Design, Synthesis, and Characterization of I-BET567, a Pan-Bromodomain and Extra Terminal (BET) Bromodomain Oral Candidate

Through regulation of the epigenome, the bromodomain and extra terminal (BET) family of proteins represent important therapeutic targets for the treatment of human disease. Through mimicking the endogenous N-acetyl-lysine group and disrupting the protein-protein interaction between histone tails and the bromodomain, several small molecule pan-BET inhibitors have progressed to oncology clinical trials. This work describes the medicinal chemistry strategy and execution to deliver an orally bioavailable tetrahydroquinoline (THQ) pan-BET candidate. Critical to the success of this endeavor was a potency agnostic analysis of a data set of 1999 THQ BET inhibitors within the GSK collection which enabled identification of appropriate lipophilicity space to deliver compounds with a higher probability of desired oral candidate quality properties. SAR knowledge was leveraged via Free-Wilson analysis within this design space to identify a small group of targets which ultimately delivered I-BET567 (27), a pan-BET candidate inhibitor that demonstrated efficacy in mouse models of oncology and inflammation.

308 The Effect Of COVID-19 On Hand Trauma Management: A Single-Centre Correlation Study, Inter-Rater Agreement and Functional Outcomes

Introduction

Management of hand trauma has evolved to incorporate assessment, treatment and rehabilitation of patients in a ‘one-stop’ clinic on initial presentation. Our aim was to evaluate the effect of COVID-19 on hand trauma management using inter-rater agreement between hand surgeons.

Method

Patients with hand fractures were consecutively assessed from March to May 2020, with atleast 6-month follow-up outcomes. Two experienced hand surgeons blinded to management and outcomes independently reviewed radiographic images and clinical history to provide their opinion on optimal treatment. Weighted-kappa analysis was performed for concordance and inter-rater agreement between the two surgeons and actual management.

Results

268 patients were identified, 82 had fractures involving tubular bones of the hand. 62 were male and 20, female. Mean age was 40.3 (SD 19.7). Mechanism of injury was secondary to home-related injuries (34%) and falls (28%). Fractures involving the metacarpals (n = 24) and distal phalanx (n = 20) were most commonly seen. 35 patients underwent surgery whereas 47 were managed conservatively. Overall agreement between actual management and both consultant-1 and consultant-2 was moderate (κ = 0.55, p < 0.0001 and κ = 0.63, p < 0.0001, respectively). Subgroup analysis showed a weak agreement between actual management of metacarpal fractures and both consultant-1 and consultant-2 (κ = 0.22, p = 0.29 and κ = 0.47, p = 0.02, respectively). Inter-rater agreement was substantial for management of metacarpal fractures (κ = 0.73, p < 0.0001) whilst functional outcomes were comparable as reported by patients.

Conclusions

Our study has shown that overall management of hand fractures remained optimized throughout the pandemic. However, lack of concordance was observed in the management of metacarpals through substantial inter-rater agreement but overall poor agreement.

Discovery of a Novel Bromodomain and Extra Terminal Domain (BET) Protein Inhibitor, I-BET282E, Suitable for Clinical Progression

The functions of the bromodomain and extra terminal (BET) family of proteins have been implicated in a wide range of diseases, particularly in the oncology and immuno-inflammatory areas, and several inhibitors are under investigation in the clinic. To mitigate the risk of attrition of these compounds due to structurally related toxicity findings, additional molecules from distinct chemical series were required. Here we describe the structure- and property-based optimization of the in vivo tool molecule I-BET151 toward I-BET282E, a molecule with properties suitable for progression into clinical studies.

Structure-based optimisation of orally active & reversible MetAP-2 inhibitors maintaining a tight 'molecular budget'

Structure-based led optimisation of orally active reversible Methionine Aminopeptidase-2 (MetAP-2) inhibitors utilising a 'molecular budget' medicinal chemistry strategy is described. The key physicochemical parameters of target molecules (cLogP, molecular size and H-bond donor count) were monitored through straightforward and intuitive use of atom count and distribution. The balance between structure-based design and an awareness of the physicochemical properties of the compounds synthesised enabled the rapid identification of a potent molecule with good oral pharmacokinetic (PK) characteristics by making fewer, higher quality compounds. The resulting candidate quality molecule was validated in a mechanistic cellular assay and a rodent secondary immunisation model.

BET Inhibition Improves NASH and Liver Fibrosis

Non-alcoholic fatty liver disease (NAFLD) is a leading form of chronic liver disease with large unmet need. Non-alcoholic steatohepatitis (NASH), a progressive variant of NAFLD, can lead to fibrosis, cirrhosis, and hepatocellular carcinoma. To identify potential new therapeutics for NASH, we used a computational approach based on Connectivity Map (CMAP) analysis, which pointed us to bromodomain and extra-terminal motif (BET) inhibitors for treating NASH. To experimentally validate this hypothesis, we tested a small-molecule inhibitor of the BET family of proteins, GSK1210151A (I-BET151), in the STAM mouse NASH model at two different dosing timepoints (onset of NASH and progression to fibrosis). I-BET151 decreased the non-alcoholic fatty liver disease activity score (NAS), a clinical endpoint for assessing the severity of NASH, as well as progression of liver fibrosis and interferon-γ expression. Transcriptional characterization of these mice through RNA-sequencing was consistent with predictions from the CMAP analysis of a human NASH signature and pointed to alterations in molecular mechanisms related to interferon signaling and cholesterol biosynthesis, as well as reversal of gene expression patterns linked to fibrotic markers. Altogether, these results suggest that inhibition of BET proteins may present a novel therapeutic opportunity in the treatment of NASH and liver fibrosis.

Comparison of distal radius fracture intra-articular step reduction with volar locking plates and K wires: a retrospective review of quality and maintenance of fracture reduction

This study investigated the accuracy and maintenance of reduction of intra-articular steps achieved with closed reduction and percutaneous K wires and open reduction and a volar locking plate for the treatment of intra-articular distal radius fractures. We performed a retrospective review of 359 patients with an intra-articular fracture of their distal radius. Multivariate linear regression was undertaken to investigate the influence of multiple variables such as age, gender, initial displacement and treatment method on reduction despite differences between groups. A total of 36% of patients treated with K wires and 29% with volar locking plate had a step greater than or equal to 1 mm present on the first post-operative radiograph. A total of 23% treated with K wires and 28% with volar locking plate had a residual step of 1 mm or more on the last available radiograph. There was no difference identified between the two techniques for quality of initial reduction or persisting step on the last available radiographs. Step behaviour and further reduction of step post-operatively was similar for both treatment methods. Initial displacement and increased age influenced initial reduction. Initial fracture displacement shown radiologically was the only variable identified that influenced the persistence of a step on post-operative radiographs.

LEVEL OF EVIDENCE

IV.

In Scaphoid Non-Union, Does the Source of Graft Affect Outcome? Iliac Crest Versus Distal End of Radius Bone Graft

Iliac crest bone grafts are sometimes preferred to other bone grafts for the treatment of non-unions of fractures of the scaphoid as they are claimed to have better osteogenic potential and biomechanical properties. We retrospectively studied a consecutive cohort of 68 symptomatic established scaphoid non-unions treated by bone grafting. An iliac crest graft was used in 44 cases and a distal radius graft in the other 24. The two treatment groups were comparable in terms of location of the fracture, duration of the non-union and the fixation implants used. Overall union was achieved in 45 of the 68 patients (66%) and the union rate was not influenced by the type of bone graft used. Twenty-nine of the 44 treated with iliac crest bone graft (66%) and 16 of the 24 (67%) treated with distal radial graft united. Donor site pain over the iliac crest was present in nine of the 44 patients in this group.

Multiple Plexiform Schwannoma of the Hand and Forearm: A Long-Term Follow-Up

We present a case report to illustrate the differential diagnosis and management of a multiple plexiform schwannoma involving the main nerve trunks of the upper limb in a 4 year-old boy. The tumour was diagnosed by MRI scan and histological examination. A 12 year follow-up is presented in which, despite multiple recurrences, the condition has been controlled by surgical means and the limb salvaged.

London Trauma Conference 2015

I1: Trauma, Pre-hospital and Cardiac Arrest Care 2015

Pascale Avery, Leopold Salm, Flora Bird

A1: Retrospective evaluation of HEMS ‘Direct to CT’ protocol

Anja Hutchinson, Ashley Matthies, Anthony Hudson, Heather Jarman

A2 Rush hour – Crush hour: temporal relationship of cyclist vs. HGV trauma admissions. A single site observational study

Maria Bergman Nilsson, Tom Konig, Nigel Tai

A3 Semiprone position endotracheal intubation during continuous cardiopulmonary resuscitation in drowned children with regurgitation: a case report and experimental manikin study

Espen Fevang, Børge Hognestad, Håkon B. Abrahamsen

A4 An audit of CO2 A-a gradient in non-trauma patients receiving pre-hospital anaesthesia

Olivia V Cheetham, Matthew JC Thomas, Kieron D Rooney

A5 Can the use of c-spine immobilisation collars be avoided in non-trauma patients presenting to the Emergency Department?

Josephine Murray, Malcolm Tunnicliff

A6 Curriculum mapping in ED point of care simulation

Joseph W Collinson, Thomas Brown, Christopher Pritchett

A7 Point of care multidisciplinary trauma team simulation & participant satisfaction in a geographically remote trauma unit in Cornwall

Christopher SA Pritchett, Mark Jadav, Gareth Meredith, Jamie Plumb, Steve Harris, Roger Langford

A8 Conservative management of head injury inpatients - the challenge of simplifying injury management in a non-neurosurgical hospital

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Roberts

A9 Improving the care of traumatic brain injury at non-neurosurgical hospitals: Introducing a head injury pathway and single place of care is associated with significant improvements in neurological observation

JG Hunter, A Sage, R Madden, O Flamank, B Broadbent, S Marsh, H Lewis, E Daniels, N Lin, N Roberts

A10 The experience of inter-disciplinary students undertaking cardiac arrest moulage training

Samuel Bulford, Silas Houghton-Budd, Sam Pearson, Megan Clear-Hill

A11 Impact brain apnoea – nine cases

David J Menzies, James P Leonard, Conor Keogh, Ray Quinn, John D Hinds

A12 Time well spent? Improving the performance improvement programme in a busy Trauma Unit

N Roberts, D Ashton-Cleary, M Jadav

A14 Clinical significant and outcome of pulmonary contusions in patients with blunt chest trauma

Ismail Mahmood, Ayman El-Menyar, Basil Younis, Ahmed Khalid, Syed Nabir, Mohamed Nadeem Ahmed, Omer Al-Yahri, Hassan Al-Thani

A15 Plastics operative workload in major trauma centres: a national prospective survey

Katie Young, Susan A. Hendrickson, Georgina Phillips, Matthew D. Gardiner, Shehan Hettiaratchy

A16 A survey to assess the accuracy of estimating height by pre-hospital clinicians: can we reliably predict those most at risk of serious injury?

Alexandra Alice Crossland, Anthony Hudson

A17 An audit of the cause, outcome and adherence to treatment Standard Operating Procedure (SOP) for all traumatic cardiac arrests at a Helicopter Emergency Medical Service over a 12-month period

Nicholas C Brassington, Anthony Hudson, Emily McWhirter

A18 Should we “stay-and-play? A study of patient physiology in Norwegian Helicopter Emergency Services

Bjørn O Reid, Marius Rehn, Oddvar Uleberg, Andreas J Krüger

A19 Training in resuscitative thoracotomy: have we cracked it? A survey of higher Emergency Medicine trainees in London

Cara Jennings, Yasmin Kapadia, Duncan Bew

A20 London’s Air Ambulance (LAA): 25-years of drownings in an urban environment

Jenny Townsend, Tom P Hurst, Elizabeth A Foster

A21 Live patients in trauma simulation – more than just simulation on a shoestring?

Thomas B Brown, Joseph Collinson, Christopher Pritchett, Toby Slade

A22 Collecting core data in pre-hospital critical care using a consensus based template

Kristin Tønsager, Marius Rehn, Kjetil G.Ringdal, Andreas J.Krüger

A23 Prehospital interventions before and after implementation of a physician staffed helicopter

Rasmus Hesselfeldt, Sandra Wulffeld, Asger Sonne, Lars S. Rasmussen, Jacob Steinmetz

A24 Duration of ventilation following prehospital drug assisted intubation; a retrospective review

Thomas J Renninson, Nadine Thomson, Harvey Pynn, Timothy J Hooper

A25 Non-haemorrhagic shock in trauma: a novel guideline for management in ED

Anthony Hudson, Jacinta Dawson, Ashley Matthies

A26 Patient-tailored triage decisions by anaesthetist-staffed pre-hospital critical care teams

Morten Langfeldt Friberg, Leif Rognås

A27 Anatomical accuracy and appropriate sizing of pre-hospital thoracostomies

Jessica FG Wills, Anthony Hudson

A28 Pre-hospital management of mass casualty civilian shootings

Conor DA Turner, Marius Rehn

A30 The prevalence of alcohol-related trauma recidivism: a systematic review

James Nunn, Mete Erdogan, Robert S. Green

A31 Development of a hospital-wide program for simulation-based training in trauma care and management

Samuel Minor, Mete Erdogan, Kathy Hartlen, Robert S. Green

A32 Out of Hospital Cardiac Arrests (OOHCA); lessons from Hollywood

Ruth Bird, Rachael L. Grupping

A33 Mechanism of injury as a predictor of severity of injury in road traffic collisions: a literature review

Amelia M. Stacey, Marius Rehn, David J. Lockey

A34 Lessons to be learned from prehospital airway intervention documentation? Are airway intervention documentation templates as successful in-hospital as prehospitally?

S. Abiks, L. Cutler, K. Monaghan, A. Al-Rais, C. Hymers, R. Bloomer, Y. Kapadia

A35 Novel biomarkers in prehospital management of traumatic brain injury (the PreTBI study protocol)

Sophie-Charlott Seidenfaden, Ingunn S. Riddervold, Hans Kirkegaard, Niels Juul, Morten T. Bøtker

A36 Hospital outcomes of traumatic railway incidents: a seven-year observational retrospective study of a major trauma centre

Alice Gao, Zane Perkins; Gareth Grier, Alex Tzannes

A37 Does taking a third crew member affect the on-scene time of HEMS jobs?

Nathan Hudson-Peacock, Quentin Otto, Laurie Phillipson, Rik Thomas, Ainsley Heyworth

A38 Does pre-hospital rapid sequence induction affect on-scene time of HEMS jobs?

Quentin Otto, Nathan Hudson-Peacock, Laurie Phillipson, Ainsley Heyworth, Erica Ley

A39 Code red: shock index as a prehospital indicator of massive haemorrhage

Daniel Banner, Ainsley Heyworth, Erica Ley

A40 Air ambulance tasking: how accurate are our current methods?

Madeleine Benson, Nathan Hudson-Peacock, Tony Stone, Erica Ley, Louise Rousson, Ainsley Heyworth

A41 Modern trauma burden in a district general hospital

Beth A Lineham, Matthew J Lee, Martin Gough

A42 Establishing a legal service for major trauma patients in two UK major trauma centres

William H Seligman, Hannah E Thould, Andrew Dinsmore, Charlotte Tan, Julian Thompson, C Andy Eynon, David J Lockey

A43 Prehospital assessment and care of patients – a study of the use of guidelines when assessing head trauma

Rebecka M Rubenson Wahlin, Veronica Lindström, Sari Ponzer, Veronica Vicente

A44 An audit of pre-hospital blood pressure management resulting from head injury

Pamela Eligio, Anthony Hudson

A45 The surgical contribution of surface shading volumetric rendering techniques in rib fracture management

Robert Young, Dimitri Amiras, Ian Sinha

The discovery of I-BET726 (GSK1324726A), a potent tetrahydroquinoline ApoA1 up-regulator and selective BET bromodomain inhibitor

Through their function as epigenetic readers of the histone code, the BET family of bromodomain-containing proteins regulate expression of multiple genes of therapeutic relevance, including those involved in tumor cell growth and inflammation. BET bromodomain inhibitors have profound antiproliferative and anti-inflammatory effects which translate into efficacy in oncology and inflammation models, and the first compounds have now progressed into clinical trials. The exciting biology of the BETs has led to great interest in the discovery of novel inhibitor classes. Here we describe the identification of a novel tetrahydroquinoline series through up-regulation of apolipoprotein A1 and the optimization into potent compounds active in murine models of septic shock and neuroblastoma. At the molecular level, these effects are produced by inhibition of BET bromodomains. X-ray crystallography reveals the interactions explaining the structure-activity relationships of binding. The resulting lead molecule, I-BET726, represents a new, potent, and selective class of tetrahydroquinoline-based BET inhibitors.

Complications after volar locking plate fixation of distal radius fractures

Volar locking plates are an increasingly popular treatment for distal radius fractures. We reviewed complications observed after volar locking plate fixation in a busy teaching hospital. The purpose of the study was to assess whether complication rates after volar locking plate use in general, routine trauma practice were higher than published literature from expert users. A retrospective review was carried out of patients treated with a volar locking plate between January 2009 and December 2010. The series included 206 procedures in 204 patients (77 males and 127 females) with mean age of 55 years (range 16-94). Surgery was performed by 18 different consultant surgeons and 11 registrars. A total of 22 complications were observed in 20 patients with an overall complication rate of 9.7%. Seven (3.4%) patients developed tendon problems including four (1.9%) tendon ruptures. Four (1.9%) patients required re-operation for metalwork problems; four patients developed complex regional pain syndrome (CRPS). Three fracture reduction problems were noted. A total of 16 further operations were carried out for complications. The overall complication rate was low even when surgery was done by many surgeons, suggesting that this is a safe and reproducible technique. This study provides information which can be used to counsel patients about risks, including those of tendon and metalwork problems. This allows patients to make an informed decision. Surgeons must have specific strategies to avoid these complications and remain vigilant so that these can be identified and managed early.

Influence of coincident distal radius fracture in patients with hip fracture: single-centre series and meta-analysis

Background

Hip and wrist fractures are the most common orthopaedic injuries. Combined hip and distal radius fractures are an important clinical and public health problem, since mobilisation and rehabilitation is challenging and likely to be prolonged in this setting. Few studies have explored the influence of an associated wrist fracture in patients with hip fracture. We present the largest series of patients with concomitant hip and wrist fractures. We perform the first meta-analysis of the literature on patients with concurrent hip and wrist fractures.

Material and methods

In this single-centre retrospective study we compared 88 consecutive patients with simultaneous hip and wrist fractures with 772 consecutive patients who suffered isolated hip fractures.

Results

Patients with the combined fracture were of a similar age compared to those with isolated hip fracture. There were a significantly higher proportion of women in the cohort with both hip and wrist fractures (female:male ratio of 9:1 versus 4:1 p < 0.0001). The combination fracture group had a greater length of hospitalisation (18 vs 13 days p < 0.0001). The survivorship of both groups was not significantly different even after adjustment for age and gender. Meta-analysis of the literature showed female preponderance, increased length of stay but no significant difference in survival in patients with concomitant hip and wrist fractures.

Conclusion

The combination fracture occurs much more commonly in women and patients require a greater length of hospitalisation. The patients who sustained simultaneous hip and wrist fractures experienced no statistically significant difference in survivorship when compared to those who suffer isolated hip fractures. This is not withstanding the presence of two fractures. This difference in mortality did not reach statistical significance.

Level of evidence

Level III (retrospective comparative study).

Discovery of epigenetic regulator I-BET762: lead optimization to afford a clinical candidate inhibitor of the BET bromodomains

The bromo and extra C-terminal domain (BET) family of bromodomains are involved in binding epigenetic marks on histone proteins, more specifically acetylated lysine residues. This paper describes the discovery and structure-activity relationships (SAR) of potent benzodiazepine inhibitors that disrupt the function of the BET family of bromodomains (BRD2, BRD3, and BRD4). This work has yielded a potent, selective compound I-BET762 that is now under evaluation in a phase I/II clinical trial for nuclear protein in testis (NUT) midline carcinoma and other cancers.

Identification of a series of 1,3,4-oxadiazol-2-amines as potent alpha-7 agonists with efficacy in the novel object recognition model of cognition

A series of α7 nicotinic acetylcholine receptor full-agonists with a 1,3,4-oxadiazol-2-amine core has been discovered. Systematic exploration of the structure-activity relationships for both α7 potency and selectivity with respect to interaction with the hERG channel are described. Further profiling led to the identification of compound 22, a potent full agonist showing efficacy in the novel object recognition model of cognition enhancement.

Inhibition of colonic motility and defecation by RS-127445 suggests an involvement of the 5-HT2B receptor in rodent large bowel physiology

BACKGROUND

5-HT(2B) receptors are localized within the myenteric nervous system, but their functions on motor/sensory neurons are unclear. To explore the role of these receptors, we further characterized the 5-HT(2B) receptor antagonist RS-127445 and studied its effects on peristalsis and defecation.

EXPERIMENTAL APPROACH

Although reported as a selective 5-HT(2B) receptor antagonist, any interactions of RS-127445 with 5-HT(4) receptors are unknown; this was examined using the recombinant receptor and Biomolecular Interaction Detection technology. Mouse isolated colon was mounted in tissue baths for isometric recording of neuronal contractions evoked by electrical field stimulation (EFS), or under an intraluminal pressure gradient to induce peristalsis; the effects of RS-127445 on EFS-induced and on peristaltic contractions were measured. Faecal output of rats in grid-bottom cages was measured over 3 h following i.p. RS-127445 and separately, validation of the effective doses was achieved by determining the free, unbound fraction of RS-127445 in blood and brain.

KEY RESULTS

RS-127445 (up to 1 micromol x L(-1)) did not interact with the 5-HT(4) receptor. RS-127445 (0.001-1 micromol x L(-1)) did not affect EFS-induced contractions of the colon, although at 10 micromol x L(-1) the contractions were reduced (to 36 +/- 8% of control, n= 4). RS-127445 (0.1-10 micromol x L(-1)) concentration-dependently reduced peristaltic frequency (n= 4). RS-127445 (1-30 mg x kg(-1)), dose-dependently reduced faecal output, reaching significance at 10 and 30 mg x kg(-1) (n= 6-11). In blood and brain, >98% of RS-127445 was protein-bound.

CONCLUSIONS AND IMPLICATIONS

High-protein binding of RS-127445 indicates that relatively high doses are required for efficacy. The results suggest that 5-HT(2B) receptors tonically regulate colonic motility.

The factors affecting outcome after non-vascular bone grafting and internal fixation for nonunion of the scaphoid

This study identified variables which influence the outcome of surgical management on 126 ununited scaphoid fractures managed by internal fixation and non-vascular bone grafting. The site of fracture was defined by a new method: the ratio of the length of the proximal fragment to the sum of the lengths of both fragments, calculated using specific views in the plain radiographs. Bone healing occurred in 71% (89) of cases. Only the site of nonunion (p = 1 × 10−6) and the delay to surgery (p = 0.001) remained significant on multivariate analysis. The effect of surgical delay on the probability of union increased as the fracture site moved proximally. A prediction model was produced by stepwise logistic regression analysis, enabling the surgeon to predict the success of surgery where the site of the nonunion and delay to surgery is known.

Oral administration of a potent and selective non-peptidic BACE-1 inhibitor decreases beta-cleavage of amyloid precursor protein and amyloid-beta production in vivo

Generation and deposition of the amyloid beta (Abeta) peptide following proteolytic processing of the amyloid precursor protein (APP) by BACE-1 and gamma-secretase is central to the aetiology of Alzheimer's disease. Consequently, inhibition of BACE-1, a rate-limiting enzyme in the production of Abeta, is an attractive therapeutic approach for the treatment of Alzheimer's disease. We have designed a selective non-peptidic BACE-1 inhibitor, GSK188909, that potently inhibits beta-cleavage of APP and reduces levels of secreted and intracellular Abeta in SHSY5Y cells expressing APP. In addition, we demonstrate that this compound can effectively lower brain Abeta in vivo. In APP transgenic mice, acute oral administration of GSK188909 in the presence of a p-glycoprotein inhibitor to markedly enhance the exposure of GSK188909 in the brain decreases beta-cleavage of APP and results in a significant reduction in the level of Abeta40 and Abeta42 in the brain. Encouragingly, subchronic dosing of GSK188909 in the absence of a p-glycoprotein inhibitor also lowers brain Abeta. This pivotal first report of central Abeta lowering, following oral administration of a BACE-1 inhibitor, supports the development of BACE-1 inhibitors for the treatment of Alzheimer's disease.

Development of a P-glycoprotein knockout model in rodents to define species differences in its functional effect at the blood-brain barrier

The objective of this study was to establish the optimal blood concentrations of the potent P-glycoprotein (P-gp) inhibitor GF120918 (Elacridar) required to achieve maximal knockout of this efflux transporter in the blood-brain barrier (BBB) of mice, rats, and guinea pigs. Genetic mdr1a/b(-/-) knockout mice and "chemical" P-gp knockout mice, rats, and guinea pigs, generated by 24 h continuous infusion of GF120918, were used to investigate the effects of P-gp modulation on the brain penetration of SB-487946. Genetic mdr1a/b(-/-) knockout mice demonstrated a >70-fold increase in brain:blood ratio of SB-487946 compared to mdr1a/b(+/+) wild-type mice. There was a similar increase in SB-487946 brain:blood ratio in GF120918-treated mice (ca. >67-fold) and rats (ca. 95-fold) but a significantly smaller increase (ca. 10-fold) in guinea pigs treated with GF120918. An appreciable difference was found in the BBB functional effect of P-gp efflux in rodents. GF120918 blood EC90 in mice and rats were similar however, the EC90 in guinea pigs was ca. 10-fold higher, suggesting a species difference in the activity of P-gp at the BBB in some rodents. This study establishes the optimal blood concentrations of GF120918 in relation to SB-487946, to achieve chemically induced P-gp knockout in rodents.

8-Piperazinyl-2,3-dihydropyrrolo[3,2-g]isoquinolines: potent, selective, orally bioavailable 5-HT1 receptor ligands

The novel 8-piperazinyl-2,3-dihydropyrroloisoquinoline template was synthesized in nine steps. The template was N-substituted to give a series of compounds showing binding to human cloned 5-HT1A, 5-HT1B and 5-HT1D receptors with pKi's greater than 9 and selectivities up to 1000-fold against other serotonin, dopamine and adrenergic receptors. Several compounds were shown to possess weak partial agonist activity in cloned receptors, which translated to antagonism in in vitro studies.

Improving the in vitro prediction of in vivo central nervous system penetration: integrating permeability, P-glycoprotein efflux, and free fractions in blood and brain

This work examines the inter-relationship between the unbound drug fractions in blood and brain homogenate, passive membrane permeability, P-glycoprotein (Pgp) efflux ratio, and log octanol/water partition coefficients (cLogP) in determining the extent of central nervous system (CNS) penetration observed in vivo. The present results demonstrate that compounds often considered to be Pgp substrates in rodents (efflux ratio greater than 5 in multidrug resistant Madin-Darby canine kidney cells) with poor passive permeability may still exhibit reasonable CNS penetration in vivo; i.e., where the unbound fractions and nonspecific tissue binding act as a compensating force. In these instances, the efflux ratio and in vitro blood-brain partition ratio may be used to predict the in vivo blood-brain ratio. This relationship may be extended to account for the differences in CNS penetration observed in vivo between mdr1a/b wild type and knockout mice. In some instances, cross-species differences that might initially seem to be related to differing transporter expression can be rationalized from knowledge of unbound fractions alone. The results presented in this article suggest that the information exists to provide a coherent picture of the nature of CNS penetration in the drug discovery setting, allowing the focus to be shifted away from understanding CNS penetration toward the more important aspect of understanding CNS efficacy.

Scaphoid non-union: the role of vascularized grafting in recalcitrant non-unions of the scaphoid

Achieving union using conventional grafts has a high chance of failure in patients with recalcitrant non-union (persistent pseudarthrosis) of the scaphoid bone, an avascular proximal fragment and previous failed surgeries because of poor host bed vascularity. Eleven patients with long-standing non-union were treated with vascularized pedicle bone grafting and supplementary corticocancellous grafting. Five had screw fixation and six were fixed with K-wires. The average age of the patients was 28 years, average duration of the non-union was 39 months and mean radiological follow-up was 32 months. There were no significant skeletal complications, although two patients developed neuromata. At review, only six of the 11 non-unions were united. Whilst this is a difficult clinical problem and achieving union is a formidable challenge, we believe that there is a role for such extensive surgery in order to achieve good postoperative function.

Assessment of the severity of hand injuries using "hand injury severity score", and its correlation with the functional outcome

INTRODUCTION

Objective assessment of hand injuries is a complex subject. However, an objective assessment, leading to a score, can help in predicting outcome and can be used as a research tool. Campbell and Kay have devised one such score known as "hand injury severity score" or HISS [J. Hand. Surg. [Br.] 21 (3) (1996) 295]. A study on this score has been carried out in our institute. The idea was to see if the hand injury severity score, correlates with the functional outcome as measured by disability arm shoulder and hand score (DASH), after a period of minimum 2 years.

METHOD

All the hand injury patients admitted in the hospital were assessed at the time of admission, and objective information was documented on a hand injury documentation form. The form captured all the data required to calculate "hand injury severity score" . A sample of 70 patients admitted during the first 6 months of 1999 was taken and their scores were calculated. The sample was selected such, that it had a reasonable representation of hand injuries of all severities. After obtaining a due approval from ethics committee, all these 70 patients were sent a DASH questionnaire. A total of 23 patients replied. Spearman's rank correlation test was used to analyse the correlation between the severity of hand injury as assessed using HISS, and functional outcome as measured using DASH. Correlations between the outcome and skeletal component score, outcome and motor component scores, and outcome and Integument component scores, were assessed separately.

RESULTS

The study shows a statistically significant association ( r = 0.7182, P = 0.000165) between the severities of injury and the functional outcome. The functional outcome also shows a statistically significant association with the severity of injury to skeletal component (r = 0.5151, P = 0.014083) and motor component (r = 0.6797, P = 0.000507). However, the severity of injury to integument component, as measured by HISS, does not show any association with the outcome (r = 0.3571, P = 0.102736). This study supports the overall structure of the HISS. However an improvement in the integument component scoring is required to improve overall accuracy.

Do CT scans aid assessment of distal tibial physeal fractures?

Distal tibial physeal fractures are the second most common growth plate injury and the most common cause of growth arrest and deformity. This study assesses the accuracy of pre-operative planning for placement of the screws in these fractures using either standard radiographs or CT scans. We studied 62 consecutive physeal fractures over a period of four years. An outline of a single cut of the CT scan was used for each patient. An ideal position for the screw was determined as being perpendicular to and at the midpoint of the fracture. The difference in entry point and direction of the screw between the ideal and the observers' assessments were compared using the paired Student's t-test. There was a statistically significant improvement (p < 0.0001) in the accuracy of the point of insertion and the direction of the screw on the pre-operative plan when CT scans were used rather than plain radiographs. We would, therefore, recommend that CT scans are routinely used in the pre-operative assessment and treatment of distal tibial physeal fractures.

Complex fractures, do we operate on enough to gain and maintain experience?

Complex fractures are generally assumed by our profession to require adequate training and continuing practice to treat optimally. The quantity of complex fractures treated in individual hospitals and by or under the care of individual orthopaedic consultants may have implications regarding the quality of care for particular patients and also for the training of specialist registrars.A complex fracture was defined as a comminuted peri- or intra-articular fracture or segmental shaft fracture: fractures acknowledged at specialist fracture courses and by special trauma surgeons to require particular training and experience to treat optimally. The AO classification was used: most fractures were in AO groups B and C [M.E. Muller, S. Narazian, P. Koch, J. Schatzker, The Comprehensive Classification of Longbones, Springer, Berlin, 1990]. Theatre records were used to identify all operated orthopaedic trauma cases over a period of 1 year in one District General Hospital (DGH) and one University Hospital, each serving populations of over 300000 and for 6 months in one DGH (population approximately 300000). Radiographs and hospital records were reviewed by two orthopaedic surgeons and the number and type of complex fractures documented as defined above. In hospital A, 69 complex fracture operations were carried out under the care of six consultants in 12 months. In hospital B, 24 complex fractures were treated by five consultants over a 6-month period and in hospital C, 127 complex fractures were treated by 10 consultants over a 12-month period. Some consultants (different consultants for different fracture regions) did not operate on any complex fracture of the proximal, mid, or distal humerus; proximal, mid, or distal radius or ulna; proximal, mid, or distal femur; proximal, mid, or distal tibia; calcaneum; peri-prosthetic; Lisfranc; or talus fracture during the specific time period. Some consultants only treated one or two such fractures. Where two surgeons had developed an area of special interest and cross-referral were encouraged individual surgeons were operating on up to 25 complex cases in their area of interest.This audit has shown that individual complex fractures present infrequently to particular hospitals and surgeons. This finding raises questions about the optimal management of such fractures: are we maintaining a sufficient level of expertise, or should there be more cross-referrals to surgeons with a specific interest either in trauma or in a particular anatomical region?

Pharmacokinetics of the novel, high-affinity and selective dopamine D3 receptor antagonist SB-277011 in rat, dog and monkey: in vitro/in vivo correlation and the role of aldehyde oxidase

1. In vitro studies with the selective dopamine D3 receptor antagonist SB-277011 were conducted in liver microsomes and homogenates from rat, dog, cynomolgus monkey and human to correlate the rate of metabolism with the in vivo pharmacokinetics of the compound in rat, dog and cynomolgus monkey. 2. In the presence of NADPH, SB-277011 was relatively stable in the presence of liver microsomes from rat, dog, cynomolgus monkey and human with an intrinsic clearance (CLi) of < 2 ml min(-1) g(-1) liver for all species. In total liver homogenates, SB-277011 was metabolized at a similar rate in rat and dog (CLi < 2 ml min(-1) g(-1) liver) to that in liver microsomes but in cynomolgus monkey and human (CLi = 9.9 and 45 ml min(-1) g(-1) liver, respectively) the intrinsic clearance was approximately 6- and 35-fold higher, respectively, than that in liver microsomes. 3. In the absence of NADPH, SR-277011 was rapidly cleared in liver homogenates from cynomolgus monkey and human (CLi = 7.4 and 27 ml min(-1) g(-1) liver, respectively) demonstrating that a significant pathway of metabolism of this compound was via an NADPH-independent non-microsomal oxidative route. This pathway was sensitive to inhibition with isovanillin suggesting that the enzyme responsible was aldehyde oxidase. 4. The in vivo pharmacokinetics showed that the plasma clearance of SB-277011 was low in rat (20 ml min(-1) kg(-1)), moderate in dog (14 ml min(-1) kg(-1)) and high in cynomolgus monkey (58 ml min(-1)kg(-1)), which is consistent with the in vitro findings and demonstrated a greater capacity for the monkey to metabolize this compound. The oral bioavailability of SB-277011 in rat, dog and cynomolgus monkey was 35, 43 and 2%, respectively. Given the high clearance of this compound in cynomolgus monkey, the low oral bioavailability is probably as a result of high first-pass elimination, specifically by aldehyde oxidase, rather than poor absorption. 5. The high in vitro clearance of SB-277011 in human liver homogenates and the involvement of aldehyde oxidase in the metabolism of SB-277011 indicates that the bioavailability of the compound is likely to be low in human.

Orexin-A, an hypothalamic peptide with analgesic properties

The hypothalamic peptide orexin-A and the orexin-1 receptor are localized in areas of the brain and spinal cord associated with nociceptive processing. In the present study, localization was confirmed in the spinal cord and demonstrated in the dorsal root ganglion for both orexin-A and the orexin-1 receptor. The link with nociception was extended when orexin-A was shown to be analgesic when given i.v. but not s.c. in mouse and rat models of nociception and hyperalgesia. The efficacy of orexin-A was similar to that of morphine in the 50 degrees C hotplate test and the carrageenan-induced thermal hyperalgesia test. However, involvement of the opiate system in these effects was ruled out as they were blocked by the orexin-1 receptor antagonist SB-334867 but not naloxone. Orexin-1 receptor antagonists had no effect in acute nociceptive tests but under particular inflammatory conditions were pro-hyperalgesic, suggesting a tonic inhibitory orexin drive in these circumstances. These data demonstrate that the orexinergic system has a potential role in the modulation of nociceptive transmission.

Patient satisfaction with pre-operative analgesia in acute trauma

We performed a prospective study of 100 consecutive patients admitted to the Orthopaedic and Trauma Unit at the North Staffordshire Royal Infirmary following acute injury. We assessed the patient's level of pain and perception of pain relief in the period from their admission to hospital and surgery, or the first 24 hours as an inpatient using a questionnaire. We found that 54% of patients described their pain as 'severe' or 'the worst possible pain'. Significantly, 36% of patients would have liked more analgesia. We conclude that patients are not receiving the analgesia they require following acute injury.

The diagnostic domain of nursing

An initial reflective paper on the issue of nurses diagnosing medical problems was the origin of this debate (Cutler, 2000). A commentary on this paper (Johns, 2000) was published and raises some interesting questions for consideration. This paper offers a brief response to and consideration of the questions and issues raised in Johns' (2000) commentary. Further wider debate is encouraged.

Reflection on diagnosing as a nurse in ITU

Brookfield's (1995) four critically reflective lenses are adapted from teaching and applied to nursing within this article. The lenses are used as a framework for exploring the author's feelings associated with diagnosing a life-threatening problem in intensive care in the presence of a disagreeing doctor. The issues surrounding the distinctions between medicine and nursing are explored. Wellington and Austin's (1996) five orientations to reflection provide the framework for the author's 'metacognition'--his thoughts about his thoughts. These are communicated by way of a critical commentary.

The problems inherent in promoting research-based practice and strategies by which they might be overcome

The historical and contemporary impetus for research in nursing is presented in brief. The factors affecting research use in practice are numerous and complicated and include political, financial, ideological and professional spheres. Various strategies that may enhance research use in practice have been suggested and evaluated and these are discussed.

Reducing relocation stress after discharge from the intensive therapy unit

Moving from the intensive therapy unit (ITU) to the ward environment can be a very stressful experience for patients. Nursing interventions can help to reduce the stress associated with this experience and help each patient to cope with it. The factors which cause relocation stress are discussed along with a strategy employed clinically to reduce or prevent this problem in patients after discharge from an ITU.

Additional validity evidence for the Harder Personal Feelings Questionnaire-2 (PFQ2): a measure of shame and guilt proneness

The present study sought to provide additional evidence for the construct validity of the Harder (Harder & Zalma, 1990) Personal Feelings Questionnaire-2 (PFQ2), a recently revised measure of shame and guilt proneness. Seventy university students, 35 male and 35 female, completed the PFQ2 and scales that assess self-derogation, instability of self-concept, shyness, social anxiety, public self-consciousness, private self-consciousness, and locus of control. The correlation results were generally consistent with validity predictions. As in previous studies, however, the discriminant validity of the shame and guilt scales was supported, but not strongly.

Assessment of shame and guilt and their relationships to psychopathology

Two studies are reported. First, we tested the previously validated Personal Feelings Questionnaire-2 (PFQ2; Harder & Zalma, 1990) shame and guilt measure and the Adapted Shame and Guilt Scale (ASGS; Hoblitzelle, 1982) Shame subscale against the newly introduced Self-Conscious Affect and Attribution Inventory (SCAAI; Tangney, 1990) for shame and guilt dispositions. Fifty-nine college undergraduates completed randomly ordered personality inventories reflecting constructs theoretically relevant to the presence of shame and guilt proneness. Correlations between the affect measures and personality variables showed evidence of validity for all shame scales. The PFQ2 Guilt subscale also demonstrated construct validity when partialled for shame, but the SCAAI did not. Second, we tested hypotheses regarding the relative importance of shame and guilt to various symptom types (Symptom Checklist-90-Revised; Derogatis, 1983) using 71 college undergraduates. Both emotions were approximately equally related to all major symptom clusters, but there was some evidence for differential patterns of relative importance for shame and guilt to different symptoms.

Ultrastructural and cytochemical evidence for single impulse initiation zones in vestibular macular nerve fibers of rat

Cupric ion-ferricyanide labeling methods and related ferrocyanide-stained tissues were used to locate and characterize, at the ultrastructural level, presumptive impulse initiation zones in the three types of vestibular macular nerve fibers. Large-diameter, M-type vestibular nerve fibers terminate in a calyx at the heminode, and labeling is coextensive with the base of the calyx. Intermediate, M/U-type nerve fibers have short, unmyelinated preterminal segments that sometimes bifurcate intramacularly, and small-diameter, U-type nerve fibers have long, unmyelinated preterminal axons and up to three branches. Preterminals of these nerve fibers display ultrastructural heterogeneity that is correlated with labeling patterns for sodium channels and/or associated polyanionic sites. They have a nodelike ultrastructure and label heavily from near the heminode to the base of the macula. Their intramacular branches, less organized ultrastructurally, label only slightly. Results indicate that vestibular nerve fibers have one impulse initiation zone, located near the heminode, that varies in length according to nerve fiber type. Structural heterogeneity may favor impulse conduction in the central direction, and length of the impulse initiation zone could influence nerve discharge patterns.

3-D components of a biological neural network visualized in computer generated imagery. II. Macular neural network organization

Computer-assisted reconstructions of small parts of the macular neural network show how the nerve terminals and receptive fields are organized in 3-dimensional space. This biological neural network is anatomically organized for parallel distributed processing of information. Processing appears to be more complex than in computer-based neural networks, because spatiotemporal factors figure into synaptic weighting. Serial reconstruction data show anatomical arrangements which suggest that 1) assemblies of cells analyse and distribute information with inbuilt redundancy, to improve reliability; 2) feedforward/feedback loops provide the capacity for presynaptic modulation of output during processing; 3) constrained randomness in connectivities contributes to adaptability; and 4) local variations in network complexity permit differing analyses of incoming signals to take place simultaneously. The last inference suggests that there may be segregation of information flow to central stations subserving particular functions.

3-D components of a biological neural network visualized in computer generated imagery. I. Macular receptive field organization

Computer-assisted, 3-dimensional reconstructions of macular receptive fields and of their linkages into a neural network have revealed new information about macular functional organization. Both type I and type II hair cells are included in the receptive fields. The fields are rounded, oblong, or elongated, but gradations between categories are common. Cell polarizations are divergent. Morphologically, each calyx of oblong and elongated fields appears to be an information processing site. Intrinsic modulation of information processing is extensive and varies with the kind of field. Each reconstructed field differs in detail from every other, suggesting that an element of randomness is introduced developmentally and contributes to endorgan adaptability.

Total complement activity in maternal sera, amniotic fluids and cord sera in women with premature labor, premature rupture of membranes or chorioamnionitis

Total hemolytic complement activity (CH50) was determined in maternal sera, amniotic fluids or cord sera, or all, from 119 patients with preterm uterine contractions, premature rupture of membranes or chorioamnionitis, or all, at 24 to 40 weeks of gestation. The mean CH50 of maternal sera exceeded the mean CH50 of both amniotic fluids and cord sera. The mean CH50 of amniotic fluids exceeded that of cord sera and increased significantly at 32 weeks. This rise preceded that of the mean CH50 of cord sera, which occurred at a fetal weight of approximately 2,500 grams. The mean CH50 of amniotic fluids varied significantly and inversely with that of cord sera. The levels of CH50 in these three fluids did not distinguish between patients with preterm uterine contractions who delivered prematurely and those who delivered at term. The CH50 in patients with premature rupture of membranes did not differ from a control population of women with uncomplicated pregnancies. The mean CH50 of maternal sera was increased in patients with chorioamnionitis but was not predictive of chorioamnionitis. The mean CH50 of maternal sera was decreased in patients who smoked cigarettes and in patients who received intravenous ritodrine.