Prehospital anaesthesia: a survey of current practice in the UK.

AIM: To establish the national picture of prehospital anaesthesia in the UK and to reference practice against the Association of prior to Anaesthetists of Great Britain and Ireland safety guideline on prehospital anaesthesia. METHODS: Lead clinicians were identified for all prehospital services in the UK that could potentially be performing prehospital anaesthesia and invited to complete a detailed online survey. The survey requested details on team structure, the process for prehospital anaesthesia, drugs and equipment used and training and governance arrangements. RESULTS: 55 responses were received from 63 invitations sent (87.3%) yielding usable data for 47 services. 31 of the 47 services (70%) responded that they performed prehospital anaesthesia. All services performing prehospital anaesthesia utilised a doctor but only 18 services (58%) always utilised a trained assistant. 28 services (90%) maintained a database and over half of services (55%) performed less than 20 prehospital anaesthetics annually. 23 services (74%) had a designated lead clinician for prehospital anaesthesia and 25 (81%) had a written difficult airway plan. 19 services (61%) had mandatory continual training requirements. CONCLUSIONS: The majority of services are currently complying with the recommendations in the Association of prior to Anaesthetists of Great Britain and Ireland safety guideline. There are still areas of concern, particularly with regard to ongoing training and the high numbers of services that do not use a trained assistant for the process of prehospital anaesthesia.

A generic consensus assessment of undergraduate competence in forceps exodontia in the United Kingdom.

UNLABELLED: The assessment of competence in clinical skills has become more frequent in published healthcare curricula and syllabuses recently. There are agreed mechanisms for the assessment of competence in the post-graduate environment, but no consensus within the undergraduate curriculum. This paper seeks to develop an agreed generic checklist for the assessment of competence in forceps exodontia. MATERIALS AND METHODS: A modified Delphi process was undertaken with representatives from all UK dental schools (n = 13) to develop a generic checklist for the assessment of competence in forceps exodontia. A content analysis of the assessments employed by each school was used to help discussion and inform the Delphi process. RESULTS: Seven schools currently employ a summative assessment of competence in forceps exodontia, with the majority employing a structured clinical objective test (n = 6). From the seven assessments, there were a total of 29 putative items and 10 putative domains identified for a generic checklist. These were reduced to five domains and 19 items through the content analysis and Delphi process, and a generic overarching checklist was created. CONCLUSION: Using this generic checklist, it may now be possible to pool data inter-institution to perform more powerful analyses on how our students obtain, or fail to obtain competence in forceps exodontia.

A family of cation ATPase-like molecules from Plasmodium falciparum.

We report the nucleotide and derived amino acid sequence of the ATPase 1 gene from Plasmodium falciparum. The amino acid sequence shares homology with the family of "P"-type cation translocating ATPases in conserved regions important for nucleotide binding, conformational change, or phosphorylation. The gene, which is present on chromosome 5, has a product longer than any other reported for a P-type ATPase. Interstrain analysis from 12 parasite isolates by the polymerase chain reaction reveals that a 330-bp nucleotide sequence encoding three cytoplasmic regions conserved in cation ATPases (regions a-c) is of constant length. By contrast, another 360-bp sequence which is one of four regions we refer to as "inserts" contains arrays of tandem repeats which show length variation between different parasite isolates. Polymorphism results from differences in the number and types of repeat motif contained in this insert. Inserts are divergent in sequence from other P-type ATPases and share features in common with many malarial antigens. Studies using RNA from the erythrocytic stages of the malarial life cycle suggest that ATPase 1 (including the sequence which encodes tandem repeats) is expressed at the large ring stage of development. Immunolocalization has identified ATPase 1 to be in the region of the parasite plasma membrane and pigment body. These findings suggest a possible model for the genesis of malarial antigens.

Solar neutrino production of technetium-97 and technetium-98.

It may be possible to determine the boron-8 solar neutrino flux, averaged over the past several million years, from the concentration of technetium-98 in molybdenite. The mass spectrometry of this system is greatly simplified by the absence of stable technetium isotopes, and the presence of the fission product technetium-99 provides a monitor of uiranium-induced backgrounds. This geochemical experiment could provide the first test of nonstandard solar models that suggest a relation between the chlorine-37 solar neutrino puzzle and the recent ice age.

Solar neutrino production of long-lived isotopes and secular variations in the sun.

Long-lived isotopes produced in the earth's crust by solar neutrinos may provide a method of probing secular variations in the rate of energy production in the sun's core. Only one isotope, calcium-41, appears to be suitable from the dual stand-points of reliable nuclear physics and manageable backgrounds. The proposed measurement also may be interesting in view of recent evidence for neutrino oscillations.

Heavy methanes as atmospheric tracers.

Methane-21 ((13)CD(4)) is potentially a useful nonradioactive tracer for testing atmospheric transport and diffusion models on a continental scale. In an experiment to demonstrate this long-range utility, the release of 84 grams of methane-21 was detected at distances of 1500 to about 2500 kilometers at concentrations of about 1 part in 2 x 10(16) parts (by volume) in the air by a technique in which methane was separated and the methane-21 content was measured with a mass spectrometer.

Germ cell differentiation in the marmoset (Callithrix jacchus) during fetal and neonatal life closely parallels that in the human.

BACKGROUND: Testicular germ cell tumours (TGCT) are thought to originate from fetal germ cells that fail to differentiate normally, but no animal model for these events has been described. We evaluated the marmoset (Callithrix jacchus) as a model by comparing perinatal germ cell differentiation with that in humans. METHODS: Immunohistochemical profiling was used to investigate germ cell differentiation (OCT4, NANOG, AP-2gamma, MAGE-A4, VASA, NANOS-1) and proliferation (Ki67) in fetal and neonatal marmoset testes in comparison with the human and, to a lesser extent, the rat. RESULTS: In marmosets and humans, differentiation of gonocytes into spermatogonia is associated with the gradual loss of pluripotency markers such as OCT4 and NANOG, and the expression of germ cell-specific proteins such as VASA. This differentiation occurs asynchronously within individual cords during fetal and early postnatal life. This contrasts with rapid and synchronous germ cell differentiation within and between cords in the rat. Similarly, germ cell proliferation in the marmoset and human occurs throughout perinatal life, in contrast to rats in which proliferation ceases during this period. CONCLUSIONS: The marmoset provides a good model for normal human germ cell differentiation and proliferation. The perinatal marmoset may be a useful model in which to establish factors that lead to failure of normal germ cell differentiation and the origins of TGCT.

Regulatory requirements for vaccine authorisation.

Vaccines are one of the most important tools available in the prevention and control of diseases in animals. It is therefore of the utmost importance that when vaccines are used, such use should meet with the requirements of the World Organisation for Animal Health Terrestrial Animal Health Code and must be authorised by the recognised licensing body in the country/region where the vaccines are to be used, in accordance with the three key criteria of quality, safety and efficacy. This article provides a comprehensive and comparative description of the regulatory requirements in place for veterinary vaccines in major regions of the world, highlighting the similarities and pointing out also where there are differences. Recent advances in harmonisation of such testing requirements achieved through the International Cooperation on Harmonisation of Technical Requirements for Registration of Veterinary Medicinal Products (VICH) are also described. The contents will provide a valuable guide to those engaged in the research and development of vaccines globally, and reassure those involved in the prevention and control of animal diseases that veterinary vaccines, when fully authorised and used according to the label instructions, are safe and efficacious.

Facing up to binge drinking: reducing binge drinking in adolescent males.

OBJECTIVE: To evaluate the effectiveness of an orofacial trauma-based brief intervention, designed to raise adolescent males' awareness about the immediate dangers of binge drinking. DESIGN: Non-randomised controlled exploratory trial. SETTING: Secondary level schools. MATERIALS & METHODS: Pre, post and follow up validated questionnaires were used to assess a variety of descriptive data and changes in behaviour. Sixty Year 12 students were recruited in the pilot study and 182 in the definitive study. INTERVENTION: A brief visual presentation containing salient information and anonymised photographs relating to orofacial injuries. MAIN OUTCOME MEASURES: Intention to binge drink. RESULTS: The majority of participants obtained alcohol from off-licence or licenced premises. At the commencement of the study, 68% of the participants were regular drinkers. Whilst there was no change in drinking behaviour, the intervention group reported that it was significantly more likely (compared to the control group) that they would reduce their drinking to less than binge levels. CONCLUSION: The intervention resulted in participants reporting a more negative attitude towards binge drinking and increased their intention to disengage from binge drinking.

EcoA and EcoE: alternatives to the EcoK family of type I restriction and modification systems of Escherichia coli.

The genes (hsd A) encoding EcoA, a restriction and modification system first identified in Escherichia coli 15T-, behave in genetic crosses as alleles of the genes (hsd K) encoding the archetypal type I restriction and modification system of E. coli K12. Nevertheless, molecular experiments have failed to detect relatedness between the A and K systems. We have cloned the hsd A genes and have identified, on the basis of DNA homology, related genes (hsd E) conferring a new specificity to a natural isolate of E. coli. We show that the overall organization of the genes encoding EcoA and EcoE closely parallels that for EcoK. Each enzyme is encoded by three genes, of which only one, hsdS, confers the specificity of DNA interaction. The three genes are in the same order as those encoding EcoK, i.e. hsdR, hsdM and hsdS and, similarly, they include a promoter between hsdR and hsdM from which the M and S genes can be transcribed. The evidence indicates that EcoA and EcoE are type I restriction and modification enzymes, but they appear to identify an alternative family to EcoK. For both families, the hsdR polypeptide is by far the largest, but the sizes of the other two polypeptides are reversed, with the smallest polypeptide of EcoK being the product of hsd S, and the smallest for the EcoA family being the product of hsdM. Physiologically, the A restriction and modification system differs from that of K and its relatives, in that A-specific methylation of unmodified DNA is particularly effective.

Conservation of organization in the specificity polypeptides of two families of type I restriction enzymes.

We have identified the recognition sequence for the Citrobacter freundii restriction endonuclease CfrA, a member of the A-family of type I R-M enzymes. This bipartite target sequence differs in both its components from those of other type I enzymes. We determined the nucleotide sequence of its specificity gene (hsdS) and a comparison of this with its relative EcoA identifies two extensive variable regions, an organization analogous to that found in the K-family of type I R-M enzymes. The specificity polypeptides of the A-family, unlike those of K, have an N-terminal conserved region, and this includes a sequence repeated within the central conserved region. A second repeat sequence, identified at the amino acid level, coincides with the only sequence similarity common to all type I S polypeptides. Sequences immediately downstream from the hsdS genes of EcoA, CfrA, EcoK, B and D are almost identical, consistent with an allelic chromosomal location.

Expression of substrate-specific transporters encoded by Plasmodium falciparum in Xenopus laevis oocytes.

When the malarial parasite Plasmodium falciparum multiplies in erythrocytes it dramatically increases uptake of essential metabolic precursors (nucleosides, nucleobases and glucose) and export of lactic acid by undefined mechanisms. The first evidence is provided here, by a detailed study in Xenopus laevis oocytes, that several specific nutrient transporters are the product of P. falciparum genes. We report the expression of nucleoside, nucleobase, hexose and monocarboxylate transport systems in Xenopus oocytes when injected with mRNA isolated from asexual stages of developing P. falciparum parasites. Their properties are distinct from transport events occurring at the infected erythrocyte membrane or the electrophysiologically identified channel localised to the parasitophorous vacuolar membrane. These novel transporters are substrate-specific and stereoselective, and represent a key regulatory step in the acquisition and export of metabolites by intraerythrocytic P. falciparum.

Influence of exercise on high-density lipoproteins.

The effects of an intensive rehabilitation course on plasma high-density lipoprotein (HDL) levels were studied in 40 men, aged 29 to 56 years, with ischemic heart disease. The exercise consisted of aerobic activities that induced up to 80% of the maximal heart rate during three 20-minute periods daily for 5 days a week; the program lasted 3 weeks. Significant increases were found in the levels of HDL and HDL2 and their ratios to total plasma cholesterol. These changes were similar in nonsmokers of cigarettes and in men who gave up or reduced smoking during the course and contrasted with negligible changes in those who continued to smoke.

What do patients, families and society expect from the bariatric surgeon?

The expectations of patients, their families and society of the bariatric surgeon are often unrealistic, but for different reasons. The morbidly obese patient often expects 'everything' from bariatric surgery. The patient's family is frequently ambivalent. Society, on the other hand, tends to unrealistically regard the morbidly obese as billboards advertising them as willful deviants whose problems can all be resolved by 'just pushing away from the table'. This invalid stereotype has prompted some to incorrectly regard bariatric surgery as an undeserved reward for individuals who will not control their own behavior. The undeserved intentional deviant status of the morbidly obese causes members of society to harass, mock or otherwise mistreat this subpopulation. Society's harmful, destructive and unjust weight harassment 'fat-ism' has made the morbidly obese modern day moral equivalents of lepers. We conclude that society must be persuaded to accept weight harassment as 'politically incorrect', subject to the same consequences as any other form of bigotry. Once society regards the morbidly obese as victims, not perpetrators, of their nonsurgically curable disease, bariatric surgery results should become held to similar standards as surgery for carcinoma, cardiovascular and other diseases. Until then, the morbidly obese remain the last true bastion of prejudice.

Assessment of the effects of a taped cognitive behavior message on postoperative complications (therapeutic suggestions under anesthesia).

BACKGROUND: The authors studied whether playing a taped cognitive-behavior message during and immediately following bariatric surgery will improve performance of a postoperative regimen designed to enhance recovery. METHODS: The double-blinded placebo-controlled study consisted of 27 morbidly obese bariatric surgical patients randomly assigned to listen to either a blank (Controls) or a positive therapeutic message audiotape (Tape). A Postoperative Regimen Checklist (PRC) quantified different parts of the postoperative recovery regimen. RESULTS: The data showed that patients in the Tape group, compared to the Controls: 1) achieved better scores at most PRC assessment points (p < 0.05), 2) required less encouragement to perform tasks (p < 0.05), and 3) were discharged from the hospital a mean of 1.6 days earlier. CONCLUSIONS: A taped cognitive-behavioral message, played to patients repetitively during and immediately following bariatric surgery, is effective in enhancing postoperative compliance and reducing in-patient length of stay.

Regulation of leptin release by troglitazone in human adipose tissue.

In pieces of human subcutaneous adipose tissue incubated in primary culture for 48 hours, the release of leptin was stimulated by 50% in the presence of 3.3 micromol/L troglitazone. Insulin (0.1 nmol/L) and dexamethasone (200 nmol/L) stimulated leptin release by 30% and 300%, respectively. Troglitazone in combination with either insulin or dexamethasone had no effect on leptin release. Instead, troglitazone inhibited leptin release in the presence of both dexamethasone and insulin. The stimulatory effect of troglitazone on leptin release was also mimicked by 1 micromol/L 15-deoxy-delta(12-14)prostaglandin J2 (dPGJ2). However, if the concentration of dPGJ2 was increased to 10 micromol/L in the presence of dexamethasone, there was a decrease in leptin release, as well as of lactate formation and lipolysis. These data indicate that both stimulatory and inhibitory effects of troglitazone and dPGJ2 can be seen on leptin release by human adipose tissue.

Synergism between insulin and low concentrations of isoproterenol in the stimulation of leptin release by cultured human adipose tissue.

The release of leptin by pieces of human adipose tissue incubated in primary culture for 24 or 48 hours in the presence of dexamethasone was reduced by isoproterenol. An inhibition of leptin release was observed at 24 hours in the presence of isoproterenol and was mediated by beta1-adrenergic receptors, since it was blocked by the specific beta1-adrenoceptor antagonist CGP-20712A. The inhibitory effect of 33 nmol/L isoproterenol on leptin release was reversed in the presence of 0.1 nmol/L insulin to a 2-fold stimulation of leptin release. These data suggest that the primary mechanism by which insulin stimulates leptin release is to blunt the inhibitory effects of beta1-adrenergic receptor agonists, and low concentrations of catecholamines actually enhance the stimulation of leptin release by insulin.

Stimulation of leptin release by arachidonic acid and prostaglandin E(2) in adipose tissue from obese humans.

The purpose of this study was to examine the effect of arachidonic acid and its metabolites on leptin formation by explants of human adipose tissue over a 48-hour incubation in primary culture. We found that arachidonic acid or prostaglandin E(2) (PGE(2)) stimulated leptin release by explants of subcutaneous adipose tissue from obese humans. The stimulatory effect of arachidonic acid on leptin formation was blocked by NS-398, a cyclooxygenase-2 (COX-2) inhibitor. There was appreciable release of PGE(2) to the medium over 48 hours, and this was inhibited by 99% in the presence of 200 nmol/L dexamethasone or 5 micromol/L NS-398. The increase in PGE(2) release correlated with induction of COX-2 activity during the 48-hour incubation. The increase in COX-2 activity was blocked by 200nmol/L dexamethasone. The level of leptin mRNA at 48 hours was reduced by 28% if PGE(2) was added in the absence of dexamethasone, while in the presence of dexamethasone, the amount of leptin mRNA was enhanced by 156%. These data suggest that when upregulation of COX-2 is blocked by dexamethasone, exogenous PGE(2) enhances both leptin release and leptin mRNA accumulation by explants of human adipose tissue in primary culture.

Early failure of expanded polytetrafluoroethylene in femoral vein replacement.

Grafts of expanded 30-mu fibril length polytetrafluoroethylene (PTFE) were inserted as segmental femoral vein replacements in nine dogs. The contralateral femoral vein served as a control, receiving a graft from each dog's right external jugular vein. Graft patency was monitored for 24 weeks postoperatively with serial venograms and venous pressures of the operated limbs. All expanded PTFE grafts and one autogenous graft thrombosed within 24 to 48 hours. Significant venous hypertension in the extremities receiving the PTFE grafts persisted for six months.

Polymerase chain reaction for the detection of Burkholderia pseudomallei.

Melioidosis is a potentially lethal infection of humans and animals in Southeast Asia and northern Australia. Current methods for detection of the causative organism, Burkholderia pseudomallei, lack both speed and sensitivity. We report the development of a highly sensitive polymerase chain reaction-based method that can detect as few as 35 colony-forming units of B. pseudomallei/mL in saline suspensions. This polymerase chain reaction test also detected the presence of B. pseudomallei DNA in culture-negative splenic tissue obtained from mice infected with the organism, but without clinical evidence of disease. Specificity has been confirmed using a variety of pathogenic and nonpathogenic organisms, including B. mallei, B. cepacia, and Pseudomonas species. The clinical usefulness of this test should be assessed prospectively and compared with conventional diagnostic techniques.