The Radical-Scavenging Activity of a Purified and Sequenced Peptide from Lactic Acid Fermentation of Thunnus albacares By-Products.

Yellowfin tuna by-products (Thunnus albacares) were processed to produce radical-scavenging peptides from hydrolysis by lactic acid fermentation (LAF) with Lactobacillus plantarum, papaya fruit (Carica papaya), and molasses as a carbon source for 72 h. A 15-kDa peptide was purified; after de novo sequencing, it was determined that fragments are rich in hydrophobic and neutral amino acids. The results suggest this effect is mainly to the hydrophobicity of the amino acids in their sequence. Further work is on progress to assess the ability of peptides to provide stability in lipids or in other types of samples sensitive to the action of free radicals.

The impact of glycaemic variability on the surgical patient.

PURPOSE OF REVIEW: Diabetes is the most prevalent long-term metabolic condition and its incidence continues to increase unabated. Patients with diabetes are overrepresented in the surgical population. It has been well recognized that poor perioperative diabetes control is associated with poor surgical outcomes. The outcomes are worst for those people who were not recognized as having hyperglycaemia. RECENT FINDINGS: Recent work has shown that preoperative recognition of diabetes and good communication between the clinical teams at all stages of the patient pathway help to minimize the potential for errors, and improve glycaemic control. The stages of the patient journey start in primary care and end when the patient goes home. The early involvement of the diabetes specialist team is important if the glycated haemoglobin is more than 8.5%, and advice sought if the preoperative assessment team is not familiar with the drug regimens. To date the glycaemic targets for the perioperative period have remained uncertain, but recently a consensus is being reached to ensure glucose levels remain between 108 and180 mg/dl (6.0 and 10.0 mmol/l). There have been a number of ways to achieve these - primarily by manipulating the patients' usual diabetes medications, to also allow day of surgery admission. SUMMARY: glycaemic control remains an important consideration in the surgical patient.

Patient evaluation of early discharge after hip arthroplasty: development of a measure and comparison of three centres with differing durations of stay.

OBJECTIVE: We compared patients' evaluation of care between a surgical unit with a rapid discharge policy and two comparison units to test the hypothesis that the centre with rapid discharge has outcomes that are not inferior to those of the comparison sites. DESIGN: Cross-sectional cohort study. SUBJECTS: Consecutive consenting patients undergoing primary hip arthroplasty during 12 months in: a unit that had reduced postoperative stay to median three days; a specialised orthopaedic surgery treatment centre with median stay of five days; a traditional unit with median stay of six days (N = 316, 125, 119, respectively). METHODS: Six weeks postoperatively, patients completed a specially developed questionnaire measuring their evaluation of care and recovery, together with measures of function and quality of life for validation purposes. RESULTS: Factor analysis of questionnaire responses identified two independent components of patients' evaluation: problems in staff care and problems in physical recovery. Neither component was impaired in the unit with rapid discharge: similar proportions of patients reported recovery problems in each site (odds radios (ORs) for the two comparators versus unit with rapid discharge: 0.96, 1.18); and more patients reported care problems in the two comparator sites (ORs 2.97, 2.16). CONCLUSION: Duration of stay after primary hip arthroplasty can be reduced to three days without intensive pre- or postoperative care, without detriment to patient evaluation.

Different responses of selected hormones to three types of exercise in young men.

Exercise is a potent stimulus for release of growth hormone (GH), cortisol, testosterone and prolactin, and prolonged exercise inhibits insulin secretion. These responses seem to be specific to the type of exercise but this has been poorly characterised primarily because they have not been compared during exercise performed by the same individuals. We investigated hormone responses to resistance, sprint and endurance exercise in young men using a repeated measures design in which each subject served as their own control. Eight healthy non-obese young adults (18-25 years) were studied on four occasions in random order: 30-s cycle ergometer sprint (Sprint), 30-min resistance exercise bout (Resistance), 30-min cycle at 70 % VO(2max) (Endurance), and seated rest in the laboratory (Rest). Cortisol, GH, testosterone, prolactin, insulin and glucose concentrations were measured for 60 min after the four different interventions. Endurance and sprint exercise significantly increased GH, cortisol, prolactin and testosterone. Sprint exercise also increased insulin concentrations, whereas this decreased in response to endurance exercise. Resistance exercise significantly increased only testosterone and glucose. Sprint exercise elicited the largest response per unit of work, but the smallest response relative to mean work rate in all hormones. In conclusion, the nature and magnitude of the hormone response were influenced by exercise type, perhaps reflecting the roles of these hormones in regulating metabolism during and after resistance, sprint and endurance exercise.

Effects of anaesthesia on the inflammatory response to injury.

PURPOSE OF REVIEW: The systemic inflammatory response to injury is essential for wound healing and recovery in concert with other endocrinological, metabolic and immunological changes. However, recent studies suggest that a hyperinflammatory state is associated with adverse perioperative outcomes. Therefore interventions that modulate the inflammatory response, surgical, anaesthetic and pharmacological, may enhance recovery with fewer complications. RECENT FINDINGS: Basic research on wound biology has shown the importance of genetic variability in determining the initial inflammatory response. Clinically, studies of cardiac surgery predominate in which genetic polymorphisms have been shown to result in a hyperinflammatory state. SUMMARY: The use of an interleukin-1 receptor antagonist to control wound pain and limit local inflammation is under consideration. The role of glucocorticoids in obtunding the inflammatory response to injury with improved outcome requires confirmation with better-quality trials. Systemic lidocaine is anti-inflammatory but is effective only in abdominal surgery. NSAIDs are neglected, despite their widespread clinical use and merit detailed investigation.

The consequences of early discharge after hip arthroplasty for patient outcomes and health care costs: comparison of three centres with differing durations of stay.

OBJECTIVE: To compare outcomes from hip arthroplasty between a surgical unit with a rapid discharge policy and two comparison units to test the hypothesis that the centre with rapid discharge has outcomes that are not inferior to the comparison sites. DESIGN: Prospective cohort study. SUBJECTS: Consecutive consenting patients receiving primary hip arthroplasty during 12 months beginning July 2006 in three UK National Health Service surgical units. One has shortened postoperative stay to median three days; one was a new treatment centre with median stay of five days; the third was a traditional unit with median stay of six days (N = 316, 119, 87, respectively). METHODS: Patients were assessed preoperatively and six weeks postoperatively. The primary indicator of function was the Oxford Hip Score. Additional secondary measures included further self-report indicators of function and quality of life and health service costs. RESULTS: Patient outcome in the unit with rapid discharge was not impaired by comparison with the other sites on any measure: Oxford Hip Score decreased from 49 to 27 in the short-stay unit, from 40 to 30 in the treatment centre and from 43 to 32 in the traditional unit. Cost of arthroplasty was least in the short-stay unit, although there was potential for cost savings in each. CONCLUSION: Short postoperative stay after hip arthroplasty can be achieved without intensive patient preparation or post-discharge care and without compromising short-term patient outcome or increasing health care costs. Longer term follow-up is needed.

Early discharge following hip arthroplasty: patients' acceptance masks doubts and concerns.

OBJECTIVE: To describe patients' experience of accelerated discharge after hip arthroplasty in order to test the acceptability to patients of economically driven shortening of post-operative stay. METHODS: Patients (n = 35) who had received primary total hip replacement up to 12 weeks previously were recruited from two UK orthopaedic units, one of which has pioneered short post-operative stay (3-4 days), and another one of which retains a traditional regimen of discharge after 6-7 days. Patients were interviewed about their experience of care, focusing particularly on their views related to length of stay and with particular attention to patients' well-known tendency to mask critical views of their care. Transcripts were analysed thematically to identify the ways that patients evaluated their care and whether these differed between sites. RESULTS: Patients were primarily concerned with how attentive and informative hospital staff had been and did not refer to length of stay spontaneously. When prompted about this, they did not question their discharge time, although those in the more traditional unit could not countenance more rapid discharge. Patients in the unit with accelerated discharge described concerns about the consequences of early discharge for them or their family, particularly managing pain and mobility problems at home and needing more support. CONCLUSIONS: Patients' traditional beliefs about the necessity of prolonged convalescence are not a barrier to early discharge after hip arthroplasty. Nevertheless, some patients' acceptance of early discharge masks doubts and concerns. More intensive post-operative management may be needed if clinical care is not to suffer.

Growth hormone responses to 3 different exercise bouts in 18- to 25- and 40- to 50-year-old men.

Exercise is a potent stimulus for growth hormone (GH) release, although aging appears to attenuate this response. The aim of this study was to investigate GH responses to different exercise stimuli in young and early middle-aged men. Eight men aged 18-25 y and 8 men aged 40-50 y completed 3 trials, at least 7 days apart, in a random order: 30 s cycle-ergometer sprint (sprint), 30 min resistance exercise bout (resistance), 30 min cycle at 70% maximal oxygen consumption (endurance). Blood samples were taken pre-, during, and post-exercise, and area under the GH vs. time curve was calculated for a total of 120 min. Mean blood lactate concentrations and percentage heart rate maximum at which the participants were working were not different between groups in any of the trials. In both groups, blood lactate concentrations were significantly lower in the endurance trial than in the sprint and resistance trials. There were no significant differences in resting GH concentration between groups or trials. GH AUC was significantly greater in the young group than the early middle-aged group, in both sprint (531 (+/-347) vs. 81 (+/-54) microg.L-1 per 120 min, p = 0.003) and endurance trials (842 (+/-616) vs. 177 (+/-137) microg.L-1 per 120 min, p = 0.010). Endurance exercise elicits a greater GH response than sprint and resistance exercise; however, aging per se, factors associated with aging, or an inability to achieve a sufficient absolute exercise intensity results in a smaller GH response to an exercise stimulus in early middle-aged men.

Surgical stress response.

Recent advances in molecular medicine have allowed the characterization and quantification of inflammatory cascades following surgery and trauma. Activation of immune cells is followed by the release of various cytokines as well as by migration of leukocytes into inflamed tissues. Various methods have been developed in order to modulate the immune-inflammatory system and at the same time to prevent overreaction and unexpected complications. In this context, the magnitude of surgical stress exerted on the patient is of paramount importance. Several factors, either controllable or not, are known to contribute to the development and amplification of the 'surgical stress response'. Therefore, they should be taken into consideration by both surgical practitioners and other medical specialties involved in the management of the traumatised patient.

Effect of creatine supplementation on training for competition in elite swimmers.

PURPOSE: The study was conducted to examine the effects of oral creatine supplementation on training for competition in 20 elite swimmers. METHODS: Subjects performed a maximal sprint test (8 x 50 yd (45.72 m), T1) before loading with creatine (Cr, 20 g.d Cr monohydrate for 5 d), 1 wk later (T2), and following a 22- to 27-wk period of training and competition (T3). Following T2, subjects supplemented with either Cr (3 g + glucose 7 g.d) or placebo (glucose 10 g.d; double blind) for the remainder of the 22- to 27-wk season and then both groups supplemented once more with 20 g.d Cr monohydrate for 5 d before their major competition. Venous and capillary blood samples were obtained pre- and posttest during the repeated sprint tests to determine blood metabolites and hormones. Competition times were recorded, and changes in subjects' best times were used to compare the effect of training and supplementation on competitive performance. RESULTS: Mean competition times in the Cr and control groups changed by+1.90 +/-1.91 and+0.72+/-1.64% for short course (SC, 25-m pool) and by+0.14+/-1.14 and -0.59+/-0.82% long course (LC, 50-m pool), respectively (Cr vs control, NS). No differences between groups were found in blood metabolites, although the human growth hormone (hGH) response to repeated sprints was blunted following Cr loading (T1, 30.42+/-14.60 and 28.95+/-18.27 microg.L; T2, 21.48+/-13.96 and 14.24+/-7.32 microg.L for Cr and control groups, respectively P<0.05). CONCLUSION: No statistically significant differences in performance were observed between groups after long-term maintenance during training, although small differences were observed that might be meaningful for elite performers.

Anaesthesia in elderly patients with neurodegenerative disorders: special considerations.

Neurodegenerative diseases are increasingly common in elderly patients, who present a particular anaesthetic challenge. The majority of people over the age of 70 years have some degree of cerebral atrophy. The pathogenesis of neurodegenerative diseases is due to alterations in the transport, degradation and aggregation of proteins. Alterations in physiology that occur with advancing age affect both the pharmacokinetics and pharmacodynamics of drugs used in the elderly. Changes in pharmacokinetics result in either increased or reduced drug concentrations depending on the variable contributions of absorption, metabolism and elimination. The distribution of a drug depends on its protein binding, cardiac output and blood volume, which are all altered in the elderly. Metabolism and excretion of drugs are also affected due to changes in hepatic and renal mass and blood flow in the elderly. A number of drugs are used in neurodegenerative disorders including antidepressants, benzodiazepines, antipsychotics, acetylcholinesterase inhibitors and levodopa. Polypharmacy is a common problem, which can lead to adverse drug interactions and an exacerbation of dementia. Levodopa, bromocriptine and tricyclic antidepressants are known to cause orthostatic hypotension in patients with neurodegenerative disease. Elderly patients are liable to excessive sedation from benzodiazepines in both the pre- and postoperative period; therefore these drugs should be prescribed in low doses. For induction of general anaesthesia propofol is a suitable agent in patients with neurodegenerative disease due to its rapid metabolism, but may not be suitable in patients with Parkinson's disease as it can induce spontaneous involuntary movements. Volatile inhalational agents should be administered carefully in the elderly, as they are more sensitive to the depressant cerebral and cardiovascular effects. Levodopa should be avoided in conjunction with halothane, which sensitises the heart to catecholamines. Co-administration of monoamine oxidase inhibitors and opioids should be avoided as it can cause agitation, muscular rigidity, sweating and hyperpyrexia. If an anticholinergic agent is required, then glycopyrronium bromide is the drug of choice in this group of patients, as it does not cross the blood brain barrier. Patients should continue to take their usual medications in hospital and do not let the change in routine alter the times at which treatments are administered. This is particularly relevant to the timing of levodopa in Parkinson's disease, as missed treatment can be detrimental. Regional anaesthesia may, however, have significant advantages in patients with Parkinson's disease, who can continue to take oral levodopa preoperatively, during surgery, if required, and early in the postoperative period. Anti-emetic drugs such as phenothiazines, butyrophenones and metoclopramide should be used carefully in the postoperative period in these patients as their antidopaminergic effects may induce or exacerbate parkinsonian effects.

Effect of 6 weeks of sprint training on growth hormone responses to sprinting.

This study examined the effect of 6 weeks of prescribed sprint training on the human growth hormone (hGH) response to cycle ergometer sprinting. Sixteen male subjects were randomly assigned to a training (n=8) or a control (n=8) group. Each subject completed two main trials, consisting of two all-out 30-s cycle-ergometer sprints separated by 60 min of passive recovery, once before, and once after a 6-week training period. The training group completed three supervised sprint-training sessions per week in addition to their normal activity, whilst control subjects continued with their normal activity. In the training group, peak and mean power increased post-training by 6% (P<0.05) and 5% (P<0.05), respectively. Post-exercise blood pH did not change following training, but the highest post-exercise blood lactate concentrations were greater [highest measured value: 13.3 (1.0) vs 15.0 (1.1) mmol l(-1)], with lower blood lactate concentrations for the remainder of the recovery period (P<0.05). Post-exercise plasma ammonia concentrations were lower after training [mean highest measured value: 184.1 (9.8) vs 139.0 (11.7) micromol l(-1), P<0.05]. Resting serum hGH concentrations did not change following training, but the peak values measured post-exercise decreased by over 40% in the training group [10.3 (3.1) vs 5.8 (2.5) microg l(-1), P<0.05], and mean integrated serum hGH concentrations were 55% lower after training [567 (158) vs 256 (121) min microg l(-1), P<0.05]. The hGH response to the second sprint was attenuated similarly before and after training. This study showed that 6 weeks of combined speed- and speed-endurance training blunted the human growth hormone response to sprint exercise, despite an improvement in sprint performance.

Reproducibility of the growth hormone response to sprint exercise.

OBJECTIVE: There is a large inter-individual variation in the growth hormone (GH) response to exercise, but within-individual variation is unknown. The purpose of this study was to determine the reproducibility of the GH response to a single 30 s sprint on a cycle ergometer. DESIGN: Eleven non-obese male volunteers completed two trials separated by at least seven days during which they completed a single all-out 30 s sprint on a cycle ergometer followed by 60 min of rest. Blood samples were taken at rest and at regular intervals post-exercise. RESULTS: No differences were found in mean power output during the sprint, or in peak blood lactate concentrations or lowest measured pH following the sprints. Re-test correlation was significant for both peak GH concentrations (r=0.97, P<0.05) and GH AUC (r=0.97, P<0.05). Within-subject error (change in mean+/-typical error) of the peak GH concentrations and GH area under the curve (AUC) was 4.3+/-3.4 microg l(-1) and 2.9+/-54.3 min microg l(-1), respectively. Within-subject percentage error (percentage change in mean+/-typical percentage error) for peak GH concentration and GH AUC was 33.5+/-26.7% and 1.1+/-20.0%, respectively. CONCLUSION: Growth hormone AUC is a reproducible measure of the GH response to sprint exercise.

Patient empowerment and control: a psychological discourse in the service of medicine.

The discourse of the patient as an active agent in managing illness and health care has become very important in medicine. It is seen in the significance attached to patient empowerment and participation, and in the burgeoning research into patients' coping with illness. The discourse cannot be fully understood from within conventional scientific frameworks because it is part of those frameworks. Instead, its current prominence can be understood by examining how it meets the needs of those who use it. Specifically, it has combined with earlier discourses of disease in a way that allows clinicians to withdraw from responsibility for areas of patient need that are problematic for medicine, such as unexplained symptoms, chronic disease and pain. This view is supported by evidence about how the discourse of patient as agent has been used in clinical consultation to constrain doctors' responsibility for patients' suffering. This discourse and other ways in which doctors and patients influence the boundaries of medical responsibility should be subjects for, rather than constraints on, empirical research.

Physiological and psychological influences on postoperative fatigue.

UNLABELLED: Fatigue is common after major surgery and delays recovery. We studied the role of physiological and psychological factors in determining fatigue and physical well being after surgery in 102 patients undergoing primary hip arthroplasty. Self-administered questionnaires were used to measure the intensity of feelings of fatigue, vigor, depression, and subjective physical well being on the day before surgery, on the third and seventh postoperative days, and 1 and 6 mo after surgery. The physiological response to surgery was determined by sequential measurements of circulating norepinephrine, epinephrine, cortisol, interleukin-6, and C-reactive protein during the 7 days after surgery. The peak value of each variable was used for statistical analysis. Physical well being decreased significantly at 3 and 7 days but increased significantly at 1 and 6 mo. Fatigue decreased significantly at 1 and 6 mo. Multiple regression analysis showed that the main predictor of worse physical well being at 3 days was the size of the C-reactive protein response. Subsequently, the main predictor was the level of preoperative well being. The severity of fatigue and vigor after surgery were predicted mostly by the preoperative levels of the respective variable. We conclude that fatigue after hip arthroplasty was not predicted by physiological variables but was largely predicted by preoperative levels of fatigue. IMPLICATIONS: Fatigue is common after major surgery and delays recovery. It is usually attributed to the physiological response to surgery. We studied patients undergoing hip arthroplasty and found that the severity of postoperative fatigue was not predicted by physiological changes. Instead, it was predicted by the preoperative level of fatigue.

Patient-controlled analgesia: what information does the patient want?

AIMS OF THE STUDY: To formulate and evaluate an information leaflet for patients using patient-controlled analgesia (PCA), incorporating information thought to be important by patients. RATIONALE: The benefit of current information leaflets, written by professionals, has not been studied and their value to patients is unknown. BACKGROUND: Previous studies have shown that information leaflets were poorly designed and written in language too difficult for patients to understand. RESEARCH METHODS: Seven focus groups were conducted to establish what information patients wanted to know about PCA. This information was incorporated into a new information leaflet. One hundred patients were randomized to receive either the new leaflet or the old leaflet in current use. A questionnaire was used to establish whether the new leaflet was more clear and informative than the old one. RESULTS: Patients wanted to know that the drug used in PCA was morphine. They wanted more information about side-effects, needed to be reassured that it was safe, and that they could not overdose or become addicted. They wanted detailed instructions and diagrams about the technique. The questionnaire study established that the new leaflet was clearer and more informative. CONCLUSION: Patients' contribution led to major change, producing a leaflet which was clearer, more attractive, more informative and which proved more satisfactory to patients.