Intravascular versus surface cooling speed and stability after cardiopulmonary resuscitation.

BACKGROUND AND OBJECTIVE: Mild therapeutic hypothermia (MTH) is used to limit neurological injury and improve survival after cardiac arrest (CA) and cardiopulmonary resuscitation, but the optimal mode of cooling is controversial. We therefore compared the effectiveness of MTH using invasive intravascular or non-invasive surface cooling with temperature feedback control. METHODS: This retrospective study in post-CA patients studied the effects of intravascular cooling (CoolGard, Zoll, n=97), applied on the intensive care unit (ICU) in one university hospital compared with those of surface cooling (Medi-Therm, Gaymar, n=76) applied in another university hospital. RESULTS: Time to reach target temperature and cooling speeds did not differ between groups. During the maintenance phase, mean core temperature was 33.1°C (range 32.7-33.7°C) versus 32.5°C (range 31.7-33.4°C) at targets of 33.0 and 32.5°C in intravascularly versus surface cooled patients, respectively. The variation coefficient for temperature during maintenance was higher in the surface than the intravascular cooling group (mean 0.85% vs 0.35%, p<0.0001). ICU survival was 60% and 50% in the intravascularly and surface cooled groups, respectively (NS). Lower age (OR 0.95; 95% CI 0.93 to 0.98; p<0.0001), ventricular fibrillation/ventricular tachycardia as presenting rhythm (OR 7.6; 95% CI 1.8 to 8.9; p<0.0001) and lower mean temperature during the maintenance phase (OR 0.52; 95% CI 0.25 to 1.08; p=0.081) might be independent determinants of ICU survival, while cooling technique and temperature variability did not contribute. CONCLUSIONS: In post-CA patients, intravascular cooling systems result in equal cooling speed, but less variation in temperature during the maintenance phase, as surface cooling. This may not affect the outcome.

Factors influencing the EBM behaviour of GP trainers: a mixed method study.

BACKGROUND: General practitioner (GP) trainees state that their trainers are not consistent in using evidence-based medicine (EBM) or are even dismissive of it. As trainers are important role models in the Dutch GP training system this could have a large influence on the EBM training of GP trainees. AIM: To establish the motivations and barriers of Dutch GP trainers in using EBM. METHODS: A questionnaire on personal characteristics, knowledge, skills (Berlin, score 0-15) and attitude (McColl, VAS score 0-100), and statements about EBM barriers were presented to 106 GP trainers. Additionally, three focus group sessions with trainers (n = 30) were held. RESULTS: Knowledge and skills were less than half correct (mean 6.1, standard deviation (SD) 2.9); the overall score on attitude was 58.8 (SD 9.4). Factor analysis showed four categories of barriers: EBM competence (mean 3.5 (SD 0.8)), search activities (mean 3.5 (SD 0.8)), motivation (mean 3.8 (SD 0.7)) and time (mean 2.5 (SD 0.9)). After analysis of the focus group sessions, five categories of motivations and barriers predominated: EBM competence, attitude and behaviour, sources, time and logistics. CONCLUSION: GP trainers experience motivations in EBM; however, these motivations can also be barriers, depending on the trainer's level of knowledge and attitude.

Teaching evidence-based practice (EBP) to speech-language therapy students: are students competent and confident EBP users?

BACKGROUND: The importance and value of the principles of evidence-based practice (EBP) in the decision-making process is recognized by speech-language therapists (SLTs) worldwide and as a result curricula for speech-language therapy students incorporated EBP principles. However, the willingness actually to use EBP principles in their future profession not only depends on EBP knowledge and skills, but also on self-efficacy and task value students perceive towards EBP. AIMS: To investigate the relation between EBP knowledge and skills, and EBP self-efficacy and task value in different year groups of Dutch SLT students. METHODS & PROCEDURES: Students from three year groups filled in a tool that measured EBP knowledge and skills: the Dutch Modified Fresno (DMF). EBP self-efficacy and task value were assessed by using a 20-item questionnaire. Both tools were validated for this population. Mean scores for the three year groups were calculated and tested for group differences using a one-way analysis of variance (ANOVA) with a post-hoc Games-Howell procedure. With a multiple linear regression technique it was assessed whether EBP self-efficacy and task value predict learning achievement scores on the DMF. Other possible predictors included in the model were: level of prior education, standard of English, having had mathematics in prior education and the SLT study year. OUTCOME & RESULTS: A total of 149 students filled in both measurement tools. Mean scores on EBP knowledge and skills were significantly different for the three year groups, with students who were further along their studies scoring higher on the DMF. Mean scores on the EBP self-efficacy and task value questionnaire were the same for the three year groups: all students valued EBP positive but self-efficacy was low in all groups. Of the possible predictors, only the year in which students study and EBP self-efficacy were significant predictors for learning achievements in EBP. CONCLUSIONS & IMPLICATIONS: Despite a significant increase in EBP knowledge and skills over the years as assessed by the DMF, the integrated EBP curriculum did not raise levels of EBP self-efficacy and task value. This lack of feeling competent might have an impact on students' willingness actually to use EBP. In curricula, therefore, there should be a focus on how to raise EBP self-efficacy in SLT students. This goes even beyond the educational department because a professional culture in which professionals are competent and confident EBP users would have a positive effect on EBP self-efficacy in students.

Competent in evidence-based practice (EBP): validation of a measurement tool that measures EBP self-efficacy and task value in speech-language therapy students.

BACKGROUND: Worldwide speech-language therapy (SLT) students are educated in evidence-based practice (EBP). For students to use EBP in their future day-to-day clinical practice, they must value EBP as positive and must feel confident in using it. For curricula developers it is therefore important to know the impact their teaching has on these aspects of students' motivational beliefs. AIMS: To develop and validate a measurement tool to assess EBP task value and self-efficacy in SLT students. METHODS & PROCEDURES: A 20-item questionnaire was developed based on a review of the literature and an additional group interview with speech-language therapists. Face validity of the questionnaire was established using a Delphi panel consisting of six EBP lecturers. Dutch bachelor SLT students (n = 149) with a different level of EBP knowledge and skills filled in the newly developed questionnaire. Reliability (internal consistency) was assessed using Cronbach's alpha and internal validity using a principal component analysis (PCA). Construct validity was assessed by comparing the bachelor SLT student scores with a group of m students (n = 15) who were highly experienced in EBP. OUTCOMES & RESULTS: The PCA showed that the questionnaire consists of two components, representing EBP task value and self-efficacy, both with good reliability (Cronbach's α = 0.83 and 0.79, respectively). The hypothesis that master's students would score significantly higher on both components than bachelor SLT students was met. CONCLUSIONS & IMPLICATIONS: The study provides evidence on the internal consistency and construct validity of this questionnaire to evaluate EBP task value and self-efficacy in SLT students. As is common with new measures, more research is needed to evaluate further its psychometric properties.

Attitudes towards obesity treatment in GP training practices: a focus group study.

BACKGROUND: Both patients and government expect the GP to treat obesity. Previous studies reported a negative attitude of GPs towards this task. Little is known about the attitude of GP trainees. OBJECTIVES: To assess the attitude and other factors that influence the willingness and ability of GP trainees to provide lifestyle interventions for overweight patients. METHODS: A qualitative study was performed using focus groups, consisting of first- and third-year trainees, GP trainers and teachers. Two researchers analysed the data independently. RESULTS: First-year trainees lack knowledge and a positive attitude. Third-year trainees, although trained in motivational interviewing techniques, lack specific knowledge and feel cheated when discussing eating habits. Trainers are despondent as they rarely observe long-lasting results. Teachers warn the trainees not to have high hopes. The trainers and trainees fear ruining the relationship with their patient, and all make a request for evidence-based multidisciplinary treatment programmes, joint responsibility and an image change in society to stop the epidemic. CONCLUSIONS: Trainees do not feel more competent in treating overweight patients successfully over the course of their GP specialty training and GP trainers are not convinced of the success of the treatment of overweight patients. Therefore, it could be equally important to reflect on the GP trainer as a role model as to concentrate on the education of the trainee. Both need a revived attitude and evidence-based treatment programmes, help from policy makers and an attitude change in society are desired.

The Secretome Deregulations in a Rat Model of Endotoxemic Shock.

INTRODUCTION: Septic shock is a systemic inflammatory response syndrome associated with organ failures. Earlier clinical diagnosis would be of benefit to a decrease in the mortality rate. However, there is currently a lack of predictive biomarkers. The secretome is the set of proteins secreted by a cell, tissue, or organism at a given time and under certain conditions. The plasma secretome is easily accessible from biological fluids and represents a good opportunity to discover new biomarkers that can be studied with nontargeted "omic" strategies. AIMS: To identify relevant deregulated proteins (DEP) in the secretome of a rat endotoxemic shock model. METHODS: Endotoxemic shock was induced in rats by intravenous injection of lipopolysaccharides (LPS, S. enterica typhi, 0.5 mg/kg) and compared to controls (Ringer Lactate, iv). Under isoflurane anesthesia, carotid cannulation allowed mean arterial blood pressure (MAP) and heart rate (HR) monitoring and blood sampling at different time points (T0 and T50 or T0 and T90, with EDTA and protease inhibitor). Samples were prepared for large-scale tandem mass spectrometry (MS-MS) based on a label-free quantification to allow identification of the proteins deregulated upon endotoxemic conditions. A Gene Ontology (GO) analysis defined several clusters of biological processes (BP) in which the DEP are involved. RESULTS: Ninety minutes after shock induction, the LPS group presents a reduction in MAP (-45%, p < 0.05) and increased lactate levels (+27.5%, p < 0.05) compared to the control group. Proteomic analyses revealed 10 and 33 DEP in the LPS group, respectively, at 50 and 90 minutes after LPS injection. At these time points, GO-BP showed alterations in pathways involved in oxidative stress response and coagulation. CONCLUSION: This study proposes an approach to identify relevant DEP in septic shock and brings new insights into the understanding of the secretome adaptations upon sepsis.

Subunit identification and reconstitution of the N-type Ca2+ channel complex purified from brain.

Calcium channels play an important role in regulating various neuronal processes, including synaptic transmission and cellular plasticity. The N-type calcium channels, which are sensitive to omega-conotoxin, are involved in the control of transmitter release from neurons. A functional N-type calcium channel complex was purified from rabbit brain. The channel consists of a 230-kilodalton subunit (alpha 1B) that is tightly associated with a 160-kilodalton subunit (alpha 2 delta), a 57-kilodalton subunit (beta 3), and a 95-kilodalton glycoprotein subunit. The complex formed a functional calcium channel with the same pharmacological properties and conductance as those of the native omega-conotoxin-sensitive calcium channel in neurons.

Ca2+ channel regulation by a conserved beta subunit domain.

The beta subunit is a cytoplasmic component that normalizes the current amplitude, kinetics, and voltage dependence of voltage-gated Ca2+ channels. Here, we identify a 30 amino acid domain of the beta subunit that is sufficient to induce a stimulation and shift in the voltage dependence of activation of the Ca2+ channel currents. This domain is located at the amino terminus of the second region of high conservation among all beta subunit gene products. Single point mutations within this region on the beta 1b subunit modified or abolished the stimulation of Ca2+ channel currents and the binding of the beta subunit to the alpha 1A subunit. The binding of this domain is also required for the observed changes in kinetics and voltage dependence of steady-state inactivation induced by beta subunits.

Inositol phosphate regulation of voltage-dependent calcium channels in cerebellar granule neurons.

The effects of intracellularly applied inositol phosphates on voltage-dependent calcium channel currents were assessed in rat cerebellar neurons using the whole-cell recording configuration of the patch-clamp technique. Intraneuronal perfusion of 10 microM inositol 1,4,5-trisphosphate (IP3) increased the amplitude of currents elicited by depolarization from a holding potential of -40 mV. IP3 did not modify current activation, but shifted the steady-state inactivation curve toward more positive values. The dose-response curve indicated an EC50 of 0.5 microM for IP3. Inositol 1,3,4,5-tetrakisphosphate (IP4), but not inositol 4,5,-bisphosphate, mimicked the effect of IP3. The effect of IP3 persisted in the presence of 100 micrograms/ml heparin and did not depend on intracellular calcium mobilization, as similar responses were not produced by 10 mM caffeine or by intrapipette calcium buffering at pCa 6 instead of pCa 7.7. Preincubation with omega-conotoxin led to a 55% inhibition of barium current; however, inhibition was reversed by IP3, which reestablished the control current amplitude. These results imply that IP3 and IP4 can elicit calcium entry by modifying both the gating characteristics and the pharmacological properties of voltage-dependent calcium channels.

Dual function of the voltage-dependent Ca2+ channel alpha 2 delta subunit in current stimulation and subunit interaction.

Voltage-dependent Ca2+ channels are modulated by complex interactions with the alpha 2 delta subunit. In vitro translation was used to demonstrate a single transmembrane topology of the alpha 2 delta subunit in which all but the transmembrane sequence and 5 carboxy-terminal amino acids are extracellular. The glycosylated extra-cellular domain is required for current stimulation, as shown by coexpression of truncated alpha 2 delta subunits with alpha 1A and beta 4 subunits in Xenopus oocytes and deglycosylation with peptide-N-glycosidase F. However, coexpression of the transmembrane domain-containing delta subunit reduced the stimulatory effects of full-length alpha 2 delta subunits and substitution of a different transmembrane domain resulted in a loss of current stimulation. These results support a model whereby the alpha 2 delta transmembrane domain mediates subunit interactions and the glycosylated extracellular domain enhances current amplitude.

The I-II loop of the Ca2+ channel alpha1 subunit contains an endoplasmic reticulum retention signal antagonized by the beta subunit.

The auxiliary beta subunit is essential for functional expression of high voltage-activated Ca2+ channels. This effect is partly mediated by a facilitation of the intracellular trafficking of alpha1 subunit toward the plasma membrane. Here, we demonstrate that the I-II loop of the alpha1 subunit contains an endoplasmic reticulum (ER) retention signal that severely restricts the plasma membrane incorporation of alpha1 subunit. Coimmunolabeling reveals that the I-II loop restricts expression of a chimera CD8-I-II protein to the ER. The beta subunit reverses the inhibition imposed by the retention signal. Extensive deletion of this retention signal in full-length alpha1 subunit facilitates the cell surface expression of the channel in the absence of beta subunit. Our data suggest that the beta subunit favors Ca2+ channel plasma membrane expression by inhibiting an expression brake contained in beta-binding alpha1 sequences.

Effect of Cu2+ on the oxidative folding of synthetic maurotoxin in vitro.

Maurotoxin (MTX) is a 34-mer scorpion toxin cross-linked by four disulphide bridges that acts on various K+ channel types. It folds according to an alpha/beta scaffold, i.e., a helix connected to a two stranded beta-sheet by two disulphide bridges. In a former study, various parameters that affect the oxidation and folding of the reduced form of synthetic MTX were investigated in vitro. It was found that MTX achieves its final 3-D structure by evolving over time through a series of oxidation intermediates, from the least to the most oxidized species. MTX oxidative intermediates can be studied by iodoacetamide alkylation of free cysteine residues followed by mass spectrometry analysis. Here, we have analysed the effect of Cu2+ (0.1 to 50 mM) on the kinetics of MTX oxidative folding and found that it dramatically speeds up the formation of the four-disulphide bridged, native-like, MTX (maximal production within 30 minutes instead of > 60 hours). This catalysing effect of Cu2+ was found to be concentration-dependent, reaching a plateau at 10 mM copper ions. Cu2+ was also found to prevent the slow transition of a three disulphide-bridged MTX intermediate towards the final four disulphide-bridged product (12% of total MTX). The data are discussed in light of the potential effects of Cu2+ on MTX secondary structure formation, disulphide bridging and peptidyl prolyl cis-trans isomerization.

Hyperoxia does not directly affect vascular tone in isolated arteries from mice.

Hospitalized patients often receive oxygen supplementation, which can lead to a supraphysiological oxygen tension (hyperoxia). Hyperoxia can have hemodynamic effects, including an increase in systemic vascular resistance. This increase suggests hyperoxia-induced vasoconstriction, yet reported direct effects of hyperoxia on vessel tone have been inconsistent. Furthermore, hyperoxia-induced changes in vessel diameter have not been studied in mice, currently the most used mammal model of disease. In this study we set out to develop a pressure-myograph model using isolated vessels from mice for investigation of pathways involved in hyperoxic vasoconstriction. Isolated conduit and resistance arteries (femoral artery and gracilis arteriole, respectively) from C57BL/6 mice were exposed to normoxia (PO2 of 80 mmHg) and three levels of hyperoxia (PO2 of 215, 375 and 665 mmHg) in a no-flow pressure myograph setup. Under the different PO2 levels, dose-response agonist induced endothelium-dependent vasodilation (acetylcholine, arachidonic acid), endothelium-independent vasodilation (s-nitroprusside), as well as vasoconstriction (norepinephrine, prostaglandin F2α) were examined. The investigated arteries did not respond to oxygen by a change in vascular tone. In the dose-response studies, maximal responses and EC50 values to any of the aforementioned agonists were not affected by hyperoxia either. We conclude that arteries and arterioles from healthy mice are not intrinsically sensitive to hyperoxic conditions. The present ex-vivo model is therefore not suitable for further research into mechanisms of hyperoxic vasoconstriction.

Subunit interaction sites in voltage-dependent Ca2+ channels: role in channel function.

Voltage-dependent Ca2+ channels are heteromeric complexes found in the plasma membrane of virtually all cell types and show a high level of electrophysiological and pharmacological diversity. Associated with the pore-forming alpha 1 subunit are the membrane anchored, largely extracellular alpha2-delta, the cytoplasmic beta and sometimes a transmembrane gamma subunit; these subunits dramatically influence the properties and surface expression of these channels. Effects vary depending on subunit isoforms, suggesting that functional diversity of native channels reflects heterogeneity of combinations. Interaction sites between subunits have been identified and advances have been made in our understanding of the molecular basis of functional effects of the auxiliary subunits, their capacity to be regulated by G proteins, and their interaction with related cellular systems.

[From the Cochrane Library: both expectant management and curettage are suitable options in case of miscarriage]. / Uit de Cochrane Library: afwachtend beleid en curettage bij miskraam beide geschikte opties.

A Cochrane systematic review of 5 randomised clinical trials compared the safety and efficacy of expectant management versus curettage for early foetal loss. The expectant-care group was more likely to have an incomplete miscarriage, a need of unplanned curettage, and bleeding. In contrast, curettage was associated with a significantly higher risk ofinfection. Given the lack of clear superiority of either approach, the woman's preference should play a dominant role in reaching a decision.

The [beta]2a subunit is a molecular groom for the Ca2+ channel inactivation gate.

Ca(2+) channel inactivation is a key element in controlling the level of Ca(2+) entry through voltage-gated Ca(2+) channels. Interaction between the pore-forming alpha(1) subunit and the auxiliary beta subunit is known to be a strong modulator of voltage-dependent inactivation. Here, we demonstrate that an N-terminal membrane anchoring site (MAS) of the beta(2a) subunit strongly reduces alpha(1A) (Ca(V)2.1) Ca(2+) channel inactivation. This effect can be mimicked by the addition of a transmembrane segment to the N terminus of the beta(2a) subunit. Inhibition of inactivation by beta(2a) also requires a link between MAS and another important molecular determinant, the beta interaction domain (BID). Our data suggest that mobility of the Ca(2+) channel I-II loop is necessary for channel inactivation. Interaction of this loop with other identified intracellular channel domains may constitute the basis of voltage-dependent inactivation. We thus propose a conceptually novel mechanism for slowing of inactivation by the beta(2a) subunit, in which the immobilization of the channel inactivation gate occurs by means of MAS and BID.

Selective blockade of P/Q-type calcium channels by the metabotropic glutamate receptor type 7 involves a phospholipase C pathway in neurons.

Although presynaptic localization of mGluR7 is well established, the mechanism by which the receptor may control Ca(2+) channels in neurons is still unknown. We show here that cultured cerebellar granule cells express native metabotropic glutamate receptor type 7 (mGluR7) in neuritic processes, whereas transfected mGluR7 was also expressed in cell bodies. This allowed us to study the effect of the transfected receptor on somatic Ca(2+) channels. In transfected neurons, mGuR7 selectively inhibited P/Q-type Ca(2+) channels. The effect was mimicked by GTPgammaS and blocked by pertussis toxin (PTX) or a selective antibody raised against the G-protein alphao subunit, indicating the involvement of a G(o)-like protein. The mGuR7 effect did not display the characteristics of a direct interaction between G-protein betagamma subunits and the alpha1A Ca(2+) channel subunit, but was abolished by quenching betagamma subunits with specific intracellular peptides. Intracellular dialysis of G-protein betagamma subunits did not mimic the action of mGluR7, suggesting that both G-protein betagamma and alphao subunits were required to mediate the effect. Inhibition of phospholipase C (PLC) blocked the inhibitory action of mGluR7, suggesting that a coincident activation of PLC by the G-protein betagamma with alphao subunits was required. The Ca(2+) chelator BAPTA, as well as inhibition of either the inositol trisphosphate (IP(3)) receptor or protein kinase C (PKC) abolished the mGluR7 effect. Moreover, activation of native mGluR7 induced a PTX-dependent IP(3) formation. These results indicated that IP(3)-mediated intracellular Ca(2+) release was required for PKC-dependent inhibition of the Ca(2+) channels. Possible control of synaptic transmission by the present mechanisms is discussed.

[Summary of the practice guideline 'Miscarriage' (second revision) from the Dutch College of General Practitioners (NHG)]. / Samenvatting van de standaard 'miskraam' (tweede herziening) van het nederlands huisartsen genootschap.

The NHG practice guideline 'Miscarriage' provides guidelines for the diagnosis and management of pregnant women with vaginal bleeding during the period up to and including the 16th week after the first day of the last menstruation. The guideline has been revised on the basis of the developments over the last few years. The most important modifications are: In case of an imminent miscarriage, more consideration than before is given to the patient's preference with regard to ultrasonography, expectant management and curettage. The GP should therefore discuss the advantages and disadvantages of these options with the patient. A midwife was involved in the formulation of the new guideline. Referral from a GP to a midwife for transvaginal ultrasonography is offered as one of the possibilities. The paragraph on 'information' has been expanded on the basis of the results of a patient focus group.

The ABC transporter BcatrB affects the sensitivity of Botrytis cinerea to the phytoalexin resveratrol and the fungicide fenpiclonil.

During pathogenesis, fungal pathogens are exposed to a variety of fungitoxic compounds. This may be particularly relevant to Botrytis cinerea, a plant pathogen that has a broad host range and, consequently, is subjected to exposure to many plant defense compounds. In practice, the pathogen is controlled with fungicides belonging to different chemical groups. ATP-binding cassette (ABC) transporters might provide protection against plant defense compounds and fungicides by ATP-driven efflux mechanisms. To test this hypothesis, we cloned BcatrB, an ABC transporter-encoding gene from B. cinerea. This gene encodes a 1,439 amino acid protein with nucleotide binding fold (NBF) and transmembrane (TM) domains in a [NBF-TM6]2 topology. The amino acid sequence has 31 to 67% identity with ABC transporters from various fungi. The expression of BcatrB is up regulated by treatment of B. cinerea germlings with the grapevine phytoalexin resveratrol and the fungicide fenpiclonil. BcatrB replacement mutants are not affected in saprophytic growth on different media but are more sensitive to resveratrol and fenpiclonil than the parental isolate. Furthermore, virulence of deltaBcatrB mutants on grapevine leaves was slightly reduced. These results indicate that BcatrB is a determinant in sensitivity of B. cinerea to plant defense compounds and fungicides.