticles and test the limits of the outer sphere model for the diffusion-related relaxation, iron oxide nanoparticle suspensions are studied in dependence on the particle concentration and size (5-40 nm). The model is modified to account for aggregation of the particles into clusters with an enlarged effective radius. For liquid suspensions containing small particles or clusters, both the longitudinal and transverse spin relaxation rates, T(1)(-1) and T(2)(-1), correspond well to the theory, which predicts passing of T(1)(-1) through a maximum and monotonic increase in T(2)(-1) with increasing particle size. For the largest particle sizes, as well as in the case of strong aggregation, the relaxation rates are significantly lower than theoretical predictions. An abrupt change in both the relaxation rates is observed in a narrow temperature range around the melting point of paraffin wax doped with magnetic nanoparticles. The applicability of fast-motion and fast-diffusion approximations is discussed for large effective sizes and limiting molecular motion cases.

Magnetic resonance in nanoparticles: between ferro- and paramagnetism

Magnetic nanoparticles of γ-Fe(2)O(3) coated with organic molecules and suspended in liquid and solid matrices, as well as non-diluted magnetic fluid, have been studied by electron magnetic resonance (EMR) at 77-380 K. Slightly asymmetric spectra observed at room temperature become much broader and symmetric, and shift to lower fields upon cooling. An additional narrow spectral component (with a line-width of 30 G) is found in diluted samples; its magnitude obeys the Arrhenius law with an activation temperature of about 850 K. The longitudinal spin-relaxation time, T(1)≈10 ns, is determined by a specially developed modulation method. The angular dependence of the EMR signal position in field-freezing samples points to substantial alignment, suggesting the formation of dipolar-coupled aggregates. The shift and broadening of the spectrum upon cooling are assigned to the effect of the surface-related anisotropy. To describe the overall spectral shape, the 'quantization' model is used which includes summation of resonance transitions over the whole energy spectrum of a nanoparticle considered as a giant exchange cluster. This approach, supplemented with some phenomenological assumptions, provides satisfactory agreement with the experimental data.

NMR and spin relaxation in systems with magnetic nanoparticles

The ¹H NMR spectra and spin dynamics of the host systems have been studied in liquid and solid suspensions of γ-Fe₂O₃ nanoparticles. Significant broadening of ¹H NMR spectra and growing relaxation rates were observed with increased concentration of nanoparticles in the liquid systems, with the relation T₁/T₂ depending on the particular host. Solid systems demonstrate inhomogeneous broadening of the spectra and practically no dependence of T₁ upon the nanoparticle concentration. We explain the experimental results taking into account the predomination of self-diffusion as a source of the relaxation in liquid suspensions, and estimate effective parameters of relaxation in the systems under study.

A child’s admission to hospital: a qualitative study examining the experiences of parents

AIMS

To compare the experiences of parents and children during inpatient admission to either a paediatric intensive care unit (PICU) or a general paediatric ward (GPW) with a specific focus on identifying factors which may influence psychological outcome.

METHODS

Semi-structured qualitative interviews of 20 parents whose children had been admitted to hospital. Cases were sampled purposively to ensure representation of both groups (PICU and GPW admissions). Interviews were tape recorded, transcribed and subjected to a thematic analysis.

RESULTS

The experiences of parents were explored with regard to illness onset, admission to PICU or GPW and the discharge period. In the PICU group, the sources of stress differed according to the stage: at onset, they were mainly related to their child's illness; during admission, concerns were focused on their child's appearance; finally, on discharge, possible relapse of the illness, impact of the admission on the child and family and the lack of clear follow-up were the central themes. In the GPW group, parents reported similar themes but with lower levels of associated stress. Both groups identified good communication with the medical team and opportunities for participation as helpful in reducing stress.

CONCLUSIONS

Admission to hospital is stressful for parents particularly if the child is admitted to PICU. Hospital staff should enhance communication with parents and maximise opportunities for parental participation in the child's treatment. Such interventions may reduce parents' experience of stress during the admission and have the potential to improve psychological outcome.

Comorbidity of substance misuse and mental illness in community mental health and substance misuse services

BACKGROUND

Improved management of mental illness and substance misuse comorbidity is a National Health Service priority, but little is known about its prevalence and current management.

AIMS

To measure the prevalence of comorbidity among patients of community mental health teams (CMHTs) and substance misuse services, and to assess the potential for joint management.

METHOD

Cross-sectional prevalence survey in four urban UK centres.

RESULTS

Of CMHT patients, 44% (95% CI 38.1-49.9) reported past-year problem drug use and/or harmful alcohol use; 75% (95% CI 68.2-80.2) of drug service and 85% of alcohol service patients (95% CI 74.2-93.1) had a past-year psychiatric disorder. Most comorbidity patients appear ineligible for cross-referral between services. Large proportions are not identified by services and receive no specialist intervention.

CONCLUSIONS

Comorbidity is highly prevalent in CMHT, drug and alcohol treatment populations, but may be difficult to manage by cross-referral psychiatric and substance misuse services as currently configured and resourced.

User involvement in the planning and delivery of mental health services: a cross-sectional survey of service users and providers

OBJECTIVE

To identify methods for involving service users in the planning and delivery of psychiatric services and factors which may assist and impede this process.

METHOD

A cross-sectional postal survey of user groups and providers of psychiatric services throughout Greater London (UK).

RESULTS

Seventeen (94%) service providers and 29 (48%) user groups responded to the survey. Service providers employed a wide variety of different methods for involving users but none met national standards for user involvement (UI). Service providers stated that the main obstacle to UI was that users who took part were not representative of local patients. User groups highlighted staff resistance as a major obstacle and 80% stated that they were not satisfied with current arrangements for UI.

CONCLUSION

While users and providers of mental health services were able to identify changes resulting from UI the responsiveness of staff and the representativeness of service users may be impeding this process.

Results of a screening survey for co-morbid substance misuse amongst patients in treatment for psychotic disorders: prevalence and service needs in an inner London borough

BACKGROUND

There is great concern in the UK, and other countries, about the clinical management of psychosis and substance misuse co-morbidity. However, relatively little is known about the UK prevalence and management of co-morbidity.

METHOD

We implemented a screening survey of patients who were in treatment with an inner London adult mental health service and measured the prevalence of substance misuse amongst 851 psychotic patients. Caseworkers reported substance misuse and assessed clinical management arrangements.

RESULTS

Current prevalence of substance misuse was 24.4% (95% CI: 21.3-27.1). Rates of co-morbidity were higher in males (31% vs 16%, chi2 1df=26.0, P < 0.001) and patients over 51 (chi2 3df=50.1, P < 0.001). Adjusted odds of co-morbidity in patients under 51 were 0.19 (95% CI: 0.10-0.34) and 0.47 for females (95% CI: 0.32-0.69). Substance misuse interventions were provided to 20% of co-morbid patients--Only 5% were compliant.

CONCLUSIONS

The findings suggest substance misuse may be highly prevalent amongst psychotic patients. Most co-morbid patients do not receive appropriate treatment. The development of evidence-based interventions should be a priority.

Residents' perceptions of water quality improvements following remediation work in the Pymme's Brook catchment, north London, UK

Residents' perceptions of water quality change following remediation work in the upper Pymme's Brook catchment (north London) were elicited by questionnaire and compared with monitored changes in Escherichia coli count and BMWP (The Biological Monitoring Working Party (BMWP)) score. The wider usefulness of consumer perception surveys was then discussed. Monthly data collected between 1990 and 1996 shows that both E. coli count and BMWP score improved following flushing of the foul sewerage system in 1992, but that only E. coli count improved following the subsequent completion of large-scale remedial engineering works. Local residents were surveyed regarding their awareness of the scheme, and the causes of pollution, together with their perceptions as to the effects of the engineering works and of the resulting water quality improvements. Most respondents selected and ranked indicators in a way that suggested they had an awareness of the significance of various indicators of pollution severity. Following completion of the remediation scheme, residents perceived the watercourse to contain less rubbish and sewage fungus, and to have an improved colour and smell, which corresponds favourably to the monitored improvements. However, respondents' perceptions were found to vary when the study population was sub-divided using a range of parameters. For instance, frequent observers of the brook were most likely to correctly identify sewage as the main form of pollution. These divergent perceptions suggest that there may be considerable difficulties when perception surveys are used to quantify 'benefits' following environmental improvement programmes. Nevertheless, the survey was clearly beneficial in enhancing residents' awareness of their environment and the role of their voice in its management.

The conceptual framework of the National Diabetes Education Outcomes System (NDEOS)

PURPOSE

This article describes the systems-based conceptual framework for the definition of diabetes education outcomes and the development of the National Diabetes Education Outcomes System (NDEOS).

METHODS

Development of the NDEOS was based on integrating diabetes education into the diabetes care system; identifying and tracking standardized learning, behavioral, and clinical outcomes measurements; and gathering data at the individual, program, and national levels. Each component was formulated based on available literature and through consensus with the American Association of Diabetes Educators (AADE) Outcomes Task Force and other multidisciplinary healthcare professionals.

RESULTS

Behavior change is the key outcome measurement for diabetes self-management education (DSME). In addition, diabetes educators should collect other immediate, intermediate, and long-term outcomes for monitoring the impact of DSME. The NDEOS system includes standardized data collection tools for the participant, the educator, and the program manager, and provides reports at the individual, program, and national levels.

CONCLUSIONS

By capturing outcomes data using valid, reliable, and evidence-based tools, the NDEOS strives to support diabetes educators and provide a uniform data set that can be used to influence public policy, support reimbursement negotiations, and assist researchers.

Patency of radial arterial catheters

BACKGROUND

Data on the influence of flush methods, blood-sampling methods, and site location on the patency of radial arterial catheters used for pressure monitoring are sparse.

OBJECTIVES

To determine the effects of flush and blood-sampling methods, insertion site, and sex of patients on catheter patency.

METHODS

In a randomized trial, 174 patients requiring radial arterial pressure monitoring were assigned to 4 groups: fast flush as needed and nonwaste blood sampling; fast flush as needed and waste blood sampling; fast flush every 4 hours and waste blood sampling; and fast flush every 4 hours and nonwaste blood sampling. All site locations were evaluated for patency, and all monitoring systems were maintained with isotonic sodium chloride solution.

RESULTS

Nonpatent catheters were 4.23 times more likely in patients with insertion sites 3 cm or higher above the bend of the wrist than in patients with lower sites (P = .01). Duration of patency did not differ between catheters maintained with fast flush every 4 hours and those flushed as needed or between catheters according to the method of blood sampling. Women were 3.05 times more likely than men to have nonpatent catheters (P = .02). With insertion sites 3 cm or higher above the radiocarpal joint, nonpatency was 7.3 times more likely in women than in men (P < .001).

CONCLUSIONS

Insertion sites closest to the bend of the wrist increase chances of maintaining patency. Catheters can be maintained with as-needed flushes, and either waste or nonwaste blood sampling can be used.

Patency of radial arterial catheters

BACKGROUND: Data on the influence of flush methods, blood-sampling methods, and site location on the patency of radial arterial catheters used for pressure monitoring are sparse. OBJECTIVES: To determine the effects of flush and blood-sampling methods, insertion site, and sex of patients on catheter patency. METHODS: In a randomized trial, 174 patients requiring radial arterial pressure monitoring were assigned to 4 groups: fast flush as needed and nonwaste blood sampling; fast flush as needed and waste blood sampling; fast flush every 4 hours and waste blood sampling; and fast flush every 4 hours and nonwaste blood sampling. All site locations were evaluated for patency, and all monitoring systems were maintained with isotonic sodium chloride solution. RESULTS: Nonpatent catheters were 4.23 times more likely in patients with insertion sites 3 cm or higher above the bend of the wrist than in patients with lower sites (P = .01). Duration of patency did not differ between catheters maintained with fast flush every 4 hours and those flushed as needed or between catheters according to the method of blood sampling. Women were 3.05 times more likely than men to have nonpatent catheters (P = .02). With insertion sites 3 cm or higher above the radiocarpal joint, nonpatency was 7.3 times more likely in women than in men (P &lt; .001). CONCLUSIONS: Insertion sites closest to the bend of the wrist increase chances of maintaining patency. Catheters can be maintained with as-needed flushes, and either waste or nonwaste blood sampling can be used.

Ventral hippocampal ibotenic acid lesions block chronic nicotine-induced spatial working memory improvement in rats

Chronic nicotine infusions have been found to significantly improve working memory performance in the radial-arm maze. This effect is blocked by co-infusions of the nicotinic antagonist mecamylamine. Acute nicotine injections also improve working memory performance in the radial-arm maze. This effect is also blocked by mecamylamine co-administration. Recent local infusions studies have demonstrated the importance of the ventral hippocampus for nicotinic involvement in memory. Local infusions of mecamylamine, DHbetaE or MLA impair working memory performance on the radial-arm maze. The current study was conducted to determine the importance of the ventral hippocampus for the chronic effects of nicotine. Rats were trained on the working memory task in an eight-arm radial maze. After acquisition they underwent either infusions of ibotenic acid lesions or vehicle infusions and received subcutaneous implants of osmotic minipumps that delivered either nicotine at a dose of 5 mg kg-1 day-1 or vehicle in a 2x2 design. The rats then were given 2 days of recovery and were tested on the radial-arm maze three times per week for the next 4 weeks. As seen in previous studies, in the sham lesioned group nicotine infusions caused a significant improvement in choice accuracy. In contrast no nicotine-induced improvement was seen in the rats after ibotenic acid lesions of the ventral hippocampus. The effect of nicotine was blocked even though this lesion did not cause a deficit in performance. Previous work showed that chronic nicotine infusion still caused a significant improvement in working memory performance in the radial-arm maze after knife-cut lesions of the fimbria-fornix carrying the septo-hippocampal cholinergic innervation. Thus it appears that it is the postsynaptic nicotinic receptors in the ventral hippocampus which are critically important for the expression of the chronic nicotine induced working memory improvement.

Nicotine-dizocilpine interactions and working and reference memory performance of rats in the radial-arm maze

Both nicotinic cholinergic and NMDA glutaminergic systems are important for memory function. Nicotine has been found repeatedly to significantly improve working memory performance in the radial-arm maze. The NMDA antagonist dizocilpine has been found to impair working memory performance. There is neuropharmacological evidence that these two systems are functionally related. Nicotine is potent at releasing many transmitters including glutamate. The current study was conducted to examine the interaction of nicotinic and NMDA systems with regard to working and reference memory. Rats were trained on a working/reference procedure on a 16-arm radial maze. After acquisition, they were administered nicotine (0, 0.2, and 0.4 mg/kg) and dizocilpine (0, 100, and 200 microg/kg) alone or in combination in a repeated measures, counterbalanced design. As seen previously, nicotine at a dose of 0.2 mg/kg caused a significant improvement in working but not reference memory performance in the radial-arm maze. The 200 microg/kg dose of dizocilpine made the rats nonresponsive on the maze so that choice accuracy could not be assessed. The 100 microg/kg dose of dizocilpine caused significant impairments in both working and reference memory. The 0.4 mg/kg dose of nicotine significantly attenuated the dizocilpine-induced deficit in both working and reference memory. NMDA blockade impairs working and reference memory and blocks the expression of the working memory improvement caused by 0.2 mg/kg of nicotine. However, a higher dose of 0.4 mg/kg of nicotine is effective at attenuating the dizocilpine-induced deficit, even though this dose alone is not effective in improving performance. A second study examined the effects of a lower dose range of dizocilpine. Comensurately smaller memory impairments were seen with lower doses of dizocilpine down to 12.5 microg/kg, which did not produce any significant effects on memory performance or response latency. Nicotine had a more modest effect in attenuating the smaller deficits caused by these lower doses of dizocilpine. These studies provide evidence for important interactions between nicotinic and NMDA systems with regard to memory function.

Crystal structures of native and recombinant yeast fumarase

Crystal structures for both native and recombinant forms of yeast fumarase from Saccharomyces cerevisiae have been completed to moderate resolution by two separate laboratories. The recombinant form was obtained by the construction of an expression plasmid for Escherichia coli. Despite a high level of amino acid sequence similarity, purification of the eukaryotic enzyme from the wild-type prokaryotic enzyme was feasible. The crystal structure of the native form, NY-fumarase, encompasses residues R22 through M484, while the recombinant form, RY-fumarase, consists of residues S27 through L485. Both crystal structures lack the N-terminal translocation segment. Each subunit of the homo-tetrameric protein has three domains. The active site is formed by segments from each of three polypeptide chains. The results of these studies on the eukaryotic proteins are unique, since the recombinant form was done in the absence of dicarboxylic acid and has an unoccupied active site. As a comparison, native fumarase was crystallized in the presence of the competitive inhibitor, meso-tartrate. Meso-tartrate occupies a position close to that of the bound citrate molecule found in the active site of the E. coli enzyme. This inhibitor participates in hydrogen bonding to an active-site water molecule. The independent determination of the two structures provides further evidence that an active-site water molecule may play an active role in the fumarase-catalyzed reaction.

Mammalian BUB1 protein kinases: map positions and in vivo expression

The spindle assembly checkpoint modulates the timing of anaphase initiation in mitotic cells containing improperly aligned chromosomes and increases the probability of successful delivery of a euploid chromosome set to each daughter cell. We have characterized cDNA sequences from several organisms with highly significant predicted protein sequence homologies to Saccharomyces cerevisiae Bub1p, a protein required for function of the spindle assembly checkpoint in budding yeast. The localization of mouse and human orthologs is in agreement with known conservation of synteny. Mouse backcross mapping data indicate that the murine gene resides on chromosome 2 near IL1A, 73 cM from the mouse centromere. Radiation hybrid mapping data indicate that the human locus exhibits linkage to microsatellite marker D2S176, which is located within 10 cM of human IL1A. Multiple-tissue Northern analysis indicates conservation of expression pattern in mouse and human with markedly high mRNA levels in testis. Northern analysis of two different spindle assembly checkpoint protein gene products from human, BUB1 and MAD2, reveals an expression pattern with common tissue distribution consistent with roles in a common pathway. In addition, we demonstrate that an mRNA found to accumulate in a rat fibroblast cell transformation system encodes rat BUB1, and we find that rat BUB1 mRNA accumulation correlates with the proliferation status of cells in culture.

The Bentham Unit: a pilot remand and assessment service for male mentally disordered remand prisoners. II: Report of an independent evaluation

BACKGROUND

Findings are presented from an evaluation of a pilot remand and assessment service--the Bentham Unit. The aims of the Bentham Unit are to provide rapid assessment, identify mentally disordered remand prisoners, and speed their transfer from prison to NHS care, where a need is indicated.

METHOD

The number, rate and speed of referral, assessment and transfer to NHS care of offenders remanded to Wormwood Scrubs prison during periods before and after the Bentham Unit opened were compared.

RESULTS

The service attracted a large volume of referrals. Between the two periods, significant increases in the numbers of referrals and hospital disposals, and major reductions in the interval between reception on remand into the prison, NHS assessment and transfer to NHS care, were observed.

CONCLUSIONS

The aims of the unit were met. Implications for service configurations are discussed.

Mutations of fumarase that distinguish between the active site and a nearby dicarboxylic acid binding site

Two mutant forms of fumarase C from E. coli have been made using PCR and recombinant DNA. The recombinant form of the protein included a histidine arm on the C-terminal facilitating purification. Based on earlier studies, two different carboxylic acid binding sites, labeled A- and B-, were observed in crystal structures of the wild type and inhibited forms of the enzyme. A histidine at each of the sites was mutated to an asparagine. H188N at the A-site resulted in a large decrease in specific activity, while the H129N mutation at the B-site had essentially no effect. From the results, we conclude that the A-site is indeed the active site, and a dual role for H188 as a potential catalytic base is proposed. Crystal structures of the two mutant proteins produced some unexpected results. Both mutations reduced the affinity for the carboxylic acids at their respective sites. The H129N mutant should be particularly useful in future kinetic studies because it sterically blocks the B-site with the carboxyamide of asparagine assuming the position of the ligand's carboxylate. In the H188N mutation at the active site, the new asparagine side chain still interacts with an active site water that appears to have moved slightly as a result of the mutation.

Genome cross-referencing and XREFdb: implications for the identification and analysis of genes mutated in human disease

Comparative genomics approaches and multi-organismal biology are valuable tools for genetic analysis. Cross-species connections between genes mutated in human disease states and homologues in model organisms can be particularly powerful, as model-organism gene function data and experimental approaches can shed light on the molecular mechanisms defective in the disease. We describe a project that is systematically identifying novel expressed sequence tag (EST) sequences that are highly related to genes in model organisms and mapping them to positions on the mouse and human maps. This process effectively cross-references model organism genes with mapped mammalian phenotypes, facilitating the identification of genes mutated in human disease states via the positional candidate approach. A public database, XREFdb (http:@www.ncbi.nlm.nih.gov/XREFdb/), disseminates similarity search, mapping and mammalian phenotype information and increases the rate at which these cross-species connections are established.

Seasonal adjustment of solar heat gain independent of coat coloration in a desert mammal

Despite the apparent importance of solar radiation as a source of heat for free-living animals, there exists no substantial body of empirical data describing physiological responses to solar radiation under the range of convective conditions likely to occur in nature. We therefore quantified effects of simulated solar radiation and wind on metabolic heat production in the rock squirrel, Spermophilus variegatus. This diurnal mammal inhabits the Sonoran Desert and seasonally replaces its pelage in a fashion in which it retains constant external appearance but incorporates optical and structural changes that are thought to significantly alter heat-transfer properties of the coat. At a given wind speed, the presence of 950 W m-2 of simulated solar radiation reduces metabolic heat production by 15% (at a wind speed of 4 m s-1) to 37% (at a wind speed of 0.25 m s-1). Independent of effects of irradiance, metabolic heat production significantly increases with wind speed such that as wind speed is increased from 0.25 m s-1 to 4.0 m s-1, metabolic heat production is elevated by 66% (sunlight absent) or 88% (sunlight present). Previous analyses demonstrated that when exposed to identical radiative and convective environments rock squirrels with summer pelages accrue solar heat loads 33%-71% lower than those experienced by animals with winter coats. This reduction of solar heat gain during the extremely hot Sonoran Desert summer apparently constitutes a previously unappreciated mode of thermal adaptation by seasonal adjustment of radiative heat gain without changes in the animal's appearance.

General practitioners' immediate management of men presenting with urethral symptoms

OBJECTIVES

To describe the immediate reported management, by general practitioners (GPs), of men presenting with symptoms of urethral discharge, or dysuria only.

SUBJECTS

All 692 GPs in practice in Brent, Harrow, Ealing, Hammersmith, and Hounslow (UK).

METHOD

Data were collected using a GP completed questionnaire concerning the management of the last male patient seen, aged less than 40 years, complaining of urethral discharge, and the last male patient under 40 years complaining of dysuria only.

RESULTS

The response rate among GPs was 52%. Fifty three per cent of men with urethral symptoms, 86% of men with a urethral discharge and 24% with dysuria only, were identified by GPs and referred without investigation or treatment to a genitourinary medicine clinic. Of men with dysuria only, 93% of investigations by GPs were reported to include a mid-stream urine (MSU) specimen for bacteriology, and 19% a urethral swab for chlamydia. Seventy eight per cent of GPs reported using treatments with a broad spectrum antibiotic, 53% with trimethoprim, whilst 14% of GPs reported using a tetracycline in common use to treat non-gonococcal urethritis. Urine specimens were reported to be "culture positive" in 41% of men who had an MSU specimen tested, and 15% of men who had a urethral swab tested were reported to be chlamydia positive.

CONCLUSION

The GPs included in this study were not a full sample, or representative of all the GPs, and the data are retrospective. Nevertheless, we found a large difference in GPs reported management for men with urethral symptoms according to whether or not urethral discharge was a reported complaint. Reported management is likely to be, at least, indicative of actual management. Therefore, the results suggest that assessment by GPs of men presenting with dysuria should be explored and more appropriate management strategies defined.

Crystallographic studies of the catalytic and a second site in fumarase C from Escherichia coli

Fumarase C catalyzes the stereospecific interconversion of fumarate to L-malate as part of the metabolic citric acid or Kreb's cycle. The recent three-dimensional structure of fumarase C from Escherichia coli has identified a binding site for anions which is generated by side chains from three of the four subunits within the tetramer (Weaver et al., 1995). These same side chains are found in the three most highly conserved regions within the class II fumarase superfamily. The site was initially characterized by crystallographic studies through the binding of a heavy atom derivative, tungstate. A number of additional crystallographic structures using fumarase crystals with bound inhibitors and poor substrates have now been studied. The new structures have both confirmed the originally proposed active site, site A, and led to the discovery of a novel second binding site that is structurally nearby, site B. Site A utilizes a combination of residues, including H188, T187, K324, N326, T100, N141, S139, and S140, to form direct hydrogen bonds to each of the inhibitors. The A-site has been demonstrated by studying crystalline fumarase with the bound competitive inhibitors-citrate and 1,2,4,5-benzenetetracarboxylic acid. The crystal structure of fumarase C with beta-(trimethylsilyl)maleate, a cis substrate for fumarase, has led to the discovery of the second site or B-site. Sites A and B have different properties in terms of their three-dimensional structures. Site B, for example, is formed by atoms from only one of the subunits within the tetramer and mainly by atoms from a pi-helix between residues H129 through N135. The crystal structures show that the two locations are separated by approximately 12 A. A highly coordinated buried water molecule is also found at the active or A-site. The high-resolution crystal structures describe both sites, and atoms near the A-site are used to propose a likely enzyme/substrate complex.