Parents' experiences of life after medicalised conception: a thematic meta-synthesis of the qualitative literature

BACKGROUND

Medicalised Conception (MAC) assists many couples to achieve pregnancy worldwide. As the impact of MAC has been linked to increased pregnancy-specific anxiety and parenting difficulties, this review aimed to explore parental experiences of pregnancy and early parenting following MAC, identifying parents' psychological, social and health needs.

METHOD

Five databases were searched systematically from inception to March 2023. Identified articles were screened for eligibility against the inclusion criteria and the results were analysed using thematic synthesis. The Critical Appraisal Skills checklist was employed to appraise methodological quality.

RESULTS

Twenty qualitative studies, drawing on a total of 19 participant samples, were included in this review, most with samples with history of subfertility. The findings were synthesised into three main themes (consisting of seven subthemes): 1) The vulnerable parent: fear, doubt, uncertainty, 2) the stark realisation of the parental dream, 3) psychosocial needs and support. Parents lacked a sense of safety during pregnancy and reported acting protectively both antenatally and postnatally. Furthermore, their identity transition was complex and non-linear, influenced by sociocultural context.

CONCLUSIONS

Considerable unmet psychosocial needs were identified including the potential for anxiety in pregnancy, the possibility of feeling excluded and marginalised, and a reluctance to share distress and experiences with healthcare professionals. These findings suggest a need for consistent, holistic care, integrating psychological services.

Pretreatment with metformin reduced dendritic spine loss following cardiac ischaemia/reperfusion injury by preventing amyloid beta aggregation, brain inflammation and mitochondrial dysfunction

Background

Cognitive impairment is a major complication following acute myocardial infarction (AMI). Although reperfusion therapy is a standard treatment for AMI, it leads to additional damage to the heart, known as cardiac ischaemia/reperfusion (I/R) injury. In addition to cardiac damage, brain damage was observed following cardiac I/R including brain mitochondrial dysfunction, brain inflammation, amyloid beta aggregation, resulting in dendritic spine loss. Metformin has been reported as an effective neuroprotective agent in several brain pathologies such as stroke, diabetes-related cognitive decline, and cerebral I/R injury. However, the effects of metformin on the brain pathology after cardiac I/R have not been investigated.

Purpose

We hypothesized that metformin attenuates brain damages and increases dendritic spine density by preventing brain mitochondrial dysfunction, brain inflammation, and amyloid beta aggregation in non-diabetic rats.

Methods

Male Wistar rats (n=30) were received either sham operation (n=6) or cardiac I/R operation (n=24). Cardiac I/R was done by left anterior descending coronary artery ligation for 30 min followed by a reperfusion for 120 min. In cardiac I/R group, rats were randomly divided into 4 interventions (n=6/group) as follows; 1) vehicle (a normal saline solution), 2) 100 mg/kg of metformin (Met 100), 3) 200 mg/kg of metformin (Met 200), and 4) 400 mg/kg of metformin (Met 400). Sham operated rats were received normal saline solution. Metformin or vehicle was given to the rats at 15 min prior to cardiac ischemia via intravenous injection. At the end of reperfusion, rats were sacrificed, and the brain was rapidly removed to determine brain mitochondrial function, microglial morphology, Alzheimer's related protein, and dendritic spine density.

Results

Cardiac I/R led to brain mitochondrial dysfunction as indicated by increasing reactive oxygen species (ROS) levels, mitochondrial membrane depolarization, and mitochondrial swelling, compared with sham. Moreover, microglial hyperactivity was observed, together with tau hyperphosphorylation and amyloid beta aggregation, compared with sham (Fig. 1). All dosages of metformin successfully activated AMPK at the similar levels, compared with vehicle group. Mitochondrial ROS and membrane potential changes were equally improved in all groups of metformin, compared with vehicle. Although mitochondrial swelling was reduced in all groups of metformin, it was markedly reduced in Met 400 group (Fig. 1). Furthermore, microglial hyperactivity, amyloid beta aggregation, and tau hyperphosphorylation were equally reduced in all groups of metformin. For dendritic spine density, metformin significantly increased dendritic spine density, and the density was highest in Met400 group, compared with other groups (Fig. 1).

Conclusion

Pretreatment with metformin offers neuroprotection against the brain damages following cardiac I/R injury in a dose-dependent manner.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Thailand Research Fund (SCC), and National Science and Technology Development Agency Thailand (NC)

Metformin exerts cardioprotection via attenuating mitochondrial fission in cardiac ischaemia-reperfusion injury in rats

Background

Cardiac ischemia/reperfusion (I/R) injury following myocardial infarction reperfusion therapy is a phenomenon that results in further cardiomyocytes death and impaired cardiac contractility. Although metformin has been shown to exert cardioprotection in addition to glycemic control, its effect on cardiac I/R injury are still controversy, and the comparative doses of metformin in cardiac I/R injury have never been investigated.

Purpose

We hypothesized that metformin given acutely prior to cardiac ischaemia exerts cardioprotection in rats with cardiac I/R injury via attenuating cardiac mitochondrial dysfunction, leading to improved left ventricular (LV) function.

Methods

Forty Male Wistar rats were subjected to cardiac I/R injury. Four treatment groups were investigated. The first group received saline as a control group. The second to the fourth groups received metformin at 100, 200, and 400 mg/kg intravenously, respectively. During the I/R protocols, the LV function, arrhythmia score, and mortality rate were determined. At the end, the hearts were rapidly removed to determine infarct size, cardiac mitochondrial function, cardiac mitochondrial dynamics, and cardiac apoptosis.

Results

Metformin 200 mg/kg exerted the highest level of cardioprotection through the attenuated incidence of arrhythmia, decreased infarct size (Fig. 1), improved cardiac mitochondrial function, and decreased mitochondrial fission (Fig. 1) and cardiac apoptotic markers, leading to improved cardiac function during I/R injury. Although Metformin at all doses effectively decreased infarct size, improved cardiac mitochondrial function and LV function, Metformin at 200 mg/kg exerted the best efficacy (Fig. 1).

Conclusions

Metformin exerts cardioprotection by attenuating mitochondrial dysfunction and decreased mitochondrial fission, leading to decreased infarct size and ultimately improved LV function after acute cardiac I/R injury in rats. These findings also indicate the potential biphasic effects of metformin on infarct size which are dose-dependent.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Science and Technology Development Agency Thailand (NC), and Thailand Research Fund (SCC)

Pre-Hospital Fast Positive Cases Identified by DFB Ambulance Paramedics: Final Clinical Diagnosis

Ischaemic stroke clinical outcomes are improved by earlier treatment with intravenous thrombolysis. An existing pathway at the Mater University Hospital for assessment of suspected acute stroke in the Emergency Department was updated, aiming to shorten door-to-needle time. This study examines the final clinical diagnosis of Dublin Fire Brigade Ambulance Paramedic identified Face-Arm-Speech-Test (FAST) positive patients presenting to the Emergency Department over a 7 month period. A retrospective analysis was carried out of 177 consecutive FAST positive patients presenting between March and November 2014. The final clinical diagnosis was acute stroke in 57.1% (n=101) of patients. Of these, 76 were ischaemic strokes of whom 56.5% (n=43) were thrombolysed. In the pre-hospital setting Ambulance Paramedics can identify, with reasonable accuracy, acute stroke using the FAST test. Over half of the ischaemic stroke patients presenting via this pathway can be treated with intravenous thrombolysis.

Synchronous breast and colon cancer: factors determining treatment strategy

A 67-year-old woman presented with synchronous breast and colonic tumours, in the absence of family history. Following multidisciplinary discussion, the patient was started on endocrine therapy for breast cancer. Initial surgical management consisted of right hemicolectomy together with segmental resection of a serosal deposit adherent to the distal ileum, for a moderately differentiated pT4NO caecal carcinoma. Three months later, right mastectomy and axillary clearance confirmed node positive invasive ductal carcinoma. The original treatment plan was to prioritise adjuvant chemotherapy for breast cancer postmastectomy. However, the subsequent CT finding of an enlarged, suspicious mesenteric lymph node mass on repeat staging raised concern regarding its origin. Image-guided biopsy revealed metastatic colonic adenocarcinoma and the patient was switched to a colon cancer chemotherapy regime. Following adjuvant chemotherapy for colonic carcinoma, an en-bloc surgical resection of the enlarging metastatic nodal mass was performed with clear resection margins. The patient is currently asymptomatic.

Chorionic plate arterial function is altered in maternal obesity

Objectives

To characterise Chorionic Plate Artery (CPA) function in maternal obesity, and investigate whether leptin exposure reproduces the obese CPA phenotype in normal-BMI women.

Study design

CPA responses to the thromboxane-A₂ mimetic U46619 (pre/post leptin incubation), to the nitric oxide donor sodium nitroprusside (SNP) and the occurrence of tone oscillations (pre/post leptin incubation) were assessed in 46 term placentas from women of normal (18.5–24.9) or obese (>30) Body Mass Index (BMI).

Outcome measures

Area Under the dose response Curve (AUC), maximum response (V_max), sensitivity (EC₅₀) to U46619 (pre/post leptin) and SNP; average vessel tone, oscillation amplitude and frequency (pre/post leptin).

Results

U46619 vasoconstriction was similar between BMI categories (p > 0.05), however vasodilatation to SNP was reduced in obesity (AUC p = 0.02, V_maxp = 0.04) compared to normal-BMI women. Leptin incubation altered responses to U46619 in both normal-BMI (EC₅₀ at 100 ng/ml leptin; p < 0.05) and obese women (AUC at 50 ng/ml; p < 0.05) but vasomotion was unaffected (p > 0.05).

Conclusions

Maternal obesity is associated with altered placental vascular function which may adversely affect placental oxygen and nutrient transport, placing the fetus at risk. Leptin incubation altered CPA vascular function but did not reproduce the obese phenotype.

Relative quantification: characterization of bias, variability and fold changes in mass spectrometry data from iTRAQ-labeled peptides

Shotgun proteomics via mass spectrometry (MS) is a powerful technology for biomarker discovery that has the potential to lead to noninvasive disease screening mechanisms. Successful application of MS-based proteomics technologies for biomarker discovery requires accurate expectations of bias, reproducibility, variance, and the true detectable differences in platforms chosen for analyses. Characterization of the variability inherent in MS assays is vital and should affect interpretation of measurements of observed differences in biological samples. Here we describe observed biases, variance structure, and the ability to detect known differences in spike-in data sets for which true relative abundance among defined samples were known and were subsequently measured with the iTRAQ technology on two MS platforms. Global biases were observed within these data sets. Measured variability was a function of mean abundance. Fold changes were biased toward the null and variance of a fold change was a function of protein mass and abundance. The information presented herein will be valuable for experimental design and analysis of the resulting data.

Lobe-specific proteome changes in the dorsal-lateral and ventral prostate of TRAMP mice versus wild-type mice

The transgenic adenocarcinoma of mouse prostate (TRAMP) is the most widely used transgenic model for prostate cancer chemoprevention studies. Although two lobe-specific lineages of carcinogenesis have been described, the molecular mechanisms are still poorly defined. Here, we concurrently profiled the proteome of dorsal-lateral (DLP) and ventral (VP) prostate lobes of both TRAMP and littermate WT C57BL/6 mice of 18 wk by 2-D LC-MALDI-TOF/TOF with iTRAQ labeling. A total of 483 and 748 proteins were identified at critical false discovery rates of 1 and 5%. In WT mice, 84 proteins were found to have different expression levels between DLP and VP. In TRAMP mice, 118 proteins significantly changed in DLP and/or VP during TRAMP carcinogenesis. Among them, 55 and 36 proteins were uniquely changed in DLP or VP lobe, respectively, and 27 proteins in both DLP and LP lobe. Ingenuity Pathway Analysis was able to segregate proteins changed in two lobes into different pathway networks. In addition to serving as reference for prostate proteomic profiles, our data suggest that different sets of proteins are involved in the carcinogenesis in DLP versus VP in the TRAMP model.

LTQ-iQuant: A freely available software pipeline for automated and accurate protein quantification of isobaric tagged peptide data from LTQ instruments

Pulsed Q dissociation enables combining LTQ ion trap instruments with isobaric peptide tagging. Unfortunately, this combination lacks a technique which accurately reports protein abundance ratios and is implemented in a freely available, flexible software pipeline. We developed and implemented a technique assigning collective reporter ion intensity-based weights to each peptide abundance ratio and calculating a protein's weighted average abundance ratio and p-value. Using an iTRAQ-labeled standard mixture, we compared our technique's performance to the commercial software MASCOT, finding that it performed better than MASCOT's nonweighted averaging and median peptide ratio techniques, and equal to its weighted averaging technique. We also compared performance of the LTQ-Orbitrap plus our technique to 4800 MALDI TOF/TOF plus Protein Pilot, by analyzing an iTRAQ-labeled stem cell lysate. We found highly correlated protein abundance ratios, indicating that the LTQ-Orbitrap plus our technique yields results comparable to the current standard. We implemented our technique in a freely available, automated software pipeline, called LTQ-iQuant, which is mzXML-compatible; supports iTRAQ 4-plex and 8-plex LTQ data; and can be modified for and have weights trained to a user's LTQ and other isobaric peptide tagging methods. LTQ-iQuant should make LTQ instruments and isobaric peptide tagging accessible to more proteomic researchers.

Prospective evaluation of a colorectal cancer nurse follow-up clinic

AIM

Colorectal Nurse Specialist (CNS) clinics for postoperative follow up of colorectal cancer aim to maintain clinical efficacy while reducing costs. We prospectively studied the efficacy and financial implications of such a clinic.

METHOD

This was a prospective study of all patients attending CNS clinics over 3 years. A lower-risk protocol for patients with Dukes A was used over 3 years and a higher-risk protocol for patients with Dukes B, C or D was used over 5 years. Department of Health Pricing Charts were used to cost the follow-up protocols, and adjustment was performed to calculate the cost of each quality adjusted life year (QALY) gained.

RESULTS

One hundred and ninety-three patients entered into this nurse-led follow-up protocol implemented by the CNS clinic between 2005 and 2007. The Dukes stages and proportions of patients in each stage were as follows: stage A, 13%; stage B, 8%; stage C, 36.3%; and stage D, 9.3%. Ninety-seven per cent underwent curative treatment and 2.6% had palliative treatment. Twenty-one per cent of patients developed recurrent disease. Overall actuarial 5-year survival was 80% and recurrences had a 30% 5-year actuarial survival. The total cost per patient for 3 years of follow up was £1506 and £1179 for lower-risk rectal and nonrectal cancers, respectively. The adjusted cost for each QALY gained for lower-risk tumours was £1914. The total cost per patient with higher-risk tumours was £1814 and £1487 for rectal and nonrectal tumours, respectively. The adjusted cost for each QALY gained was £2180 for higher-risk tumours.

CONCLUSIONS

This clinic demonstrated cost-effective detection of recurrent disease. Computed tomography (CT) was the most sensitive alert test. As all recurrences were detected within 4 years, we suggest that this is the indicated time to follow up.

Cytomegalovirus infection in association with early onset pre-eclampsia

This case describes a woman who presented with raised α-fetoprotein (AFP) on second trimester screening, and developed early onset fetal growth restriction (FGR) and severe pre-eclampsia (PET) before 24 weeks' gestation requiring magnesium sulphate and intravenous antihypertensives. Ultrasonography revealed a structurally normal fetus with estimated weight <3rd centile, abnormal uterine artery Dopplers and deteriorating fetal arterial Dopplers over the following 2 weeks. The pregnancy ended in fetal death before a viable weight was reached. Postmortem examination revealed a growth restricted fetus (birth weight <0.4th centile) and chronic villitis secondary to placental cytomegalovirus (CMV) infection. CMV has previously been associated with PET and FGR. This case highlights its potential role in the pathogenesis of placental failure and has relevance for counselling and management for future pregnancies. Furthermore, raised AFP may represent ongoing placental damage and offers potential for future therapeutic measures--for example, antivirals or immunisations to alter the natural history and prognosis of placental infection.

Identification of candidate biomarkers in ovarian cancer serum by depletion of highly abundant proteins and differential in-gel electrophoresis

Ovarian cancer is the fifth leading cause of cancer death for women in the US, yet survival rates are over 90% when it is diagnosed at an early stage, highlighting the need for biomarkers for early detection. To enhance the discovery of tumor-specific proteins that could represent novel serum biomarkers for ovarian cancer, we depleted serum of highly abundant proteins which can mask the detection of proteins present in serum at low concentrations. Three commercial immunoaffinity columns were used in parallel to deplete the highly abundant proteins in serum from 60 patients with serous ovarian carcinoma and 60 non-cancer controls. Medium and low abundance serum proteins from each serum pool were then evaluated by the quantitative proteomic technique of differential in-gel electrophoresis. The number of protein spots that were elevated in ovarian cancer sera by at least twofold ranged from 36 to 248, depending upon the depletion and separation methods. From the 33 spots picked for MS analysis, nine different proteins were identified, including the novel candidate ovarian cancer biomarkers leucine-rich alpha2 glycoprotein-1 and ficolin 3. Western blotting validated the relative increases in serum protein levels for three of the proteins identified, demonstrating the utility of this approach for the identification of novel serum biomarkers for ovarian cancer.

Warfarin interactions with substances listed in drug information compendia and in the FDA-approved label for warfarin sodium

Interactions of warfarin with other drugs or substances can pose a serious problem. We assessed three drug information compendia-Clinical Pharmacology, ePocrates, and Micromedex-and the warfarin sodium (Coumadin) product label (August 2007) approved by the US Food and Drug Administration for listings of interactions between warfarin and drugs, biologics, foods, and dietary supplements. The drug information compendia and warfarin label differed greatly as to the total number of substances that interact with warfarin. Of a total of 648 entries from the four sources, only 50 were common to all the sources. The types of substances listed as interacting with warfarin were entire classes of drugs, individual drugs, and combinations; biologics; dietary supplements; foods; alcohol; and tobacco. These sources were then examined for classification by severity of interaction and the underlying evidence base. This study provides evidence that there is little concordance among commonly used drug compendia and product labels with respect to interactions involving warfarin.

Second prize: Comprehensive proteomic analysis of human calcium oxalate monohydrate kidney stone matrix

BACKGROUND AND PURPOSE

Previous efforts to identify the protein content of stone matrix have been limited by the lack of technology necessary to analyze the highly insoluble protein-crystalline complex. Our study objective is to characterize the matrix of calcium oxalate monohydrate (COM) stones using a comprehensive proteomics approach.

MATERIALS AND METHODS

Seven pure COM stones were powdered, and proteins were extracted using four different buffer solutions. Detergent cleanup spin columns or concentrators were used to remove detergent and to exchange buffers before trypsin digestion. Tryptic peptides were analyzed with reversed-phase, high-performance liquid chromatography (RP-HPLC) and tandem mass spectrometry (MS/MS) using a QSTAR Pulsar i quadrapole time of flight mass spectrometer. Tandem mass spectra were searched against National Center for Biotechnology Information human nonredundant database using ProteinPilot 1.0 software (Applied Biosystems, Inc.) for protein hits; peptide MS/MS spectra were manually inspected.

RESULTS

Of the four buffers, only 2% sodium dodecyl sulfate (SDS) samples had normal HPLC and MS/MS elution patterns. We identified 68 distinct proteins with 95% confidence. More than 50 of the proteins have not been previously identified in stone matrix. Of particular note, a significant number of inflammatory proteins were identified, including immunoglobulins, defensin -3, clusterin, complement C3a, kininogen, and fibrinogen.

CONCLUSIONS

SDS reducing buffer was efficient at solubilizing proteins from stone matrix for further MS-based proteomic analysis. A variety of cellular, structural, and plasma proteins comprise COM stone matrix. Several of the stone proteins are involved in cell injury pathways, which suggests that inflammation plays a role in human COM stone formation.

Transfer of pectoralis major for the treatment of irreparable tears of subscapularis

Transfer of pectoralis major has evolved as the most favoured option for the management of the difficult problem of irreparable tears of subscapularis. We describe our experience with this technique in 30 patients divided into three groups. Group I comprised 11 patients with a failed procedure for instability of the shoulder, group II included eight with a failed shoulder replacement and group III, 11 with a massive tear of the rotator cuff. All underwent transfer of the sternal head of pectoralis major to restore the function of subscapularis.

At the latest follow-up pain had improved in seven of the 11 patients in groups I and III, but in only one of eight in group II. The subjective shoulder score improved in seven patients in group I, in one in group II and in six in group III. The mean Constant score improved from 40.9 points (28 to 50) in group I, 32.9 (17 to 47) in group II and 28.7 (20 to 42) in group III pre-operatively to 60.8 (28 to 89), 41.9 (24 to 73) and 52.3 (24 to 78), respectively.

Failure of the tendon transfer was highest in group II and was associated with pre-operative anterior subluxation of the humeral head. We conclude that in patients with irreparable rupture of subscapularis after shoulder replacement there is a high risk of failure of transfer of p?ctoralis major, particularly if there is pre-operative anterior subluxation of the humeral head.

Effect of the Deyo score on outcomes and costs in shoulder arthroplasty patients

PURPOSE

To evaluate the effect of preoperative comorbidity status (defined by the Deyo index) on hospital mortality, postoperative complications, length of hospital stay, and hospital costs for shoulder arthroplasty patients.

METHODS

The overall mean hospital mortality and postoperative complication rates, and length of hospital stay and hospital costs stratified by the Deyo score were compared using the Pearson Chi squared test and the F-test, respectively. The effects of the Deyo score on hospital mortality and postoperative complications were estimated using multiple logistic regression. The length of hospital stay and hospital costs were estimated using multiple linear regression. The magnitude of the estimated effects of the Deyo score on the 4 outcomes were expressed as crude odds ratios (ORs) and adjusted ORs for age, race, gender, surgeon volume, and hospital volume.

RESULTS

Higher Deyo scores tended to be associated with higher hospital mortality, length of hospital stay, postoperative complications, and hospital costs. Compared with the referent group (Deyo score=0), patients with the highest Deyo scores (5-36) exhibited adjusted ORs of 11.8 for hospital mortality (p=0.011) and 1.1 for developing postoperative complications (p=0.098), and had the highest length of hospital stay (mean, 4.1 days) and hospital costs (mean, US$18,549).

CONCLUSION

The Deyo score was a predictor of outcomes and costs in the shoulder arthroplasty population. By identifying relevant factors, health care providers can better determine who should be referred for shoulder arthroplasty and what should be considered when assessing risks and benefits.

Chemopreventive agents modulate the protein expression profile of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone plus benzo[a]pyrene-induced lung tumors in A/J mice

We used isobaric tag labeling coupled with mass spectrometry to compare the relative abundance of proteins in lung tumors from A/J mice treated with a mixture of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone and benzo[a]pyrene versus normal mouse lung tissues. Levels of 59 proteins changed-30 increased and 29 decreased-in tumor tissues versus normal tissues. Among proteins that showed increased levels in tumor tissues versus normal tissues were glycolytic enzymes, ribosomal proteins, fatty acid synthase, cathepsins D and H and carbonic anhydrase 2. On the other hand, the levels of cytochrome P450 enzymes 2B10 and 2F2, glutathione S-transferases mu-1, procollagen VI, Clara cell 10 kDA (CC10) protein, histones, receptor advanced glycation end product, and lung carbonyl reductase were lower in tumor tissues versus normal lung tissues. Upon dietary administration of a combination of N-acetyl-S-(N-2-phenethylthiocarbamoyl)-L-cysteine plus myo-inositol or indole-3-carbinol to carcinogen-treated mice, the relative abundance of 60S ribosomal protein L4 and carbonic anhydrase in tumor tissues decreased whereas that of histones, glutathione S-transferases mu, receptor advanced glycation end product, transglutaminase, and procollagen VI increased. Western assays with lung tissue homogenates not only verified the proteomics results for selected proteins but also showed differential expression of hypoxia inducible factor-1alpha, a transcription factor for most of the proteins that showed changes in relative abundance. This is the first report on the application of quantitative proteomics to study the relative abundance of proteins in a mouse model of lung carcinogenesis. These proteins may have utility for development of candidate lung cancer biomarkers and as targets of chemopreventive/chemotherapeutic agents.

Differential protein expression in male and female human lumbar cerebrospinal fluid using iTRAQ reagents after abundant protein depletion

Cerebrospinal fluid (CSF) has become one of the most frequently used biological medium for physiological studies for neurological disorders due to its proximity to the brain and clinical availability; however, before undertaking a rational approach to biomarker discovery or diagnostics, it is crucial to understand the underlying characteristics of CSF proteome in subpopulations. In this study, we examined the differential expression of proteins in pooled male and female CSF utilizing isobaric tags for relative and absolute quantification (iTRAQ) reagents after the depletion of six high abundant proteins using a multiple affinity removal system (MARS). A total of 219 proteins were identified (95% confidence level), and 12 proteins showed difference in expression levels. Eleven out of 12 differentially expressed proteins showed ratios of male/female between 1.15 and 1.29 (duplicate average), indicating a remarkable similarity between male and female CSF. One notable exception was the slightly lower expression level of ceruloplasmin (ferroxidase) in male CSF (0.81), a copper containing protein that catalyzes the conversion of ferrous iron to ferric iron with antioxidant properties. We also examined the levels of ceruloplasmin in each individual patient sample which constituted the pooled CSF using Western blot analysis which confirmed the lower expression levels of ceruloplasmin in male CSF.

iTRAQ is a useful method to screen for membrane-bound proteins differentially expressed in human natural killer cell types

We are interested in the biological as well as the molecular processes involved in natural killer (NK) cell development and function. Determining the proteomic complement could be a useful tool in predicting cellular function and fate. For the first time shown here, we have utilized iTRAQ, a new method that allows identification and quantification of proteins between multiple samples, to determine the expression of membrane-bound proteins in two previously characterized human NK cell populations. One population was derived from umbilical cord blood (UCB) stem cells (CD34+38-Lin-) and the other from expanded CD3-depleted adult peripheral blood. iTRAQ was employed for multiplex peptide labeling of proteins from fractionated membranes followed by two-dimensional high-performance liquid chromatography (2D-HPLC), and tandem mass spectrometry was used to identify protein signatures. We were able to identify and quantify differences in expression levels of 400-800 proteins in a typical experiment. Ontology analysis showed the majority of the proteins to be involved in cell signaling, nucleic acid binding, or mitochondrial function. Nearly all proteins were associated with the plasma membrane, membrane-bound organelle (lysosome or mitochondria), or nucleus. We found several novel proteins highly expressed in UCB stem cell derived NK cells compared to adult NK cells including CD9, alpha-2 macroglobulin, brain abundant signaling protein (BASP1), and allograft inflammatory factor-1 (AIF-1). In addition, we were able to confirm several of our iTRAQ results by RT-PCR, Western blot, and fluorescence-activated cell-sorting (FACS) analysis. This is the first demonstration and verification using iTRAQ to screen for membrane-bound protein differences in human NK cells and represents a powerful new tool in the field of proteomics.

Gefitinib and irinotecan in patients with fluoropyrimidine-refractory, irinotecan-naive advanced colorectal cancer: a phase I-II study

BACKGROUND

To establish the recommended dose level (RDL) and to evaluate the efficacy and safety of gefitinib plus irinotecan in patients with advanced fluoropyrimidine-refractory colorectal cancer (CRC).

PATIENTS AND METHODS

Patients with advanced CRC progressing on or within 12 weeks of fluoropyrimidine-based chemotherapy, irinotecan naive and performance status of two or less were recruited. During dose-finding phase, dose-limiting toxicity (DLT) was encountered at dose level 1, therefore subsequent dose de-escalation and pharmacokinetic (PK) studies were carried out. The RDL was then expanded in a multicentre setting to further evaluate safety and efficacy.

RESULTS

From June 2002 to February 2005, 39 patients were treated in total with 27 at the RDL. The RDL was established at irinotecan 225 mg/m(2) every 3 weeks and gefitinib 250 mg daily. The DLTs were neutropenia and diarrhoea. For the patients treated at RDL, the objective tumour response rate was 11.1% (95% confidence interval 2.4% to 29.2%) and median survival was 9.3 months. PK studies indicated that the addition of irinotecan to gefitinib resulted in an average of 50% increase in exposure to gefitinib (P < 0.05), but gefitinib did not alter the PK profiles of irinotecan or SN-38. Grade 3-4 toxic effects in all patients included diarrhoea (35.9%), lethargy (15.4%), neutropenia (15.4%), febrile neutropenia (10.3%) and skin rash (7.7%).

CONCLUSIONS

Irinotecan and gefitinib at this dose schedule was tolerable, but gefitinib did not appear to add substantial efficacy to irinotecan.

Gefitinib and irinotecan in patients with fluoropyrimidine-refractory irinotecan-naïve advanced colorectal cancer (CRC): dose-finding, pharmacokinetics, safety and efficacy

13520

Background: Gefitinib (IRESSA) is an oral epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor that has shown supra-additive activity in human CRC xenografts when combined with irinotecan. We have previously established that the recommended dose level (RDL) to be irinotecan 225mg/m2 q3 weeks and gefitinib 250mg daily (Chau et al ASCO 2004). The dose limiting toxicities were neutropenia and diarrhoea. The continuation phase of this study aimed to evaluate the efficacy and safety of this combination. Patients and Methods: Between Jun 2002 and Feb 2005, patients (pts) with advanced CRC progressing on or within 12 weeks of fluoropyrimidines-based chemotherapy, irinotecan-naïve and performance status ≤2 were recruited. Thirty-nine pts were treated with irinotecan and gefitinib in total with 27 treated at the RDL. Results: Median age was 61 years (range: 31–79) and 13 (33.3%) pts were females. All pts were Caucasians (94.9%) and non-oriental Asians (5.1%). Thirteen (33.3%) pts had received (neo)adjuvant chemotherapy and 16 (41.0%) pts had prior oxaliplatin-based chemotherapy for metastatic disease. Grades 3–4 toxicities were anaemia 2.6%, neutropenia 15.4%, febrile neutropenia 10.3%, diarrhoea 35.9%, nausea 2.6%, vomiting 5.1%, lethargy 15.4% and skin rash 7.7%. For the pts treated at RDL, the objective tumour response rate was 11.1% (3 partial responses [PRs]; 95% confidence interval [CI]: 2.4–29.2%) and the disease control rate was 40.7% (3PRs, 8 stable diseases lasting for ≥12 weeks). The median time to progression was 4.2 months and median survival was 9.3 months. Six-month progression free survival was 22.2% (95% CI: 6.5–37.9%) and 6-month overall survival was 73.4% (95% CI: 56.5–90.3%). Preliminary pharmacokinetic data suggested that the addition of irinotecan to gefitinib resulted in an average of 14–33% increase in exposure to gefitinib (p<0.05). Conclusions: Irinotecan and gefitinib at this dose schedule was tolerable. Gefitinib did not appear to add substantial efficacy to irinotecan. The relative low dose of irinotecan at the RDL and the rarity of EGFR somatic mutation in CRC may be contributory to the modest activity of irinotecan and gefitinib combination.

[Table: see text]

Proteomic comparison of needles from blister rust-resistant and susceptible Pinus strobus seedlings reveals upregulation of putative disease resistance proteins

In order to characterize a hypersensitive-like reaction in selected Pinus strobus seedlings to Cronartium ribicola, a proteomic comparison of needles from resistant and susceptible seedlings was undertaken using two-dimensional gel electrophoresis (2-DE). The results revealed 19 polypeptides specific to resistant seedlings and seven of these specific to infected resistant seedlings. There were 13 polypeptides up-regulated (> or = 3-fold increase) in resistant family P327 in comparison to needle tissue from susceptible and mock-inoculated seedlings. Electrospray ionization liquid chromatography and tandem mass spectrometry was used to sequence 11 proteins from the 2-DE gels. Sequences obtained from electrospray ionization liquid chromatography and tandem mass spectrometry were used for MS-BLAST and Pro-ID database searches allowing identification with a 95 to 99% confidence level. Six proteins were determined to be homologs of proteins with known roles in disease resistance, five were determined to be homologs of members of the leucine-rich repeat (LRR) superfamily, and one was a homolog of heat shock protein 90, a protein that serves as a cofactor for certain LRR proteins. This is the first report of members of the LRR family with functional homologs in Pinus strobus and of a molecular basis for white pine blister rust resistance in Pinus strobus.

More than zero tolerance? Burnout and tolerance for patient aggression amongst mental health nurses in China and the UK

OBJECTIVE

The aim of the study was to examine attitudes toward patient aggressive behaviour amongst mental health nurses in China and the UK and the relationship between these attitudes and burnout. The UK government policy of 'zero tolerance' of patient aggression may conflict with practitioner attitudes and could potentially increase the risk of aggression occurring.

METHOD

Two surveys of mental health nurses were conducted, one in the People's Republic of China and one in the UK using the Perceptions of Aggression Scale (POAS). The UK sample also completed the Maslach Burnout Inventory (MBI).

RESULTS

Some nurses in both groups agreed that patient aggression could sometimes have positive benefits. A sense of personal accomplishment at work (MBI) was significantly associated with a tendency to endorse positive statements about aggression.

DISCUSSION

Nurses seem to have a complex set of attitudes toward this issue that do not simply equate with 'zero tolerance'.

Reduced outer membrane permeability of Escherichia coli O157:H7: suggested role of modified outer membrane porins and theoretical function in resistance to antimicrobial agents

Outer membrane permeability of Escherichia coli O157:H7 was determined by an in vivo kinetic model with the periplasmic enzyme alkaline phosphatase [Martinez et al. (1996) Biochemistry 35, 1179-1186]. p-Nitrophenyl phosphate (PNPP) substrate, added to intact bacteria, must diffuse through the outer membrane to reach the enzyme. At low substrate concentration the bacterium was in the perfectly reactive state where all molecules that entered the periplasm were captured and converted to product. Transmembrane diffusion was rate limiting, and the permeability of the outer membrane was determined from kinetic properties. The O157:H7 strain grown at 30 degrees C showed one-sixth the permeability of wild-type E. coli grown at 30 degrees C. Wild-type bacteria grown at >/=37 degrees C show a physiological response with a shift in expression of outer membrane porins that lowered permeability to PNPP by approximately 70%. The O157:H7 strain did not display this temperature-sensitive shift in permeability even though a change in porin expression could be visualized by staining intensity of Omp F and Omp C on acrylamide gels. Altered behavior of the O157:H7 membrane was also indicated by a several thousand-fold lower response to transformation relative to wild-type E. coli. Matrix-assisted laser desorption ionization time of flight mass spectrometry and electrospray ionization mass spectrometry confirmed the expression of the Omp F and Omp C variants that are unique to E. coli O157:H7. This reduced outer membrane permeability can contribute to enhanced resistance of O157:H7 to antimicrobial agents.

Enhancing recall of information from a patient education booklet: a trial using cardiomyopathy patients

A quasi-experimental trial was conducted to compare the effect on information recall of: (a) the use of adjunct questions (AQ) in printed materials; and (b) a procedure (the 5Rs) for integrating printed patient education materials into face-to-face teaching. A total of 51 patients with severe left ventricular failure (cardiomyopathy) was assigned to one of three groups (n=17). Each group worked with a purpose-prepared booklet, the first in association with the 5Rs procedure; the second group with a version of the booklet containing adjunct questions; and the third with a text only version of the booklet. Recall of information from the booklet was measured using a checklist scored on the basis of responses secured in a standardised interview. Improved recall was associated with both the adjunct questions and the 5Rs procedure, with the latter achieving a substantially superior outcome. The practical implications of these findings are presented and directions for further research indicated.

Composition and mass of the bacteriophage phi29 prohead and virion

The protein composition of the Bacillus subtilis bacteriophage phi29 prohead and virion was determined by combustion of gel bands of (3)H-labeled proteins. Copy numbers of individual proteins were calculated relative to the 12 copies of the head-tail connector protein. The mean numbers of copies of the major capsid protein in the prohead and virion were 241 and 218, respectively, approaching the 235 copies determined previously by cryoelectron microscopy. The mean numbers of copies of the dimeric head fiber on the prohead and virion were 24 and 31, respectively, demonstrating partial occupancy of the 55 fiber binding sites. Measured copies of neck and tail proteins in the virion included 11 of the lower collar, 58 of the appendage, and 9 of the tail; if the true copies of these proteins are 12, 60, and 9, respectively, the entire neck and tail of phi29 has quasi-sixfold symmetry. The mass of the fiberless prohead with pRNA was about 14.2 MDa, and the mass of the prohead determined by scanning transmission electron microscopy was consistent with the biochemical data. The mass of the fiberless virion containing the 12.8-MDa DNA genome was about 30.4 MDa. A full complement of dimeric fibers on the prohead or virion would increase the mass of the particle by about 3.2 MDa. The data complement studies relating the structure of phi29 components to dynamic functions in morphogenesis and infection.

An assessment of the reaction energetics for cytochrome P450-mediated reactions

Regioselectivity is used to determine the absolute energetic differences for four different reactions catalyzed by P450. Abstraction of a hydrogen from a benzylic carbon containing a chlorine has a 1.0 kcal/mol lower barrier than abstraction from a simple benzylic carbon, which in turn is 0.4 to 0.9 kcal/mol lower than abstraction from the methyl group of an aromatic ether and 0.1 to 0.6 kcal/mol easier than aromatic hydroxylation. Isotope effects are used to determine if the enzyme-substrate complexes leading to each product, from a given substrate, are in rapid equilibrium. For all enzymes isotopically sensitive branching is observed from the benzylic carbon upon deuterium incorporation at that position to each of the other positions, indicating that each product arises from the same active oxygen species. The energetic differences determined experimentally are accurately reproduced by theoretical hydrogen atom abstractions at both the AM1 semiempirical and DFT levels of theory.

Mass spectrometric analysis of recombinant adenylate cyclase toxin from Bordetella pertussis strain 18323/pHSP9

The adenylate cyclase toxin-hemolysin (ACT) is a key virulence factor of the whooping cough agent Bordetella pertussis (Bp). The major cytotoxic activity of this 1706-residue protein consists of its capacity to invade a variety of eukaryotic cells directly across their cytoplasmic membrane and to deliver into cells a catalytic adenylate cyclase domain. This causes impairment of immune effector cells and apoptosis of lung macrophages by uncontrolled conversion of ATP to cAMP. The adenylate cyclase toxin-hemolysin acquires biological activity upon post-translational amide-linked palmitoylation of the epsilon-amino group of lysine 983 (K983) by the accessory fatty acyltransferase, CyaC. However, an additional conserved acylation site can be identified in ACT at lysine 860 (K860) and this residue is palmitoylated when recombinant ACT is produced in Escherichia coli (r-Ec-ACT). In this paper we report the double acylation of r-Bp-ACT secreted by a recombinant Bp strain 18323/pHSP9. This strain overproduces ACT from an oligocopy plasmid carrying the entire cya locus of Bordetella pertussis 18323. Palmitoylation of both conserved lysines (K860 and K983) of r-Bp-ACT expressed by this Bp strain was found. In addition, an error in the deduced protein sequence was identified, with Leu being the real residue at position 1001 and not the Val residue given in the published gene sequence. We also discuss these results in comparison with those from recombinant ACT expressed in E. coli strain K12 XL1-Blue. The analytical approach for characterization of the fatty acylation of ACT from strain 18323/pHSP9 consisted of multiple proteolytic digestion procedures (trypsin, Asp-N), microcapillary liquid chromatography/tandem mass spectrometry and matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.

Diagnosis and treatment of anterosuperior rotator cuff tears

Nineteen of 407 patients who underwent rotator cuff repair surgery over a 6-year period were found to have a tear of the subscapularis in combination with the supraspinatus and infraspinatus tendons. Nine of these patients had an unsuccessful prior surgery, which failed to recognize the extent of the subscapularis component. Surgical repair of the subscapularis tendon required a deltopectoral approach, and repair of the supraspinatus and infraspinatus components of the tear could only be accomplished through this approach in 4 patients. In the remaining 15, an extended superior approach was required to mobilize and repair the supraspinatus and infraspinatus tendons. In all cases, the biceps tendon was either torn or severely degenerated, requiring tenodesis. At a mean follow-up of 40 months (range 24 to 75 months), subjective results were excellent in 5 patients, good in 3, fair in 4, and poor in 7. The modified Constant score improved to a mean of 69% (range 23% to 130%), compared with a preoperative mean of 38% (range 23% to 100%). Physical findings positive for subscapularis insufficiency persisted in 14 of 19 patients. A significant correlation (P <.05) was found between a lower Constant score and duration of symptoms longer than 6 months as well as an appearance of severe fatty degeneration and atrophy of the subscapularis muscle on magnetic resonance imaging. We conclude that anterosuperior rotator cuff tears are an infrequent configuration that may require surgical repair through an extended approach combining deltopectoral mobilization of the subscapularis with transdeltoid mobilization of the supraspinatus and infraspinatus. Repair before 6 months of symptoms is associated with a better functional outcome and is the result of less involution of muscle and tendon tissue.

A tissue specific IL-1 receptor antagonist homolog from the IL-1 cluster lacks IL-1, IL-1ra, IL-18 and IL-18 antagonist activities

Interleukin (IL)-1-like protein 1 (IL-1L1) is a 155-amino acid protein that shares 27% identity with IL-1beta and 47% with IL-1 receptor antagonist (IL-1ra). A 2.7-kb IL-1L1 mRNA was cloned from human placenta and is detectable in the trophoblastic cell line JEG-3, in macrophages and in endotoxin-stimulated monocytes. Expression of IL-1L1 is much less abundant and less widespread than IL-1ra. We have determined the human and mouse IL-1L1 cDNA sequences and the complete sequence of the human gene, IL1L1. IL1L1 consists of four coding exons, has two alternative non-coding first exons, lies between IL1B and IL1RN, is orientated in the same direction as IL1RN and is separated from it by approximately 53 kb. The predicted IL-1L1 protein lacks both signal sequence and glycosylation signals. A 17-kDa protein was recovered by immunoprecipitation with IL-1L1-specific antibodies from JEG-3. IL-1L1 did not stimulate IL-6 production from primary human fibroblasts or human umbilical vein endothelial cells nor did it block the IL-1alpha or IL-1beta-dependent activation of IL-6 expression. We conclude, contrary to a recent suggestion made by others, that IL-1L1 is not a functional IL-1ra. IL-1L1 also had no detectable agonistic or antagonistic effect on IFN-gamma production in response to IL-18 in KG-1 cells.

Critical pathways: application to selected patient outcomes following coronary artery bypass graft

As health care reform evolves in the United States, many hospitals are implementing strategies to contain the cost of coronary artery bypass graft (CABG) surgery. The purpose of this study was to examine the length of stay in the intensive care unit (ICU) after CABG surgery relative to the number of hours, postoperation, when ambulation occurred, and to examine the overall postoperative length of hospital stay. The study found a significant difference between ICU length of stay and the time when ambulation was initiated (t(150) = -2.68; p = .004). These results suggest that CABG patients with shorter ICU stays begin ambulation sooner, thus potentially reducing the risk of postoperative complications as well as cost. No other significant differences were demonstrated.

Effect of circumferential plasma-spray porous coating on the rate of femoral osteolysis after total hip arthroplasty

BACKGROUND

Osteolysis of the femur has been a serious problem associated with some designs of total hip-replacement implants; it frequently leads to failure of the femoral component. We evaluated the effect of a circumferential plasma-spray porous coating on the rate of osteolysis in a study that included two groups of hips, each of which received an implant with the same design except for the extent of the porous coating. Our goal was to determine the possible role of circumferential porous coating in protecting the bone-implant interface from osteolysis.

METHODS

A series of consecutive primary total hip replacements performed with insertion of the Mallory-Head implant without cement was divided into two study groups. The first 126 hips (Group 1) were treated with a femoral stem that had a noncircumferential plasma-spray porous titanium coating. The next ninety hips (Group 2) were treated with a circumferentially coated stem of the same design. The average duration of radiographic follow-up was 7.8 years in Group 1 and 7.5 years in Group 2.

RESULTS

The average rate of polyethylene wear was similar for the two groups (0.187 millimeter per year in Group 1 and 0.189 millimeter per year in Group 2). The prevalence of osteolysis in Group 1 (40 percent; fifty of 126 hips) was significantly higher than that in Group 2 (10 percent; nine of ninety hips) (p < 0.001). Osteolysis remote from the joint space (distal to zones 1 and 7) was found in 11 percent (fourteen) of the hips in Group 1 but in none of those in Group 2 (p = 0.0004). The average total area of osteolysis in Group 1 (5.0 square centimeters) was significantly larger than that in Group 2 (2.9 square centimeters) (p < 0.05).

CONCLUSIONS

A circumferential plasma-spray titanium porous coating on the femoral component of a total hip-replacement prosthesis inserted without cement appears to provide an effective barrier preventing wear debris from gaining access to the endosteal surface of the femur and the greater trochanter. This finding supports the hypothesis of the so-called effective joint space, which predicts that wear debris from the joint bearing can migrate, driven by intracapsular pressures, to all areas to which joint fluid has access and thus can result in osteolysis. The reduction of the prevalence of osteolysis and the elimination of osteolysis from the zones remote from the joint space by the use of a circumferential plasma-spray porous coating indicates that the femur was effectively sealed off from the joint space. We believe that the durability and longevity of the femoral component should be enhanced by the use of such a coating.

Association Between Continuing Education and Job Satisfaction of Nurses Employed in Long-Term Care Facilities

BACKGROUND

The purpose of this descriptive, correlational study was to investigate the relationship between continuing education and job satisfaction among RNs and licensed practical nurses (LPNs) employed in long-term care facilities.

METHOD

Herzberg's Motivational-Hygiene Theory was used as a framework to guide the design of the study. The Professional Educational Activities Scale and the McCloskey/Mueller Satisfaction Scale were completed by 110 nurses employed in long-term care facilities.

RESULTS

No difference was found between type of employment status (full-time versus part-time) on the level of professional educational activities. However, RNs participated in more continuing education activities than LPNs. Nurses who reported higher family incomes also had greater participation in educational activities. Registered nurses reported greater job satisfaction than LPNs. No significant difference was found between the degree of job satisfaction for Black and White nurses. The results of this study indicated nurses who participated in more continuing education activities scored higher on the job satisfaction scale.

CONCLUSION

As the elderly population increases, a critical need exists for nurses to be knowledgeable about current research-based information, including the economic and psychosocial effects of illness in later life. To provide the most effective care for the elderly population, nurses in long-term care must be knowledgeable about the complexity and specific characteristics of chronic illnesses. Continuing education activities are an important way to access this information.

The treatment of symptomatic os acromiale

During a four-year period, fourteen individuals (fifteen shoulders) who had been seen at the shoulder service of our institution because of pain in the shoulder had a radiographic finding of an os acromiale. On clinical examination, the pain appeared to be due to an unstable os acromiale because the patients had point tenderness over the acromion and pain on forward elevation of the shoulder. The diagnosis of an os acromiale was confirmed on radiographs, magnetic resonance images, or a bone scan. Eight patients had an associated tear of the rotator cuff. The os acromiale was located in the pre-acromion in one shoulder, the meso-acromion in eleven shoulders, and the meta-acromion in three shoulders. At the operation, the anterior aspect of the acromion was found to be unstable in all shoulders. Eleven patients (twelve shoulders) had open reduction of the os acromiale and insertion of an autogenous iliac-crest bone graft. Of those patients, four (five shoulders) had open reduction and internal fixation with a tension-band procedure with use of pins and wires. Only one of those shoulders had a solid osseous union, and the other four shoulders had a non-union that was due to a disruption of the fixation. The remaining seven patients (seven shoulders) had open reduction and internal fixation with use of cannulated screws and a tension-band construct; a solid osseous union was achieved in all but one of them. One patient had excision of the pre-acromion, which relieved the pain. Two patients who had had failed open reduction and internal fixation had excision of a grossly unstable os acromiale in the meso-acromion; both patients had pain and weakness after this procedure. Of the twelve shoulders that had open reduction and bone-grafting, seven had union of the os acromiale; the average time to radiographic and clinical union was nine weeks (range, seven to twenty weeks). We concluded that, although it is rare, symptomatic unstable os acromiale does occur and can be effectively treated with use of autogenous bone-grafting and internal fixation with a rigid tension-band construct and cannulated screws.

Design of a novel P450: a functional bacterial-human cytochrome P450 chimera

We report the construction of a functional chimera from approximately 50% bacterial (cytosolic) cytochrome P450cam and 50% mammalian (membrane-bound) cytochrome P450 2C9. The chimeric protein shows a reduced CO-difference spectrum absorption at 446 nm, and circular dichroism spectra indicate that the protein is globular. The protein is soluble and catalyzes the oxidation of 4-chlorotoluene using molecular oxygen and reducing equivalents from bacterial putidaredoxin and putidaredoxin reductase. This chimera provides a novel method for addressing structure-function issues and may prove useful in the design of oxidants for benign and stereospecific synthesis, as well as catalysts for bioremediation of polluted areas. Furthermore, these results provide the first evidence that bacterial P450 enzymes and mammalian P450 enzymes are likely to share a common tertiary structure.

Evaluation of cytochrome P450 mechanism and kinetics using kinetic deuterium isotope effects

In this paper two hypotheses are tested: (i) the active oxygen species is similar in energetics for all cytochrome P450 (CYP) enzymes and (ii) linear free-energy relationships can be used to evaluate the mechanism of the reaction of these enzymes. A series of intramolecular isotope effects were determined and compared for CYPs 1A2, 2B1, 2C9, 2E1, and P450cam. The results indicate that the isotope effects are very similar for each of these isoforms of P450 and that the first hypothesis is likely to be true. Attempts to establish a linear free-energy relationship were only moderately successful: log Vmax = 0.11sigma+p + 1.73; r2 = 0.588. It was determined, through the use of intermolecular isotope effects, that the rates of hydrogen atom abstraction are masked. Thus, the second hypothesis is found to be false. This is likely to be a general result for CYP reactions, and linear free-energy relationships can only be used to determine the mechanism under very special circumstances. In all cases, the rate-limiting step should be evaluated with isotope effect experiments before any mechanistic conclusions can be drawn. If the intermolecular isotope effects are found to be masked, no mechanistic conclusion can be drawn from the linear free-energy relationship study.