PROTOCOL: Digital interventions to reduce social isolation and loneliness in older adults: An evidence and gap map

This is the protocol for a Campbell systematic review. The objectives are as follows: the aim is to map available evidence on the effects of digital interventions to mitigate social isolation and/or loneliness in older adults in all settings except hospital settings.

Pancreas Transplantation in Black, Asian and Minority Ethnic Patients-Single Centre Experience in the UK

Ethnic disparities in the outcomes after simultaneous pancreas kidney (SPK) transplantation still exist. The influence of ethnicity on the outcomes of pancreas transplantation in the UK has not been reported and hence we aimed to investigate our cohort. A retrospective analysis of all pancreas transplant recipients (n = 171; Caucasians = 118/Black Asian Ethnic Minorities, BAME = 53) from 2006 to 2020 was done. The median follow-up was 80 months. Patient & pancreas graft survival, rejection rate, steroid free maintenance rate, HbA1c, weight gain, and the incidence of secondary diabetic complications post-transplant were compared between the groups. p < 0.003 was considered significant (corrected for multiple hypothesis testing). Immunosuppression consisted of alemtuzumab induction and steroid free maintenance with tacrolimus and mycophenolate mofetil. Pancreas graft & patient survival were equivalent in both the groups. BAME recipients had a higher prevalence of type-2 diabetes mellitus pre-transplant (BAME = 30.19% vs. Caucasians = 0.85%, p < 0.0001), and waited for a similar time to transplantation once waitlisted, although pre-emptive SPK transplantation rate was higher for Caucasian recipients (Caucasians = 78.5% vs. BAME = 0.85%, p < 0.0001). Despite equivalent rejections & steroid usage, BAME recipients gained more weight (BAME = 7.7% vs. Caucasians = 1.8%, p = 0.001), but had similar HbA1c (functioning grafts) at 3-,12-, 36-, and 60-months post-transplant.

Characterization of stimulus response curves obtained with transcranial magnetic stimulation from bilateral anterior digastric muscles in healthy subjects

PURPOSE

The purpose of the study was to describe measurements of stimulus-response curves in the anterior digastric muscle (ADM) bilaterally following transcranial magnetic stimulation (TMS) to the right and left hemispheres. The first dorsal interosseous muscle (FDI) was the control muscle.

MATERIALS AND METHODS

The subjects were 20 healthy young adults. Test sessions determined motor thresholds (MT) and stimulus-response curves (1.0, 1.2, 1.4, 1.6 × MT) from either the FDI or ADM following TMS to left and right hemispheres using the double cone coil. Bilateral recordings of MEPs in the left and right ADM allowed us to generate stimulus response curves following ipsilateral and contralateral TMS.

RESULTS

Intraclass correlation coefficients (ICC) for MEP amplitudes from ipsilateral and contralateral ADMs were >0.60 at motor threshold (MT) and >0.90 at stimulus intensities above MT. There was a linear increase in MEP amplitudes across stimulus intensities for the FDI following contralateral TMS, while MEP amplitudes from the ADM following contralateral and ipsilateral TMS increased linearly across stimulus intensities [F_{(3, 57) [Muscle × Recording Site × Stim Intensity]} = 33.57; p < 0.05]; (ηp2 = 0.64). The slopes of the stimulus-response curve of the contralateral FDI was greater than the slopes of the stimulus response curves of the ipsilateral and contralateral ADM (p < 0.05).

CONCLUSIONS

The current study provided insights on the methodology for recording stimulus response curves in the ADM with TMS. These findings may translate into a valid, reliable, and relevant clinical outcome to study the pathophysiology of the corticobulbar motor system.

Turning the oil tanker: a novel approach to shifting perspectives in medical practice

Although health care is encouraged to follow an evidence-based approach, there are perceived instances where suboptimal practice persists in the presence of better options due to an inherent resistance to change within many health care systems. To continue striving for clinical excellence, it is important to identify deficient practices and make appropriate corrections by implementing new and improved techniques and treatments. Bringing about change, however, tends to be a long, arduous process consisting of several small and successive deviations from the norm, analogous to "turning the oil tanker". Analyzing the methods employed by successful health care innovators has allowed the development of a "three-pronged" approach to overcoming resistance to change: 1) a determined opinion leader with a network or like-minded opinion leaders; 2) the presentation of hard evidence with adequate praise for current practice and the generation of clearly worded, specific guidelines; and 3) the use of simple reminders and continuous analysis of outcomes. Employing this three-pronged approach could lead to faster and more successful implementation of change within the health care system.

Screening for older inpatients at risk for long length of stay: which clinical tool to use?

Background

Screening for inpatients at risk for long length of stay (LOS) is the first step of an effective hospital care plan for older inpatients. This study aims, in older adults admitted to a geriatric acute care ward, to examine and compare the 6-item brief geriatric assessment (BGA) and the “Programme de Recherche sur l’Intégration des Services pour le Maintien de l’Autonomie” (PRISMA-7) risk levels with long LOS, and to establish their performance criteria (i.e., sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios) for LOS.

Methods

Based on an observational, retrospective, cohort design, 166 inpatients aged ≥75 admitted to a geriatric acute care ward of a McGill University-affiliated hospital (Montreal, Quebec, Canada) were recruited. The risk levels of the 6-item BGA (low, moderate and high) and the PRISMA-7 (low versus high) were calculated from a baseline assessment. The LOS was subsequently calculated in number of days.

Results

Only the 6-item BGA high risk level was associated with a long LOS (Odds ratio = 1.1 with P = 0.028 and Hazard ratio = 2.1 with P = 0.004). Kaplan-Meier distributions showed that there was no significant difference in the delay of hospital discharge between the low and high-risk level reported by the PRISMA-7 (P = 0.381), whereas the 6-item BGA three risk levels differed significantly (P = 0.008), with individuals at high risk levels being discharged later when compared to those with low (P = 0.001) and moderate (P = 0.019) risk levels. Both tools’ performance criteria were poor (i.e., < 0.70), except for PRISMA-7’s sensitivity which was 100%.

Conclusion

The 6-item BGA risk levels were associated with LOS, low risk-level being associated with short LOS and high-risk level with long LOS, but no association was reported with the PRISMA-7 risk levels. Both tools had poor performance criteria for long LOS, suggesting that they cannot be used as prognostic tools with current scientific knowledge.

Allosensitization after transplant failure: the role of graft nephrectomy and immunosuppression - a retrospective study

There are conflicting data about the role of transplant nephrectomy and immunosuppression withdrawal on the development of allosensitization and the impact on re-transplantation. We divided 109 first graft recipients into two groups according to whether they underwent nephrectomy (NX+, n = 61) or their graft was left in situ (NX-, n = 48). Sera were assessed for HLA-A/B/Cw/DR/DQ antibodies at the time of NX/transplant failure and after 3, 6, 12, 24 months. The NX+ group showed a higher rate of donor specific antibody (DSA) and non-DSA human leukocyte antigen (HLA) antibody production at all the time points. Multivariable analysis showed that nephrectomy was a strong, independent risk factor for the development of DSAs after 12 and 24 months (P = 0.005 and 0.008). In the NX- group, low tacrolimus levels correlated with DSA formation (AUC 0.817, P = 0.002; best cut-off level 2.9 ng/ml). Analysis with a standardized pool of UK donors showed a more difficult grade of HLA matchability following nephrectomy compared with the NX- group. Nephrectomy is followed by the long-term production of DSA and non-DSA HLA antibodies and negatively impacts on the chances of finding a HLA-compatible kidney. Tacrolimus levels ≥3 ng/ml are protective against the development of allosensitization and could facilitate re-transplantation in the NX- group.

Predicting a long hospital stay after admission to a geriatric assessment unit: Results from an observational retrospective cohort study

OBJECTIVE

Morbidities and related disabilities often lead to older inpatients having a long hospital stay. The aim of this study was to examine whether the 6-item brief geriatric assessment (BGA), developed and validated in France to determine a priori levels of risk of a long hospital stay (i.e.; low, moderate, high), could be successfully used with patients admitted to a geriatric assessment unit (GAU) in Quebec.

STUDY DESIGN

Observational retrospective cohort design.

SETTING

A GAU of a McGill University affiliated hospital (Montreal, Quebec, Canada).

PARTICIPANTS

499 inpatients (84.7 ± 7.2 years; 73.3% female) recruited upon their admission.

MAIN OUTCOME MEASURES

The BGA comprises 6 items: age > 85 years, male gender, ≥ 5 drugs per day, use of home-help support, history of falls and temporal disorientation. It was administered at baseline and a priori levels of risk of a long hospital stay (i.e., low, moderate, high) were determined. Length of hospital stay (LHS, in days) was calculated using the hospital registry. The association between a priori levels of risk from the BGA and LSH was examined using regression models and Kaplan-Meier curves.

RESULTS

The LHS increased with the 6-item BGA a priori level of risk (P = 0.010). High-risk (Hazard ratio (HR) = 1.68 with P < 0.001) and moderate-risk (HR = 1.24 with P = 0.039) of a long hospital stay successfully predicted a long stay. Kaplan-Meier distributions of time to discharge showed that inpatients classified as having high and moderate risk levels for a long hospital stay were discharged later than those with a low risk level (P < 0.001 and P = 0.013).

CONCLUSION

The 6-item BGA a priori levels of risk for a long hospital stay successfully predicted a long stay among patients admitted to a GAU in Quebec.

HIIT produces increases in muscle power and free testosterone in male masters athletes

High-intensity interval training (HIIT) improves peak power output (PPO) in sedentary aging men but has not been examined in masters endurance athletes. Therefore, we investigated whether a six-week program of low-volume HIIT would (i) improve PPO in masters athletes and (ii) whether any change in PPO would be associated with steroid hormone perturbations. Seventeen male masters athletes (60 ± 5 years) completed the intervention, which comprised nine HIIT sessions over six weeks. HIIT sessions involved six 30-s sprints at 40% PPO, interspersed with 3 min active recovery. Absolute PPO (799 ± 205 W and 865 ± 211 W) and relative PPO (10.2 ± 2.0 W/kg and 11.0 ± 2.2 W/kg) increased from pre- to post-HIIT respectively (P < 0.001, Cohen's d = 0.32-0.38). No significant change was observed for total testosterone (15.2 ± 4.2 nmol/L to 16.4 ± 3.3 nmol/L (P = 0.061, Cohen's d = 0.32)), while a small increase in free testosterone occurred following HIIT (7.0 ± 1.2 ng/dL to 7.5 ± 1.1 ng/dL pre- to post-HIIT (P = 0.050, Cohen's d = 0.40)). Six weeks' HIIT improves PPO in masters athletes and increases free testosterone. Taken together, these data indicate there is a place for carefully timed HIIT epochs in regimes of masters athletes.

Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer

BACKGROUND

Robust data on patient-reported outcome measures comparing treatments for clinically localized prostate cancer are lacking. We investigated the effects of active monitoring, radical prostatectomy, and radical radiotherapy with hormones on patient-reported outcomes.

METHODS

We compared patient-reported outcomes among 1643 men in the Prostate Testing for Cancer and Treatment (ProtecT) trial who completed questionnaires before diagnosis, at 6 and 12 months after randomization, and annually thereafter. Patients completed validated measures that assessed urinary, bowel, and sexual function and specific effects on quality of life, anxiety and depression, and general health. Cancer-related quality of life was assessed at 5 years. Complete 6-year data were analyzed according to the intention-to-treat principle.

RESULTS

The rate of questionnaire completion during follow-up was higher than 85% for most measures. Of the three treatments, prostatectomy had the greatest negative effect on sexual function and urinary continence, and although there was some recovery, these outcomes remained worse in the prostatectomy group than in the other groups throughout the trial. The negative effect of radiotherapy on sexual function was greatest at 6 months, but sexual function then recovered somewhat and was stable thereafter; radiotherapy had little effect on urinary continence. Sexual and urinary function declined gradually in the active-monitoring group. Bowel function was worse in the radiotherapy group at 6 months than in the other groups but then recovered somewhat, except for the increasing frequency of bloody stools; bowel function was unchanged in the other groups. Urinary voiding and nocturia were worse in the radiotherapy group at 6 months but then mostly recovered and were similar to the other groups after 12 months. Effects on quality of life mirrored the reported changes in function. No significant differences were observed among the groups in measures of anxiety, depression, or general health-related or cancer-related quality of life.

CONCLUSIONS

In this analysis of patient-reported outcomes after treatment for localized prostate cancer, patterns of severity, recovery, and decline in urinary, bowel, and sexual function and associated quality of life differed among the three groups. (Funded by the U.K. National Institute for Health Research Health Technology Assessment Program; ProtecT Current Controlled Trials number, ISRCTN20141297 ; ClinicalTrials.gov number, NCT02044172 .).

Improving the immunogenicity of a trivalent Neisseria meningitidis native outer membrane vesicle vaccine by genetic modification

Trivalent native outer membrane vesicles (nOMVs) derived from three genetically modified Neisseria meningitidis serogroup B strains have been previously evaluated immunologically in mice and rabbits. This nOMV vaccine elicited serum bactericidal activity (SBA) against multiple N. meningitidis serogroup B strains as well as strains from serogroups C, Y, W, and X. In this study, we used trivalent nOMVs isolated from the same vaccine strains and evaluated their immunogenicity in an infant Rhesus macaque (IRM) model whose immune responses to the vaccine are likely to be more predictive of the responses in human infants. IRMs were immunized with trivalent nOMV vaccines and sera were evaluated for exogenous human serum complement-dependent SBA (hSBA). Antibody responses to selected hSBA generating antigens contained within the trivalent nOMVs were also measured and we found that antibody titers against factor H binding protein variant 2 (fHbpv2) were very low in the sera from animals immunized with these original nOMV vaccines. To increase the fHbp content in the nOMVs, the vaccine strains were further genetically altered by addition of another fHbp gene copy into the porB locus. Trivalent nOMVs from the three new vaccine strains had higher fHbp antigen levels and generated higher anti-fHbp antibody responses in immunized mice and IRMs. As expected, fHbp insertion into the porB locus resulted in no PorB expression. Interestingly, higher expression of PorA, an hSBA generating antigen, was observed for all three modified vaccine strains. Compared to the trivalent nOMVs from the original strains, higher PorA levels in the improved nOMVs resulted in higher anti-PorA antibody responses in mice and IRMs. In addition, hSBA titers against other strains with PorA as the only hSBA antigen in common with the vaccine strains also increased.

Surgical Stapler for Right Renal Vein Elongation Using the Inferior Vena Cava in Kidney Transplant

Elongation of the right renal vein with the inferior vena cava (caval patch) using a vascular stapler offers a safe means of extending the deceased-donor right renal vein, while minimizing the ischemic time of the kidney during preparatory dissection. The aortic patch of the right renal artery also can be preserved, which minimize the danger of arterial stenosis, kinking, and dissection.

Encapsulation of exenatide in poly-(D,L-lactide-co-glycolide) microspheres produced an investigational long-acting once-weekly formulation for type 2 diabetes

Exenatide once-weekly (EQW [2 mg s.c.]) is under development as monotherapy as an adjunct to diet and exercise or as a combination therapy with an oral antidiabetes drug(s) in adults with type 2 diabetes. This long-acting formulation contains the active ingredient of the original exenatide twice-daily (EBID) formulation encapsulated in 0.06-mm-diameter microspheres of medical-grade poly-(D,L-lactide-co-glycolide) (PLG). After mechanical suspension and subcutaneous injection by the patient, EQW microspheres hydrate in situ and adhere to one another to form an amalgam. A small amount of loosely bound surface exenatide, typically less than 1%, releases in the first few hours, whereas drug located in deeper interstices diffuses out more slowly (time to maximum, ~2 weeks). Fully encapsulated exenatide (i.e., drug initially inaccessible to diffusion) releases over a still longer period (time to maximum, ~7 weeks) as the PLG matrix hydrolyzes into lactic acid and glycolic acid, which are subsequently eliminated as carbon dioxide and water. For EQW, plasma exenatide concentrations reach the therapeutic range by 2 weeks and steady state by 6-7 weeks. This gradual approach to steady state seems to improve tolerability, as nausea is less frequent with EQW than EBID. EQW administrations may be associated with palpable skin nodules that generally resolve without further medical intervention. In comparative trials, EQW improved hemoglobin A1c more than EBID, sitagliptin, pioglitazone, or insulin glargine and reduced fasting plasma glucose more than EBID. Weight loss due to EQW or EBID was similar. EQW is the first glucose-lowering agent that is administered once weekly.

An atypical presentation of aortic rupture: intuition and investigation can avoid disaster

INTRODUCTION

Patients with an acute abdomen are a common presentation for those participating in emergency surgery cover. The aetiology of this presentation incorporates the spectrum of organ systems and is often not identified satisfactorily. Nevertheless, certain diagnoses will always be difficult to make and some presentations can be deceptive. Radiological investigations increasingly play a role in establishing an accurate diagnosis and frequently allow prompt management to be instituted.

INTRODUCTION

Patients with an acute abdomen are a common presentation for those participating in emergency surgery cover. The aetiology of this presentation incorporates the spectrum of organ systems and is often not identified satisfactorily. Nevertheless, certain diagnoses will always be difficult to make and some presentations can be deceptive. Radiological investigations increasingly play a role in establishing an accurate diagnosis and frequently allow prompt management to be instituted.

INTRODUCTION

Ruptured AAA should be considered as a differential diagnosis in all elderly patients presenting with acute severe abdominal pain who may be haemodynamically stable. Atypical history and examination with inconsistent or equivocal clinical signs should raise the suspicion of aneurysm, particularly in elderly men with known arterial disease. There should be a low threshold for both requesting and justifying definitive imaging (ie CT) in such cases if a catastrophic outcome through misdiagnosis is to be avoided.

Vitellogenesis in Oncopeltus fasciatus: PLC/IP(3), DAG/PK-C pathway triggered by CaM

In Oncopeltus fasciatus, evidence shown here indicates it is calmodulin (CaM) that activates phospholipase-C (PLC), beginning a signalling pathway necessary for endocytic uptake of yolk precursor molecules. Epithelial cell-produced CaM, transported to oocytes via gap junctions, has been shown to be required for receptor-mediated endocytic uptake of vitellogenins (Vgs, the protein precursors of yolk). To determine if CaM was directly or indirectly stimulating the phospholipase-C (PLC) signalling cascade and thus controlling Vg endocytosis we used a series of molecules known to inactivate various elements of the pathway. W-7 prevents CaM from interacting with other molecules. Neomycin isolates PIP(2) from PLC. U-73122 directly inactivates PLC. 2-APB blocks IP(3) receptors which would otherwise cause release of Ca(2+). Verapamil and CdCl(2) block Ca(2+) release channels. Staurosporin and calphostin are inhibitors of PK-C. 1-Hexadecyl-2-acetyl glycerol (HAG) binds to diacylglycerol (DAG). Through the use of these antagonists we show here that: (1) the activation of phospholipase-C in this system requires CaM. (2) Stimulated phospholipase-C converts PIP(2) into IP(3) and DAG. (3) IP(3) causes increase in cytosolic Ca(2+). (4) DAG and Ca(2+) each stimulate phosphokinase-C, resulting in endocytosis of Vgs.

Mini-incision donor nephrectomy techniques: a systematic review

OBJECTIVES

The aim of this article is to compare different mini-incision donor nephrectomy techniques in the literature.

MATERIALS AND METHODS

We did a literature search using PUBMED using the search term "donor nephrectomy." We compared different surgical techniques using different parameters like length of incision, length of operation, pain medications required after the operation, site of the operation, and intraoperative and postoperative complications.

RESULTS

We found 7 different surgical techniques of mini-invasive donor nephrectomy. Hakim and associates described the smallest initial incision size of 4 cm. There also are limited data on the analgesia requirements in 4 of the series, and 3 series that describe the requirements vary.

CONCLUSIONS

These techniques offer advantages and disadvantages to the donor and the kidney. We hope to encourage further work. Ideally, there must be a working discussion, long-term outcomes of donor kidney and recipient, as well as accurate pain records, both quantitative and qualitative, and a discussion of time to mobilization.

Relationship between biogenic amines and free amino Acid contents of wines and musts from Alentejo (Portugal)

The concentration of biogenic amines and free amino acids was studied in 102 Portuguese wines and 18 musts from Alentejo demarcated (D.O.C.) regions. Most wines were commercial, except for 38 monovarietals obtained by micro vinification. Musts from the varieties used to produce the latter wines were also studied. Both biogenic amines and free amino acids were analyzed by HPLC using fluorescence detection for their o-phthalaldehyde/fluorenylmethyl chloroformate (OPA/FMOC) derivatives. The most significant amines (average 10.8 mg/L for histamine+tyramine in red, and 7.4 mg/L for white wines) were found to be present at low levels and, although no important relationship between each individual biogenic amine could be obtained, the total amine content depends significantly on the assimilable amino acid content in wine.

In-vitro evaluation of the PALL Leukotrap Affinity Prion Reduction Filter as a secondary device following primary leucoreduction

BACKGROUND AND OBJECTIVES

A filter (PRF1) designed to remove abnormal prion proteins from red-cell units has been developed. The purpose of this study was to evaluate the quality of red cells produced using this device.

MATERIALS AND METHODS

Leucocyte-depleted red-cell units (CPD, CPD-A1 and CPD/SAGM) processed according to standard UK practices were filtered using PRF1. Filtered and control units were stored and sampled on day 1, day 7 and on the date of expiry and were tested using standard measures of red-cell quality.

RESULTS

Filtered units were found to have significantly higher percentage haemolysis levels, lower haemoglobin levels and a smaller volume compared with controls. All results, however, were well within the permitted 0.8% haemolysis level at the end of storage and all units met the UK guidelines for haemoglobin and volume. The other test parameters measured showed no significant differences between the test and control units.

CONCLUSIONS

The PRF1 filter was found to be easy to use and resulted in red-cell units that met all relevant UK and European Guidelines.

Atomic force microscopy reveals the stoichiometry and subunit arrangement of 5-HT3 receptors

The 5-HT3 receptor is a cation-selective ligand-gated ion channel of the Cys-loop superfamily. The receptor is an important therapeutic target, with receptor antagonists being widely used as antiemetics in cancer therapy. The two known receptor subunits, A and B, form homomeric 5-HT 3A receptors and heteromeric 5-HT 3A/B receptors. The heteromeric receptor has the higher single-channel conductance and more closely mimics the properties of the native receptor. We have used atomic force microscopy to study the architecture of 5-HT 3A and 5-HT 3A/B receptors. We engineered different epitope tags onto the A- and B-subunits and imaged receptors that were doubly liganded by anti-epitope antibodies. We found that, for the 5-HT 3A/B receptor, the distribution of angles between antibodies against the A-subunit had a single peak at approximately 144 degrees , whereas the distribution for antibodies against the B-subunit had two peaks at approximately 72 degrees and 144 degrees . Our results indicate that the subunit stoichiometry is 2A:3B and that the subunit arrangement around the receptor rosette is B-B-A-B-A. This arrangement may account for the difference between the agonist Hill coefficients and the single-channel conductances for the two types of receptor.

Treatment of psychogenic polydipsia: comparison of risperidone and olanzapine, and the effects of an adjunctive angiotensin-II receptor blocking drug (irbesartan)

OBJECTIVE

Our objective was to determine the outcome of novel strategies in managing a case of severe polydipsia.

CLINICAL PICTURE

The patient was a 39-year-old male with a 20-year history of paranoid schizophrenia who, despite only mild residual psychotic symptoms, had been hospitalized for the previous 10 years because of severe polydipsic behaviour complicated by water intoxication.

TREATMENT

Novel antipsychotic agents, risperidone and olanzapine, as well as the specific angiotensin-II receptor blocking drug, irbesartan were employed at selected intervals in a study lasting nearly 3 years. A strict behavioural management programme was ongoing, in which diurnal weight change and the number of breaches of weight limits, requiring management in a low-stimulus environment, were documented on a daily basis. Summary measures of diurnal weight change and behavioural intervention were charted against changes in treatment.

OUTCOME

Polydipsic behaviour improved on risperidone up to 4 mg daily, but was not sustained. Olanzapine was similarly successful in stabilizing polydipsia, and improvement was achieved with the addition of irbesartan.

CONCLUSION

We suggest that the D2-sparing profiles of receptor binding achieved with low-dose risperidone and olanzapine may account for this beneficial effect. The benefit derived with irbesartan implicates the involvement of brain angiotensin systems centrally in helping to regulate drinking behaviour.

Missense translation errors in Saccharomyces cerevisiae

We describe the development of a novel plasmid-based assay for measuring the in vivo frequency of misincorporation of amino acids into polypeptide chains in the yeast Saccharomyces cerevisiae. The assay is based upon the measurement of the catalytic activity of an active site mutant of type III chloramphenicol acetyl transferase (CATIII) expressed in S. cerevisiae. A His195(CAC)-->Tyr195(UAC) mutant of CATIII is completely inactive, but catalytic activity can be restored by misincorporation of histidine at the mutant UAC codon. The average error frequency of misincorporation of histidine at this tyrosine UAC codon in wild-type yeast strains was measured as 0. 5x10(-5) and this frequency was increased some 50-fold by growth in the presence of paromomycin, a known translational-error-inducing antibiotic. A detectable frequency of misincorporation of histidine at a mutant Ala195 GCU codon was also measured as 2x10(-5), but in contrast to the Tyr195-->His195 misincorporation event, the frequency of histidine misincorporation at Ala195 GCU was not increased by paromomycin, inferring that this error did not result from miscognate codon-anticodon interaction. The His195 to Tyr195 missense error assay was used to demonstrate increased frequencies of missense error at codon 195 in SUP44 and SUP46 mutants. These two mutants have previously been shown to exhibit a translation termination error phenotype and the sup44+ and sup46+ genes encode the yeast ribosomal proteins S4 and S9, respectively. These data represent the first accurate in vivo measurement of a specific mistranslation event in a eukaryotic cell and directly confirm that the eukaryotic ribosome plays an important role in controlling missense errors arising from non-cognate codon-anticodon interactions.

Competency to stand trial evaluations: a study of actual practice in two states

A criminal defendant must be competent to stand trial (CST) to safeguard the fundamental right to a fair trial. If there is a question as to a defendant's ability to assist in his or her own defense, a mental health professional is asked to perform a CST evaluation. Forensic assessment is a growing field, and CST is the most frequent evaluation requested. Over the years, forensic examiners' reports to the courts have been criticized for lack of relevance, insufficiency, and invading the province of the judge. If mental health professionals wish to advance the field of forensic assessment and respond to these criticisms, research on current practice with suggestions for advancement are necessary. A total of 66 CST reports conducted within the last five years in two states were compared to a proposed model for CST assessment. Results indicated that although forensic examiners are maintaining legal relevance, some CST reports may lack thoroughness and/or provide information that exceeds their role responsibilities. The findings support the need for the development of a standardized method of conducting and writing CST evaluations that should improve the quality of such reports.

Midwifery in Canada: the struggle for recognition

The pattern of development of midwifery as a profession in Canada and the UK has been similar, but Canada is nearly 75 years behind. Despite its size and international stature, Canada is one of only eight countries in the world where midwifery has not yet been legally recognised nationally. Each of the 12 provincial governments of Canada enacts its own legislation. So far, four provinces have passed appropriate legislation. Midwifery degree programmes are now under way in some provinces.

Support of first-time mothers in the first three months after birth

This paper examines the perceptions of first-time mothers of the visits of family members and friends during the first three months post partum. It is a prospective, longitudinal study which uses a multiple method approach. Twenty-four first-time mothers participated in the study. An article concerning computerisation of midwifery services starts on p. 42.

It's all in the name

In recent years it has become fashionable to call a person seeking health care a client instead of a patient. Some consider that this is part of the change in nursing, from the old military model that Florence Nightingale was acquainted with to the new consumer model. Nurses are also finding themselves in the position of acting as advocates for the care-seeking person. For me, none of these models appear appropriate for nursing.

The assessment of disability in patients on an acute medical ward for elderly people

The level of independence in self-care was monitored weekly in 212 patients admitted over 6 months to an acute medical ward for elderly people, and documented on discharge using a standard assessment, the Barthel Index. At discharge from the admitting ward, 39% of patients were independent (Barthel score of 20), 36% were mildly dependent (Barthel 15-19), 15% were moderately dependent (Barthel 10-14), 4% severely dependent (Barthel 5-9) and 6% very severely dependent (Barthel 0-4). Approximately 80% were able to transfer, walk, were continent of urine and could wash their top half, but one-third were unable to dress or use the toilet independently. Over half were unable to bath themselves or climb stairs unaided. It is feasible to assess disability in a busy acute service this way. Information can be provided both to community services on discharge of individual patients, and to managers responsible for planning services for elderly people.

Albumin Canterbury (313 Lys----Asn). A point mutation in the second domain of serum albumin

Albumin Canterbury is a fast-migrating variant of human albumin. It constituted 50% of the total serum albumin in two unrelated New Zealand males. Two-dimensional tryptic mapping suggested that the mutation occurred between residues 313 and 317 inclusive. This was confirmed by mapping of S. aureus V8 proteinase digests. The expected neutral peptide Ser-Lys-Asp-Val-Cys-Lys-Asn-Tyr-Ala-Glu (312-321) was missing and was replaced by an acidic peptide Ser-ASN-Asp-Val, Cys, Lys, Asn, Tyr, Ala, Glu. The mutation of 313 Lys----Asn, which occurs in the second domain of albumin Canterbury, does not alter the thyroxine (T4) or T3 binding. There was no discernible physical handicap associated with the presence of this new albumin.

Evaluation of a new range of air drawover vaporizers. The 'PAC' series--laboratory and 'field' studies

The 'Ether Pac' and 'Fluo Pac' temperature compensated vaporizers have been evaluated in the laboratory and the 'field'. Rigorous testing has demonstrated that these vaporizers are robust and reliable. Shaking, tilting and overturning do not significantly affect their performance. Both vaporizers deliver lower concentrations of the vapour than the setting on the vaporizers at low tidal volumes (100 ml). The 'Ether Pac' vaporizer output declines progressively with ambient temperatures below 23 degrees C and a similar result occurs with the 'Fluo Pac' at temperatures below 20 degrees C. Clinical trials in Nepal, Kenya, Burma and the UK have demonstrated that, when halothane is used, oxygen enrichment is necessary during spontaneous and controlled ventilation. When ether is used with controlled ventilation oxygen enrichment is probably not necessary even with ambient pressures as low as 619 mmHg.

In vitro activity of Ro 13-9904, cefuroxime, cefoxitin, and ampicillin against Neisseria gonorrhoeae

In vitro susceptibilities of 87 isolates of non-penicillinase-producing Neisseria gonorrhoeae and 8 isolates of penicillinase-producing N. gonorrhoeae to Ro 13-9904, cefuroxime, cefoxitin, and ampicillin were determined. Ro 13-9904 was the most effective of the four drugs, inhibiting growth of both non-penicillinase-producing and penicillinase-producing N. gonorrhoeae.