Defining capabilities in deployed UK military prehospital emergency care

The UK military prehospital emergency care (PHEC) operational clinical capability framework must be updated in order that it retains its use as a valid operational planning tool. Specific requirements include accurately defining the PHEC levels and the 'Medical Emergency Response Team' (MERT), while reinforcing PHEC as a specialist area of clinical practice that requires an assured set of competencies at all levels and mandatory clinical currency for vocational providers.A military PHEC review panel was convened by the Defence Consultant Advisor (DCA) for PHEC. Each PHEC level was reviewed and all issues which had, or could have arisen from the existing framework were discussed until agreement between the six members of this panel was established.An updated military PHEC framework has been produced by DCA PHEC, which defines the minimum requirements for each operational PHEC level. These definitions cover all PHEC providers, irrespective of professional background. The mandatory requirement for appropriate clinical exposure for vocational and specialist providers is emphasised. An updated definition of MERT has been agreed.This update provides clarity to the continually evolving domain of UK military PHEC. It sets out the PHEC provider requirements in order to be considered operationally deployable in a PHEC role. There are implications for training, manning and recruitment to meet these requirements, but the processes required to address these are already underway and well described elsewhere.

MYCN-Amplified Neuroblastoma Is Addicted to Iron and Vulnerable to Inhibition of the System Xc-/Glutathione Axis

MYCN is amplified in 20% to 25% of neuroblastoma, and MYCN-amplified neuroblastoma contributes to a large percent of pediatric cancer-related deaths. Therapy improvements for this subtype of cancer are a high priority. Here we uncover a MYCN-dependent therapeutic vulnerability in neuroblastoma. Namely, amplified MYCN rewires the cell through expression of key receptors, ultimately enhancing iron influx through increased expression of the iron import transferrin receptor 1. Accumulating iron causes reactive oxygen species (ROS) production, and MYCN-amplified neuroblastomas show enhanced reliance on the system Xc- cystine/glutamate antiporter for ROS detoxification through increased transcription of this receptor. This dependence creates a marked vulnerability to targeting the system Xc-/glutathione (GSH) pathway with ferroptosis inducers. This reliance can be exploited through therapy with FDA-approved rheumatoid arthritis drugs sulfasalazine (SAS) and auranofin: in MYCN-amplified, patient-derived xenograft models, both therapies blocked growth and induced ferroptosis. SAS and auranofin activity was largely mitigated by the ferroptosis inhibitor ferrostatin-1, antioxidants like N-acetyl-L-cysteine, or by the iron scavenger deferoxamine (DFO). DFO reduced auranofin-induced ROS, further linking increased iron capture in MYCN-amplified neuroblastoma to a therapeutic vulnerability to ROS-inducing drugs. These data uncover an oncogene vulnerability to ferroptosis caused by increased iron accumulation and subsequent reliance on the system Xc-/GSH pathway. SIGNIFICANCE: This study shows how MYCN increases intracellular iron levels and subsequent GSH pathway activity and demonstrates the antitumor activity of FDA-approved SAS and auranofin in patient-derived xenograft models of MYCN-amplified neuroblastoma.

Allograft theory: transmission of devil facial-tumour disease

The Tasmanian devil, a large carnivorous Australian marsupial, is under threat from a widespread fatal disease in which a malignant oral-facial tumour obstructs the animal's ability to feed. Here we show that the chromosomes in these tumours have undergone a complex rearrangement that is identical for every animal studied. In light of this remarkable finding and of the known fighting behaviour of the devils, we propose that the disease is transmitted by allograft, whereby an infectious cell line is passed directly between the animals through bites they inflict on one another.

Resynchronization of ovulation and timed insemination in lactating dairy cows

The objective was to compare pregnancy rates to resynchronization and timed AI (TAI) protocols in lactating dairy cows that received GnRH at 23 d and were diagnosed not pregnant at 30 d after the pre-enrollment AI. Nonpregnant cows (624) at ultrasonography on day 30 (study day 0) were classified as diestrus (74.8%), metestrus (5.6%) and without a CL (19.5%). Cows in diestrus were assigned either to the GnRH group (PGF2alpha on day 0, GnRH on day 2 and TAI 16 h later, n = 238) or the estradiol cypionate (ECP) group (PGF2alpha on day 0, ECP on day 1, and TAI 36 h later, n = 229). Cows in metestrus were assigned to the Modified Heatsynch Group (GnRH on day 0, PGF(2alpha) on day 7, ECP on day 8 and TAI on day 9, n = 35). Cows without a CL (n = 122) were classified either as proestrus (10.6%), ovarian cysts (7.5%) or anestrus (1.4%), and assigned to factorial treatments (i.e., use of GnRH versus CIDR) to either the GnRH group (GnRH on day 0, PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 28), the CIDR group (CIDR insert from days 0 to 7, PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 34), the GnRH + CIDR group (GnRH on day 0, CIDR insert from days 0 to 7, PGF2alpha on day 7, GnRH on day 9 and TAI 16h later, n = 32), and the control group (PGF2alpha on day 7, GnRH on day 9 and TAI 16 h later, n = 28). For cows without a CL, plasma P4 concentrations were determined on days 0, 7, 10 and 17 and ovarian structures determined on days 0, 7 and 17. Pregnancy rates were evaluated at 30, 55 and 90 d after the resynchronized AI. For cows in diestrus, there were no differences in pregnancy rates on days 30, 55 and 90 for cows in the GnRH (27.5, 26.5 and 24.2%) or ECP (29.1, 25.5 and 24.1%) groups. In addition, there were no differences in pregnancy losses between days 30 and 55 and 55 and 90 between the GnRH (7.0 and 8.6%) and ECP (9.8 and 5.4%) groups. For cows without a CL, GnRH on day 0 increased the proportion of cows with a CL on days 7 and 17 and plasma P4 concentration on day 17 in cows with ovarian cysts but not for cows in proestrus. The CIDR insert increased pregnancy rate in cows with ovarian cysts but reduced pregnancy rate for cows in proestrus.

Resynchronization of ovulation and timed insemination in lactating dairy cows

The objective was to compare pregnancy rates and pregnancy losses in lactating dairy cows that were diagnosed not pregnant and re-inseminated following either the Ovsynch or Heatsynch protocols. Also evaluated were the effects of stages of the estrous cycle, ovarian cysts and anestrus on pregnancy rates for both treatments. Non-pregnant cows (n = 332) as determined by ultrasonography on day 27 post-AI (study day 0) were divided into two groups. Cows in the Ovsynch group (n = 166) received GnRH on day 0, PGF2alpha on day 7, GnRH on day 9, and timed AI (TAI) 16 h later (day 10). Cows in the Heatsynch group (n = 166) received GnRH on day 0, PGF2alpha on day 7, estradiol cypionate (ECP) on day 8, and TAI 48 h later (day 10). Cows detected in estrus on days 8 and 9 were inseminated and included in the study. On day 0, cows were classified according to different stages of the estrous cycle, or presence of ovarian cysts or anestrus. Pregnancy rates were evaluated 27, 45 and 90 days after resynchronized AI. Overall, there was no difference in pregnancy rates on days 27, 45 and 90 between cows in the Ovsynch (25.2, 17.5, and 13.9%) and Heatsynch (25.8, 19.9, and 16.1%) groups. There was no difference in pregnancy losses from days 27 to 45 and days 45 to 90 for cows in the Ovsynch (25.0 and 17.9%) and Heatsynch (14.7 and 10.3%) groups. However, pregnancy rates were increased when cows in metestrus were subjected to the Heatsynch protocol and cows with ovarian cysts were subjected to the Ovsynch protocol.

Resynchronization of ovulation and timed insemination in lactating dairy cows, II: assigning protocols according to stages of the estrous cycle, or presence of ovarian cysts or anestrus

Pregnancy rates were compared in lactating dairy cows (n = 1083) assigned to protocols for resynchronization of ovulation based on stages of the estrous cycle, or presence of ovarian cysts or anestrus. Cows were detected not pregnant by ultrasonography 30 d after a previous AI (study day 0) and classified as diestrus, metestrus, proestrus, with ovarian cysts or anestrus. Cows in diestrus (January-May) were assigned to either Ovsynch (GnRH day 0, PGF2alpha day 7, GnRH day 9, and timed-AI [TAI] 16 h later; n = 96), or Quicksynch (PGF2alpha day 0, estradiol cypionate [ECP] day 1, AI at detected estrus [AIDE] on day 2, or TAI on day 3; n = 96). Cows in diestrus (June-December) were assigned to either Ovsynch (n = 156) or Modified Quicksynch (PGF2alpha day 0, ECP day 1, AIDE days 2 and 3, and to Ovsynch on day 4 if not detected in estrus; n = 142). Cows in metestrus were assigned either to Ovsynch (n = 68), Heatsynch (GnRH day 0, PGF2alpha day 7, ECP day 8, AIDE day 9, or TAI day 10; n = 62), or GnRH + Ovsynch (GnRH on day 0, followed by Ovsynch on day 8; n = 64). Cows in proestrus, with ovarian cysts, or anestrus were assigned to either Ovsynch (proestrus n = 89, ovarian cysts n = 97, anestrus n = 8) or GnRH + Ovsynch (proestrus n = 87, ovarian cysts n = 109, anestrus n = 9). Pregnancy rate was evaluated 30, 55 and 90 d after resynchronized AI. For cows in diestrus (January-May), pregnancy rates were higher for Ovsynch (35.9, 29.2 and 26.0%) than for Quicksynch (21.7, 16.7 and 15.6%). For cows in diestrus (June-December), pregnancy rates were similar for Ovsynch (34.4, 24.0 and 23.6%) and Modified Quicksynch (27.1, 26.2 and 21.6%). For cows in metestrus, pregnancy rates were higher for GnRH + Ovsynch (33.3, 24.5 and 20.3%) than for Heatsynch (20.3, 12.9 and 9.8%). For cows with ovarian cysts, pregnancy rates were higher for GnRH + Ovsynch (30.3, 26.6 and 22.9%) than for Ovsynch (20.2, 18.5 and 14.7%). Assignment to resynchronization protocols based on the stages of the estrous cycle, or presence of ovarian cysts improved pregnancy rates.

Strategic use of gonadotrophin-releasing hormone (GnRH) to increase pregnancy rate and reduce pregnancy loss in lactating dairy cows subjected to synchronization of ovulation and timed insemination

The objective of this study was to determine the effect of GnRH (100 microg i.m.) treatment 5 and 15 days after timed insemination (TAI) on pregnancy rate and pregnancy loss in lactating dairy cows subjected to synchronization of ovulation. The study included 831 lactating dairy cows subjected to a Presynch-Ovsynch protocol for first service. On the day of TAI (Day 0), cows were randomly assigned to one of four experimental groups. Cows in Group 1 (n = 214) were treated with GnRH on Day 5; cows in Group 2 (n = 209) were treated with GnRH on Day 15; cows in Group 3 (n = 212) were treated with GnRH on both Day 5 and Day 15; cows in Group 4 (n = 196) were not treated. Pregnancy rate was evaluated at Day 27 and Day 45 after TAI. The interestrus interval and the proportion of cows diagnosed not pregnant based on expression of estrus and insemination before pregnancy diagnosis on Day 27 were determined. The results of this study are: (1) GnRH treatment on Day 5 or Day 15 did not increase pregnancy rate, or reduce pregnancy loss between Day 27 and Day 55 after TAI; (2) cows treated with GnRH on both Day 5 and Day 15 had a lower (P < 0.01) proportion of cows diagnosed not pregnant based on expression of estrus before ultrasonography on Day 27 (26.5%) compared to control cows (52.9%), and these cows had an extended (P = 0.05) interestrus interval (23.4 days vs. 21.5 days); and (3) GnRH treatment on both Day 5 and Day 15 after TAI reduced pregnancy rate on Day 27 (36.8% vs. 44.4% for control cows; P < 0.03) and Day 55 (28.3% vs. 36.2% for control cows; P < 0.01). Therefore, strategies to stimulate CL function using multiple doses of GnRH during the luteal phase need to consider potential negative effects.

8RESYNCHRONIZATION OF OVULATION AND TIMED INSEMINATION IN LACTATING DAIRY COWS USING THE OVSYNCH AND HEATSYNCH PROTOCOLS INITIATED 7 DAYS BEFORE PREGNANCY DIAGNOSIS ON DAY 30 BY ULTRASONOGRAPHY

Rapid re-synchronization of ovulation and insemination in cows found nonpregnant to a previous service is important to maintain high reproductive efficiency. The objective was to compare pregnancy rate (PR) and pregnancy losses (PL) in cows subjected to Ovsynch or Heatsynch protocols 7 days before pregnancy diagnosis by ultrasonography (U/S) on Day 30. Initiation of both protocols included administration of GnRH on Day 23, which was considered the optimal time according to the distribution of interestrus intervals in cows previously inseminated. The study was conducted in a large dairy herd located in north central Florida from March to May, 2003. Of 593 cows treated with GnRH on Day 23 (±1) after insemination and found nonpregnant at U/S on Day 30 (±1; experimental Day 0), 75% (445) had a CL (diestrus) and were sequentially assigned to the two experimental groups. Cows in the Ovsynch Group (n=225) received 25mg (i.m.) PGF2α (Lutalyse, Pharmacia, Kalamazoo, MI, USA) on Day 0, 100μg (i.m.) GnRH (Cystorelin, Merial Limited, Iselin, NJ, USA) on Day 2, and were timed inseminated 16h later. Cows in Heatsynch Group (n=220) received 25mg (i.m.) PGF2α on Day 0, and 1mg (i.m.) estradiol cypionate (ECP, Pharmacia, Kalamazoo, MI, USA) on Day 1, and were timed-inseminated 36h later. Pregnancy at Day 30 was determined by U/S and at Day 55 by rectal examination of the genital tract. Pregnancy rate and PL were evaluated using multiple logistic regression. Pregnancy rate at Day 30 for Ovsynch (64/225, 28.4%) and Heatsynch (63/220, 28.6%) and PR at Day 55 for Ovsynch (58/225, 25.8%) and Heatsynch (54/220, 24.5%) were not different. In addition, PL between Days 30 and 55 for Ovsynch (6/64, 9.4%) and Heatsynch (9/63, 14.3%) were not different. There were no effects of parity, inseminator and days in milk on PR. However, PR at day 30 was higher in lots with cooling systems (46/141, 32.6%) and lots of first calf heifers (41/135, 30.4%) compared to lots of multiparous cows late in lactation without cooling systems (32/148, 21.6%). In conclusion, Heatsynch and Ovsynch initiated 7 days before pregnancy diagnosis on Day 30 had comparable PR of 25% at Day 55 in lactating dairy cows during the period of March–May.

Probing inhibitors binding to human urokinase crystals by Raman microscopy: implications for compound screening

Inhibition of urokinase activity represents a promising target for antimetastatic therapy for several types of tumor. The present study sets out to investigate the potential of Raman spectroscopy for defining the molecular details of inhibitor binding to this enzyme, with emphasis on single crystal studies. It is demonstrated that high quality Raman spectra from a series of five inhibitors bound individually to the active site of human urokinase can be obtained in situ from urokinase single crystals in hanging drops by using a Raman microscope. After recording the spectrum of the free crystal, a solution of inhibitor containing an amidine functional group on a naphthalene ring was added, and the spectrum of the crystal-inhibitor complex was obtained. The resulting difference Raman spectrum contained only vibrational modes due to bound inhibitor, originating from the protonated group, i.e., the amidinium moiety, as well as naphthalene ring modes and features from other functionalities that made up each inhibitor. The identification of the amidinium modes was placed on a quantitative basis by experimental and theoretical work on naphthamidine compounds. For the protonated group, -C-(NH2)(2)(+), the symmetric stretch occurs near 1520 cm(-1), and a less intense antisymmetric mode appears in the Raman spectra near 1680 cm(-1). The presence of vibrational modes near 1520 cm(-1) in each of the Raman difference spectra of the five complexes examined unambiguously identifies the protonated form of the amidinium group in the active site. Several advantages were found for single crystal experiments over solution studies of inhibitor-enzyme complexes, and these are discussed. The use of single crystals permits competitive binding experiments that cannot be undertaken in solution in any kind of homogeneous assay format. The Raman difference spectrum for a single crystal that had been exposed to equimolar amounts of all five inhibitors in the hanging drop showed only the Raman signature of the compound with the lowest K(i). These findings suggest that the Raman approach may offer a route in the screening of compounds in drug design applications as well as an adjunct to crystallographic analysis.

Solution structure of the antiapoptotic protein bcl-2

The structures of two isoforms of Bcl-2 that differ by two amino acids have been determined by NMR spectroscopy. Because wild-type Bcl-2 behaved poorly in solution, the structures were determined by using Bcl-2/Bcl-x(L) chimeras in which part of the putative unstructured loop of Bcl-2 was replaced with a shortened loop from Bcl-x(L). These chimeric proteins have a low pI compared with the wild-type protein and are soluble. The structures of the two Bcl-2 isoforms consist of 6 alpha-helices with a hydrophobic groove on the surface similar to that observed for the homologous protein, Bcl-x(L). Comparison of the Bcl-2 structures to that of Bcl-x(L) shows that although the overall fold is the same, there are differences in the structural topology and electrostatic potential of the binding groove. Although the structures of the two isoforms of Bcl-2 are virtually identical, differences were observed in the ability of the proteins to bind to a 25-residue peptide from the proapoptotic Bad protein and a 16-residue peptide from the proapoptotic Bak protein. These results suggest that there are subtle differences in the hydrophobic binding groove in Bcl-2 that may translate into differences in antiapoptotic activity for the two isoforms.

Rationale for Bcl-xL/Bad peptide complex formation from structure, mutagenesis, and biophysical studies

The three-dimensional structure of the anti-apoptotic protein Bcl-xL complexed to a 25-residue peptide from the death promoting region of Bad was determined using NMR spectroscopy. Although the overall structure is similar to Bcl-xL bound to a 16-residue peptide from the Bak protein (Sattler et al., 1997), the Bad peptide forms additional interactions with Bcl-xL. However, based upon site-directed mutagenesis experiments, these additional contacts do not account for the increased affinity of the Bad 25-mer for Bcl-xL compared to the Bad 16-mer. Rather, the increased helix propensity of the Bad 25-mer is primarily responsible for its greater affinity for Bcl-xL. Based on this observation, a pair of 16-residue peptides were designed and synthesized that were predicted to have a high helix propensity while maintaining the interactions important for complexation with Bcl-xL. Both peptides showed an increase in helix propensity compared to the wild-type and exhibited an enhanced affinity for Bcl-xL.

Sequential single doses of cisapride, erythromycin, and metoclopramide in critically ill patients intolerant to enteral nutrition: a randomized, placebo-controlled, crossover study

OBJECTIVE

To evaluate the comparative efficacy of enteral cisapride, metoclopramide, erythromycin, and placebo for promoting gastric emptying in critically ill patients with intolerance to gastric enteral nutrition (EN).

DESIGN

A randomized, crossover study.

SETTING

Adult medical intensive care unit at a university-affiliated private hospital and trauma intensive care unit at a university teaching hospital.

PATIENTS

Ten adult, critically ill, mechanically ventilated patients not tolerating a fiber-containing EN product defined as a single aspirated gastric residual volume >150 mL or two aspirated gastric residual volumes >120 mL during a 12-hr period.

INTERVENTIONS

Patients received 10 mg of cisapride, 200 mg of erythromycin ethylsuccinate, 10 mg of metoclopramide, and placebo as 20 mL of sterile water every 12 hrs over 48 hrs. Acetaminophen solution (1000 mg) was administered concurrently. Gastric residual volumes were assessed, and plasma acetaminophen concentrations were serially determined by TDx between 0 and 12 hrs to evaluate gastric emptying.

MEASUREMENTS AND MAIN RESULTS

Gastric residual volumes during the study were not significantly different between agents. No differences in area under the concentration vs. time curve or elimination rate constant were identified between agents. Metoclopramide and cisapride had a significantly shorter mean residence time of absorption than erythromycin (6.3+/-4.5 [SEM] mins and 10.9+/-5.8 vs. 30.1+/-4.5 mins, respectively [p<.05]). Metoclopramide (9.7+/-15.3 mins) had a significantly shorter time to peak concentration compared with erythromycin and placebo (60.7+/-8.1 and 50.9+/-13.5 mins, respectively [p<.05]). The time to onset of absorption was significantly shorter for metoclopramide vs. cisapride (5.7+/-4.5 vs. 22.9+/-5.7 mins [p<.05]).

CONCLUSION

In critically ill patients intolerant to EN, single enteral doses of metoclopramide or cisapride are effective for promoting gastric emptying in critically ill patients with gastric motility dysfunction. Additionally, metoclopramide may provide a quicker onset than cisapride.

Psychotherapy with phobic patients: the marriage relationship as the source of symptoms and focus of treatment

Four patients demonstrating phobic symptoms occurring in the context of maladaptive marriages are presented. Thorough historical data collection is stressed. Similarities in family backgrounds and personality styles emerge in these cases and are discussed in relation to genesis of symptoms within the marital relationships. A psychotherapeutic approach is described and results of treatment examined.

Cell-mediated immunoselection against cell-surface antigens of somatic cell hybrids

Cytotoxic lymphoid cells derived from in vivo immunization of mice across H2 barriers were utilized in in vitro cytotoxicity assays. The target cells were somatic cell hybrids derived from parental cells differing at the H2 locus. The hybrid cells surviving cytotoxicity were grown to confluent populations and the H2 antigens selected against were no longer demonstrable by indirect immunofluorescence. Comparative karyology of hybrid cells expressing both parental H2 types before immunoselection with hybrid cells surviving immunoselection revealed a decrease in the number of murine chromosomes number 17, suggesting that those cells surviving cytotoxicity had spontaneously lost these chromosomes prior to the selection event. The possibility of immunoconstruction of somatic cell hybrids on the basis of their cell-surface antigens is discussed.