Seating and pressure support needs of people with cancer in the cervix or rectum: a case series on the clinical usefulness of pressure mapping assessment.

Pressure sores present a challenge to people with rectal and cervical cancers due to weight loss, compromised nutrition, chemotherapy and radiotherapy. Affected individuals often experience intense pain on sitting, and prefer to spend the majority of their time lying down. This pilot study, employing a case study design, investigated the pressure care needs of such persons using pressure mapping, a technology designed to measure pressures at the seating interface. Four participants were mapped on a selection of five cushions, three of which were developed to specifically reduce midline posterior pressure/pain relief. Participants rated the cushions for comfort. Findings demonstrated an inconsistent relationship between interface pressures and perceived cushion comfort, suggesting that patient-rated comfort is a poor indicator of high interface pressures. The specialized cushions did not always meet the needs of this target population and no one cushion suited all. This study demonstrated the precarious clinical balance needed between comfort and achieving optimal pressure reduction in cushion prescription for this client group, and suggested that comfort was more important than pressure reduction in terms of their seating needs.

Interface pressure measurements: visual interpretation of pressure maps with MS clients.

PURPOSE: Pressure mapping systems provide useful information for pressure care assessment. Healthcare professionals tend to rely upon their colour-coded pressure maps to assist clinical decision-making, based on ranking these from best to worst pressure distribution. The current study investigated whether such ranking is an appropriate method of assessment when compared to use of the numerical output of average and maximum pressure values (mmHg), yielded by the system. METHOD: This community-based correlational study involved 27 multiple sclerosis clients (15 wheelchair users; 12 non-wheelchair users). Pressure maps were recorded on each participant's current seating surface and on six pressure reducing cushions, using the Force Sensing Array pressure mapping system. Outcome measures included (1) rank order of pressure maps based on visual interpretation by two occupational therapists, (2) average pressure (mmHg) and (3) maximum pressure (mmHg). Visual ranking of the colour-coded pressure maps was correlated with average and maximum pressure values for each map. RESULTS: Correlations between visual ranking of maps and maximum pressures were high for six out of seven surfaces (p < 0.05) for non-wheelchair users; however, they were much less between average pressures and visual interpretation for the same cohort. Similarly, correlations between visual ranking of maps and average pressures for wheelchair users was minimal and was only noted as being high (p < 0.05) on two surfaces when considering maximum pressures and visual interpretation. CONCLUSIONS: This study contests the usefulness of the visual ranking of pressure maps in interpreting interface pressures with MS clients, especially with wheelchair users. Visual interpretation of pressure maps by clinicians may be useful in eliminating inappropriate support surfaces from a selection, or those that display easily identifiable 'extremes' of pressure values. Clinicians need to incorporate and interpret the numerical data as well as pressure maps when conducting their assessment and making provision.

Mad proteins contain a dominant transcription repression domain.

Transcription repression by the basic region-helix-loop-helix-zipper (bHLHZip) protein Mad1 requires DNA binding as a ternary complex with Max and mSin3A or mSin3B, the mammalian orthologs of the Saccharomyces cerevisiae transcriptional corepressor SIN3. The interaction between Mad1 and mSin3 is mediated by three potential amphipathic alpha-helices: one in the N terminus of Mad (mSin interaction domain, or SID) and two within the second paired amphipathic helix domain (PAH2) of mSin3A. Mutations that alter the structure of the SID inhibit in vitro interaction between Mad and mSin3 and inactivate Mad's transcriptional repression activity. Here we show that a 35-residue region containing the SID represents a dominant repression domain whose activity can be transferred to a heterologous DNA binding region. A fusion protein comprising the Mad1 SID linked to a Ga14 DNA binding domain mediates repression of minimal as well as complex promoters dependent on Ga14 DNA binding sites. In addition, the SID represses the transcriptional activity of linked VP16 and c-Myc transactivation domains. When fused to a full-length c-Myc protein, the Mad1 SID specifically represses both c-Myc's transcriptional and transforming activities. Fusions between the GAL DNA binding domain and full-length mSin3 were also capable of repression. We show that the association between Mad1 and mSin3 is not only dependent on the helical SID but is also dependent on both putative helices of the mSin3 PAH2 region, suggesting that stable interaction requires all three helices. Our results indicate that the SID is necessary and sufficient for transcriptional repression mediated by the Mad protein family and that SID repression is dominant over several distinct transcriptional activators.

Oxidative N-demethylation of N,N-dimethylaniline by purified isozymes of cytochrome P-450.

The metabolism of N,N-dimethylaniline (DMA) by rabbit liver microsomes results in the formation of N-methylaniline (NMA) and formaldehyde. The N-oxide of DMA (DMA N-oxide) has been suggested as an intermediate in the cytochrome P-450-catalyzed demethylation reaction. The role of DMA N-oxide as an intermediate in demethylation has been investigated in a reconstituted system consisting of NADPH-cytochrome P-450 reductase, phospholipid, and several different purified isozymes of cytochrome P-450. The abilities of several cytochrome P-450 isozymes from rabbit liver (P-450 form 2 and P-450 form 4) and rat liver (P-450b and P-450c) to catalyze N-oxide formation and their abilities to catalyze demethylation of the N-oxide were determined and compared with their abilities to catalyze the demethylation of DMA. The metabolism of DMA by the purified isozymes of cytochrome P-450 in the reconstituted system did not result in the formation of measurable amounts of the N-oxide. The turnover numbers for the metabolism of DMA and DMA N-oxide to formaldehyde by the reconstituted system containing cytochrome P-450 form 2 were 25.6 and 3.4 nmol/min/nmol cytochrome P-450, respectively. The three other isozymes (P-450 form 4, P-450b, and P-450c) also exhibited significantly greater rates for the demethylation of DMA than for the N-oxide. If the N-oxide were an intermediate in the demethylation reaction, it should be metabolized at a rate greater than or at least equal to DMA. Therefore, these data, along with the inability to detect N-oxide formation during the cytochrome P-450-catalyzed demethylation of DMA, suggest that the N-oxide of DMA is not an intermediate in demethylation of DMA by these forms of cytochrome P-450 and that DMA N-oxidase activity is not associated with these isozymes.

Intrauterine vascular deficiency of the upper limb.

We report six cases of intrauterine vascular deficiency of the upper limb, presenting over a 12-year period, with established areas of necrosis at the time of birth. Three of the six mothers were diabetic. An urgent examination of the neonate should be done to exclude occult systemic thomboses, as early anticoagulation or thrombolytic therapy may be indicated. The majority of cases were managed conservatively with dressings and splintage of the limb; exceptionally surgical intervention was required. Long-term sequelae included flexion contractures and shortening of the forearm bones.

Apocrine hidrocystoma: report of a case.

A case of apocrine hidrocystoma, mimicking a naso-labial cyst of the maxilla is reported. The histopathological features and treatment of these rare lesions is discussed.

Travelling abroad for aesthetic surgery: Informing healthcare practitioners and providers while improving patient safety.

Travelling abroad for surgery is a phenomenon reported internationally. It is particularly likely for aesthetic procedures not undertaken routinely by national health services. We assessed the impact of these patients presenting to the UK National Health Service (NHS) with concerns or complications on their return. All 326 UK consultant members of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) were asked to complete a short questionnaire about patients that had presented to the NHS with complications or concerns following surgery abroad. The results were subsequently presented to the Department of Health (DH). 203 (62%) UK consultant plastic surgeons responded. 76 (37%) of the 203 respondents had seen such patients in their NHS practice, most commonly following breast or abdominal procedures. A quarter underwent emergency surgery, a third out-patient treatment and a third elective surgical revision. In response to these findings, the DH clarified that NHS teams should provide emergency care to such patients but should not undertake any elective revision procedures. Travelling abroad for aesthetic surgery may reduce its cost. However, aesthetic procedures have high minor complication rates, and peri-operative travel is associated with increased risks. Fully informed consent is unlikely when patients do not meet their surgeon prior to paying and travelling for surgery, and national health services are used to provide a free safety net on their return. To help minimise the potential risks, BAPRAS has clarified the responsibilities of the NHS and is acting to better inform UK patients considering travelling abroad.

Hammocking: the effect of cushion covers on interface pressure measurements.

PURPOSE: To investigate the effects of the cushion covers on interface pressure measurements using pressure mapping technology. METHODS: Sixty-one healthy participants were recruited for a laboratory-based study using a single group design. Participants were pressure mapped on a visco-elastic foam cushion and a foam and fluid pack cushion with their covers on and with their covers removed. An air-filled cushion was tested with two different types of covers, an incontinence cover and a 'Comfair' cover. Average and maximum pressures recorded at 6 mins by the Force Sensing Array pressure mapping system were used for statistical analysis. RESULTS: There were no significant differences in maximum pressures for the three cushions tested with their covers on or with their covers removed. The cushion with the foam base and fluid pack did not demonstrate any significant differences in average pressure with the cover on or with the cover removed. However, the visco-elastic foam cushion showed significantly lower average pressures with the cover on (p=0.019). The air-filled cushion showed lower average pressures with the incontinence cover on, when compared to the Comfair cover (p=0.029). CONCLUSION: Contrary to the belief that the process of hammocking may create surface tension within the cushion covers, which in turn may adversely affect the cushions ability to reduce interface pressure, the cushions tested in the current study did not show significantly lower interface pressure measurements with the covers removed. Therefore the covers did not adversely affect the cushion's ability to reduce interface pressure. The findings of this study require verification with disabled clients.

An investigation of the impact of the Force Sensing Array pressure mapping system on the clinical judgement of occupational therapists.

OBJECTIVES: To examine the impact of pressure mapping technology on the clinical decisions of occupational therapists and to examine the role of the Braden Scale in assisting with the selection of pressure-reducing cushions. DESIGN: Case studies. SETTING: Community. SUBJECTS: Forty clients. INTERVENTIONS: Clients were pressure mapped on their current seating surface and on four pre-selected cushions by the principal researcher. An occupational therapist completed the Braden Scale and a decision tree to assist in recommending a suitable pressure-reducing cushion. MAIN OUTCOME MEASURES: Interface pressure maps, Braden Scale, and the cushion recommended, using a decision tree to guide clinical judgement. RESULTS: Thirty per cent (12) of the 40 cushions recommended were changed when the pressure maps from the Force Sensing Array (FSA) system were viewed. In 70% (26) of cases, the maps supported the cushion recommended. In 25% (10) of the cases, the maps showed that the client's current seating surface was unsuitable. After viewing the pressure maps, a surface other than the client's current surface was recommended in 47% (19) of the cases. There was a lack of agreement between the risk level of the clients as identified by the Braden Scale score, and the risk level of the clients as identified by the occupational therapist using a decision tree and the FSA maps. CONCLUSION: Pressure mapping technology has a positive impact on clinical decisions regarding the provision of pressure-reducing cushions. Future research should examine the predictive validity of this technology. The Braden Scale may underpredict the risk level of the clients.

Tessier 30 median mandibular cleft: case report and literature review.

A median mandibular facial cleft (Tessier 30) is a rare congenital abnormality. We report on the two-stage repair of a median cleft of the lower lip and mandible and the seven-year follow-up of such a cleft.

Mechanism-based inactivation of rat liver cytochrome P-450 2B1 by 2-methoxy-5-nitrobenzyl bromide.

Mechanism-based inactivators serve as probes of enzyme mechanism, function, and structure. Koshland's Reagent II (2-methoxy-5-nitrobenzyl bromide, KR-II) is a potential mechanism-based inactivator of enzymes that perform O-dealkylations. The major phenobarbital-inducible form of cytochrome P-450 in male rat liver microsomes, CYP2B1, is capable of catalyzing O-dealkylations. The interactions of KR-II with purified CYP2B1 in the reconstituted system containing P-450, NADPH:P-450 oxidoreductase, and sonicated dilaurylphosphatidyl choline were studied. The benzphetamine N-demethylase activity of CYP2B1 was inactivated by KR-II in a time- and NADPH-dependent manner, and the loss of activity followed pseudo-first-order kinetics. The inactivation also required KR-II, and the rate of activity loss was dependent on the concentration of KR-II in a saturable fashion. The inactivator concentration required for the half-maximal rate of inactivation (KI) was approximately 0.1 mM. The inactivation was not prevented by the addition of the nucleophiles dithiothreitol and glutathione, nor was it reversed by gel filtration. The present results demonstrate that KR-II is a mechanism-based inactivator of rat CYP2B1.

Nail gun injury: a barbed problem.

A case of nail gun injury is reported. Preoperative radiographs are essential to determine whether copper barbs project from the nail shaft before any attempt is made to remove the nail. Thorough exploration is required.

Patient satisfaction with Trilucent breast implants.

We report our findings in a retrospective study of patient satisfaction with soybean oil-filled mammary implants. Sixty-two women who had breast augmentation with Trilucent breast implants were sent a questionnaire to assess their satisfaction with implant placement; 19 of the 62 attended for clinical examination. Overall satisfaction with triglyceride implant placement was high: very pleased 45% (18/40), pleased 32.5% (13/40), content 12.5% (5/40). The majority of women felt that it had enhanced their body image and lifestyle (82.5%).

Informed consent: are we doing enough?

We report our findings in a prospective, randomised study of patient recall of verbal versus written preoperative warnings. There were 132 patients in the verbal group and 137 in the written group, with a similar age and sex distribution in both groups. Four of the seven preoperative warnings were remembered significantly better by the group receiving the written warnings (P < 0.001-0.05). However, the mean number of warnings recalled was fewer than 3 in the verbal group, and fewer than 4 (P = 0.0057) in the written group (Mann-Whitney U-test). Patients given verbal warnings were less able to recall them than those receiving written warnings. The inference is that they entered into surgery less well informed.

Audiovisual demonstration for patient counselling in the use of pressurised aerosol bronchodilator inhalers.

The use of video as a method of instructing subjects on correct inhaler technique was compared with the written and personal instruction of 150 volunteer subjects with no previous experience of such a device. Video was found to be as effective as personal tuition by a pharmacist and significantly (P less than 0.05) superior to the manufacturer's package insert in teaching correct inhaler technique. The technique was assessed by a panel of five investigators in each case and was found to deteriorate over a 2-week period regardless of the instruction method. The video, which was prepared 'in-house', was then assessed in both the hospital out-patient and the general practice pharmacy settings. Asthmatic patients found the video useful at identifying mistakes they were making and felt that this approach to their education should be more widely available.

Pathological findings in breast reduction surgery.

A retrospective analysis of pathological findings in 157 female patients undergoing breast reduction is presented. In 33 months 295 breasts were reduced. 25.6% of these patients had an abnormal pathology report, but no cases of premalignant disease or breast cancer were found. A postal questionnaire sent to consultant members of the British Association of Plastic Surgeons in 1994 found 89% routinely sent breast reduction tissue for pathological study. 42% had seen at least one case of breast cancer reported from this tissue. Recommendations for the use of pathology in breast reduction surgery are proposed.

Human T-cell leukemia virus type I Tax protein represses gene expression through the basic helix-loop-helix family of transcription factors.

The human T-cell leukemia virus type I (HTLV-I) oncoprotein Tax is a potent activator of viral and cellular gene transcription. Tax does not bind DNA directly but utilizes cellular transcription factors to mediate activation. In this report, we examine the role of the basic helix-loop-helix (bHLH) proteins in Tax deregulation of gene expression, as these proteins play a critical role in progression through the cell cycle and have been implicated in neoplastic disease. We show that the bHLH proteins do not mediate activation, but instead mediate repression of gene expression in the presence of Tax. We further show that a consensus bHLH binding site in the promoter of the beta-polymerase gene, which encodes an enzyme involved in DNA repair, mediates the previously reported repression of beta-polymerase gene expression by Tax. Together, these results suggest that Tax may induce malignant transformation, at least in part, through bHLH-mediated repression of key cellular regulatory genes.