Quid Pro Flow.

How do you get into flow? We trained in flow chemistry during postdoctoral research and are now applying it in new areas: materials chemistry, crystallization, and supramolecular synthesis. Typically, when researchers think of "flow", they are considering predominantly liquid-based organic synthesis; application to other disciplines comes with its own challenges. In this Perspective, we highlight why we use and champion flow technologies in our fields, summarize some of the questions we encounter when discussing entry into flow research, and suggest steps to make the transition into the field, emphasizing that communication and collaboration between disciplines is key.

Dynamic Crystallization Pathways of Polymorphic Pharmaceuticals Revealed in Segmented Flow with Inline Powder X-ray Diffraction.

Understanding the transitions between polymorphs is essential in the development of strategies for manufacturing and maximizing the efficiency of pharmaceuticals. However, this can be extremely challenging: crystallization can be influenced by subtle changes in environment, such as temperature and mixing intensity or even imperfections in the crystallizer walls. Here, we highlight the importance of in situ measurements in understanding crystallization mechanisms, where a segmented flow crystallizer was used to study the crystallization of the pharmaceuticals urea: barbituric acid (UBA) and carbamazepine (CBZ). The reactor provides highly reproducible reaction conditions, while in situ synchrotron powder X-ray diffraction (PXRD) enables us to monitor the evolution of this system. UBA has two polymorphs of almost equivalent free-energy and so is typically obtained as a polymorphic mixture. In situ PXRD analysis uncovered a progression of polymorphs from UBA III to the thermodynamic polymorph UBA I, where different positions along the length of the tubular flow crystallizer correspond to different reaction times. Addition of UBA I seed crystals modified this pathway such that only UBA I was observed throughout, while transformation from UBA III into UBA I still occurred in the presence of UBA III seeds. Information regarding the mixing-dependent kinetics of the CBZ form II to III transformation was also uncovered in a series of seeded and unseeded flow crystallization runs, despite atypical habit expression. These results illustrate the importance of coupling controlled reaction environments with in situ XRD to study the phase relationships in polymorphic materials.

Viewing Exemplars of Melanomas and Benign Mimics of Melanoma Modestly Improves Diagnostic Skills in Comparison with the ABCD Method and Other Image-based Methods for Lay Identification of Melanoma.

Using an experimental task in which lay persons were asked to distinguish between 30 images of melanomas and common mimics of melanoma, we compared various training strategies including the ABC(D) method, use of images of both melanomas and mimics of melanoma, and alternative methods of choosing training image exemplars. Based on a sample size of 976 persons, and an online experimental task, we show that all the positive training approaches increased diagnostic sensitivity when compared with no training, but only the simultaneous use of melanoma and benign exemplars, as chosen by experts, increased specificity and diagnostic accuracy. The ABCD method and use of melanoma exemplar images chosen by laypersons decreased specificity in comparison with the control. The method of choosing exemplar images is important. The levels of change in performance are however very modest, with an increase in accuracy between control and best-performing strategy of only 9%.

Image training, using random images of melanoma, performs as well as the ABC(D) criteria in enabling novices to distinguish between melanoma and mimics of melanoma.

Robust experimental evidence supporting many attempts to facilitate early melanoma diagnosis is lacking. In an experimental study using a browser interface we have examined diagnostic accuracy, sensitivity and specificity of novices in distinguishing between melanomas and mimics of melanoma. We show that rule-based ABC methods and image training, based on random images of melanoma, improve specificity to similar degrees, with-out effects on sensitivity, leading to small improvements in overall accuracy. There was a significant effect of age with older subjects performing better. Although both the ABC method and image training groups showed improved performance over the control group, overall performance was poor. For instance, for a task in which 1 in 4 test images was a melanoma, and 3 out of 4 benign, both interventions (ABC or image training) increased accuracy from the control value of 53% to around 61%. For reference, dermatology trainees performed at a much higher level of accuracy. Our study provides little support for the use of such methods in public education, but suggests ways in which performance might be improved.

PDI-Functionalized Glass Beads: Efficient, Metal-Free Heterogeneous Photocatalysts Suitable for Flow Photochemistry.

Perylene diimides (PDI) have an extraordinary ability to activate both energy and electron transfer processes upon light excitation; however, their extremely low solubility has hindered their wide use as photocatalysts. Here, we show that the combination of solid-supported PDIs with continuous flow photochemistry offers a promising strategy for process intensification and a scalable platform for heterogeneous photocatalysis. The photocatalyst immobilized onto glass beads is highly efficient, easy to separate, and extremely reusable, with a broad synthetic application range. Using the photo-oxidation of n-butyl sulfide as a benchmark reaction, we demonstrate that immobilized PDI are highly active, outperforming reported homogeneous photosensitizers, and capable of extensive reuse (turnover number (TON) >57,000 over 2 months). Transferring the process from batch to flow results in a 10-fold reduction in irradiation time and an increase in the space-time yield by a factor of 33 (40 vs 1338 mmol-1 h-1 L-1 batch vs flow). What is more, the same catalyst sample can be used for the preparation of a range of sulfoxides, the aza-Henry reaction between nitromethane and N-Ar tetrahydroisoquinolines, and the photo-oxidation of furfural with high catalytic activity. Overall, our work combines the remarkable photocatalytic properties of PDI with inert, easy-to-handle glass beads, producing hybrid materials that are reusable and can be adapted for performing heterogeneous photocatalysis in a range of scalable photochemical reactors.

Serial small- and wide-angle X-ray scattering with laboratory sources.

Recent advances in X-ray instrumentation and sample injection systems have enabled serial crystallography of protein nanocrystals and the rapid structural analysis of dynamic processes. However, this progress has been restricted to large-scale X-ray free-electron laser (XFEL) and synchrotron facilities, which are often oversubscribed and have long waiting times. Here, we explore the potential of state-of-the-art laboratory X-ray systems to perform comparable analyses when coupled to micro- and millifluidic sample environments. Our results demonstrate that commercial small- and wide-angle X-ray scattering (SAXS/WAXS) instruments and X-ray diffractometers are ready to access samples and timescales (≳5 ms) relevant to many processes in materials science including the preparation of pharmaceuticals, nanoparticles and functional crystalline materials. Tests of different X-ray instruments highlighted the importance of the optical configuration and revealed that serial WAXS/XRD analysis of the investigated samples was only possible with the higher flux of a microfocus setup. We expect that these results will also stimulate similar developments for structural biology.

Variation in epidermal morphology in human skin at different body sites as measured by reflectance confocal microscopy.

Two methods of estimating stratum corneum thickness using reflectance confocal microscopy were examined, and epidermal thickness measurements at multiple body sites were compared. Measurements of stratum corneum thickness were made using the derivative method, which is based on the rate of change of image intensity as a proxy for keratin concentration, and simple visual analysis of confocal images. To compare epidermal thickness we collected 1491 z-axis stacks of confocal images from 10 body sites in 39 subjects. An artefact associated with the imaging process interfered with the derivative method for stratum corneum thickness, and simple visual analysis is to be preferred. Although some epidermal properties varied by site, the most striking finding was the degree of within-site variation, which accounted for between 50% and 74% of the total variation observed. The majority of this variation was not due to measurement error, and represents genuine topographical irregularity. This fine-scale variation limits the ease of use of reflectance confocal microscopy for quantitative studies of the epidermis and stratum corneum.

Poly[(mu6-rac-cis-cyclohexane-1,2-dicarboxylato)strontium].

In the title layered coordination polymer, [Sr(C(8)H(10)O(4))](n), the strontium ion adopts a distorted square-antiprismatic SrO(8) geometry, arising from its coordination by six different cis-cyclohexane-1,2-dicarboxylate dianions (two bidentate and four monodentate). Within the dianion, the cyclohexane ring adopts a chair conformation and the dihedral angle between the planes of the -CO(2)(-) groups is 80.4 (6) degrees. The polyhedral linkage pattern leads to (100) sheets in the crystal in which the SrO(8) groups share triangular faces and edges in which the Sr...Sr topological connectivity is a 6(3) net. The crystal studied was a nonmerohedral twin, with the components related by a 180 degree rotation about [100].

Hospital-acquired acute hyponatremia and reports of pediatric deaths.

Information from four voluntary reports of hospital-acquired acute hyponatremia leading to the death of otherwise healthy children is highlighted. In this column, we present two cases and information from a recent ISMP Canada Safety Bulletin, as well as two cases reported to ISMP United States. Information is shared to enhance health care practitioners' awareness of the potential for acute hyponatremia and to provide an overview of some of the potential underlying factors.

Interaction of the Saccharomyces cerevisiae cortical actin patch protein Rvs167p with proteins involved in ER to Golgi vesicle trafficking.

We have used affinity chromatography to identify two proteins that bind to the SH3 domain of the actin cytoskeleton protein Rvs167p: Gyp5p and Gyl1p. Gyp5p has been shown to be a GTPase activating protein (GAP) for Ypt1p, a Rab GTPase involved in ER to Golgi trafficking; Gyl1p is a protein that resembles Gyp5p and has recently been shown to colocalize with and belong to the same protein complex as Gyp5p. We show that Gyl1p and Gyp5p interact directly with each other, likely through their carboxy-terminal coiled-coil regions. In assays of GAP activity, Gyp5p had GAP activity toward Ypt1p and we found that this activity was stimulated by the addition of Gyl1p. Gyl1p had no GAP activity toward Ypt1p. Genetic experiments suggest a role for Gyp5p and Gyl1p in ER to Golgi trafficking, consistent with their biochemical role. Since Rvs167p has a previously characterized role in endocytosis and we have shown here that it interacts with proteins involved in Golgi vesicle trafficking, we suggest that Rvs167p may have a general role in vesicle trafficking.

Inhibition of hydroxyapatite formation by osteopontin phosphopeptides.

Osteopontin (OPN) is an acidic phosphoglycoprotein that is believed to function in the prevention of soft tissue calcification. In vitro studies have shown that OPN can inhibit the formation of hydroxyapatite (HA) and other biologically relevant crystal phases, and that this inhibitory activity requires phosphorylation of the protein; however, it is not known which phosphorylated residues are involved. We have synthesized peptides corresponding to four phosphoserine-containing sequences in rat OPN: OPN7-17, containing phosphoserines 10 and 11; OPN41-52, containing phosphoserines 46 and 47; OPN248-264, containing phosphoserines 250, 257 and 262; and OPN290-301, containing phosphoserines 295-297. The abilities of these peptides to inhibit de novo HA formation were determined using a constant-composition autotitration assay. All four OPN phosphopeptides caused a dose-dependent increase in nucleation lag time, but did not significantly affect subsequent formation of the crystals. However, OPN41-52 (inhibitory constant 73.5 min/microM) and OPN290-301 (72.2 min/microM) were approx. 4 times more potent inhibitors than OPN7-17 (19.7 min/microM) and OPN247-264 (16.3 min/microM). 'Scrambling' the amino acid sequence of OPN290-301 resulted in decreased potency (45.6 min/microM), whereas omission of the phosphate groups from this peptide caused a greater decrease (5.20 min/microM). These findings have identified phosphorylated sequences that are important for the ability of rat bone OPN to inhibit HA crystal formation, and suggest that negative-charge density is an important factor in this activity.

Enhancing immunogenicity of a 3'aminomethylnicotine-DT-conjugate anti-nicotine vaccine with CpG adjuvant in mice and non-human primates.

Tobacco smoking is one of the most preventable causes of morbidity and mortality, but current smoking cessation treatments have relatively poor long term efficacy. Anti-nicotine vaccines offer a novel mechanism of action whereby anti-nicotine antibodies (Ab) in circulation prevent nicotine from entering the brain, thus avoiding the reward mechanisms that underpin nicotine addiction. Since antibody responses are typically long lasting, such vaccines could potentially lead to better long-term smoking cessation outcomes. Clinical trials of anti-nicotine vaccines to date have not succeeded, although there was evidence that very high anti-nicotine Ab titers could lead to improved smoking cessation outcomes, suggesting that achieving higher titers in more subjects might result in better efficacy overall. In this study, we evaluated CpG (TLR9 agonist) and aluminum hydroxide (Al(OH)3) adjuvants with a model anti-nicotine antigen comprising trans-3'aminomethylnicotine (3'AmNic) conjugated to diphtheria toxoid (DT). Anti-nicotine Ab titers were significantly higher in both mice and non-human primates (NHP) when 3'AmNic-DT was administered with CpG/Al(OH)3 than with Al(OH)3 alone, and affinity was enhanced in mice. CpG also improved functional responses, as measured by nicotine brain levels in mice after intravenous administration of radiolabeled nicotine (30% versus 3% without CpG), or by nicotine binding capacity of NHP antisera (15-fold higher with CpG). Further improvement should focus on maximizing Ab function, which takes into account both titer and avidity, and this may require improved conjugate design in addition to adjuvants.

Selection of a novel anti-nicotine vaccine: influence of antigen design on antibody function in mice.

Anti-nicotine vaccines may aid smoking cessation via the induction of anti-nicotine antibodies (Ab) which reduce nicotine entering the brain, and hence the associated reward. Ab function depends on both the quantity (titer) and the quality (affinity) of the Ab. Anti-nicotine vaccines tested previously in clinical studies had poor efficacy despite high Ab titer, and this may be due to inadequate function if Ab of low affinity were induced. In this study, we designed and synthesized a series of novel nicotine-like haptens which were all linked to diphtheria toxoid (DT) as carrier, but which differed in the site of attachment of linker to nicotine, the nature of linker used, and the handle used to attach the hapten to DT. The resulting hapten conjugates were evaluated in a mouse model, using CpG (a TLR9 agonist) and aluminum hydroxide (Al(OH)3) as adjuvants, whereby Ab titers, affinity and function were evaluated using a radiolabeled nicotine challenge model. A series of additional linkers varying in length, rigidity and polarity were used with a single hapten to generate additional DT-conjugates, which were also tested in mice. Conjugates made with different haptens resulted in various titers of anti-nicotine Ab. Several haptens gave similarly high Ab titers, but among these, Ab affinity and hence function varied considerably. Linker also influenced Ab titer, affinity and function. These results demonstrate that immune responses induced in mice by nicotine-conjugate antigens are greatly influenced by hapten design including site of attachment of linker to nicotine, the nature of linker used, and the handle used to attach the hapten to DT. While both Ab titer and affinity contributed to function, affinity was more sensitive to antigen differences.

Policy and practice in the management of postnatal depression in Scotland.

To investigate current policy and practice in postnatal depression in Scotland and to consider how effectively guidelines were addressed. A questionnaire survey of all National Health Service Boards in Scotland between September 2003 and February 2004 to determine what written policies for postnatal depression were in place as at September 2003. This was followed by a questionnaire survey of a representative sample of general practices in Scotland to determine the routine procedures in use for managing postnatal depression in general practice primary care teams. NHS Boards and general practices in Scotland, UK. Forty-seven per cent of policies and 68% of General Practices had implemented the majority of the Scottish Intercollegiate Guidelines Network 60 evidence based recommendations. Practices were more likely than NHS Boards to have addressed a higher percentage of the recommendations (p < 0.05). Practices were more likely to implement antenatal screening for a history of puerperal psychosis if they were within NHS Boards that recommend this as routine practice. Practices within NHS Boards that had in-patient facilities for mother and baby admissions were more likely to identify these services as a treatment option than in the areas where the NHS Boards indicated the facilities were unavailable. Board guidance did not relate significantly to the likelihood of practices following the other evidence-based recommendations. Minimum standards represented by the SIGN 60 evidence-based recommendations were mostly followed in both policy and practice. If Board policy followed guidelines, the guidelines were more likely to be implemented at primary care level.

DNA repair gene polymorphisms and genetic predisposition to cutaneous melanoma.

The incidence of cutaneous melanoma is rising rapidly in a number of countries. The key environmental risk factor is exposure to the ultraviolet (UV) component in sunlight. The nucleotide excision repair (NER) pathway deals with the main forms of UV-induced DNA damage. We have investigated the hypothesis that polymorphisms in NER genes constitute genetic susceptibility factors for melanoma. However, not all melanomas arise on sun-exposed sites and so we investigated the hypothesis that genes involved in other pathways for the repair of oxidative DNA damage may also be involved in susceptibility to melanoma. Scotland, with its high incidence of melanoma and stable homogeneous population, was ideal for this case-control study, involving 596 Scottish melanoma patients and 441 population-based controls. Significant associations were found for the NER genes ERCC1 and XPF, with the strongest associations for melanoma cases aged 50 and under [ERCC1 odds ratio (OR) 1.59, P = 0.008; XPF OR 1.69, P = 0.003]. Although an XPD haplotype was associated with melanoma, it did not contain the variant 751 Gln allele, which has been associated with melanoma in some previous studies. No associations were found for the base excision repair and DNA damage response genes investigated. An association was also found for a polymorphism in the promoter of the vitamin D receptor gene, VDR (OR 1.88, P = 0.005). The products of the two NER genes, ERCC1 and XPF, where associations with melanoma were found, act together in a rate-limiting step in the repair pathway.

New nursing roles: the experience of Scotland's consultant nurse/midwives.

AIM: To describe career pathways of consultant nurses/midwives and identify postholders views on key factors in role initiation, development and progression to inform future development and appointment of nurse/midwife consultants in National Health Service Scotland. BACKGROUND: Nurse/midwife consultants represent the highest levels of clinical practice. Given the Scottish Executive Health Department's aim to treble numbers conditions and circumstances that enable them to flourish must be identified. METHOD: A postal survey was undertaken of all nurse/midwife consultants in post (n = 16). RESULTS: Key themes emerged around factors that consultant nurse/midwives considered important including mentorship, autonomy and clinical credibility. Barriers to role delivery included lack of understanding of roles and the wide scope of some posts. Considerable variation in support, conditions of service and line management arrangements was found. CONCLUSIONS: Development of a recognized career pathway and a consistent approach to employment and support of postholders is recommended.

Peritonitis bacteriana espontánea en cirrosis hepática: experiencia con 20 casos / Spontaneous bacterial peritonitis in cirrhosis: experience of 20 cases

Se presenta la experiencia del Servicio de Medicina, analizando una casuística de 20 enfermos con cirrosis hepática y peritonitis bacteriana espontánea. En el 45% de los casos se aisló germen en el cultivo del líquido ascítico y 65% de ello tuvieron algún cultivo positivo durante su hospitalización. Concomitante al episodio de peritonitis bacteriana espontánea, 65% de los pacientes tuvieron hemorragia digestiva alta; 70% elevación de la creatinina y 50% encefalopatía. La mortalidad durante la hospitalización fue de 60%. Se determinó en forma prospectiva la prevalencia de peritonitis bacteriana espontánea en cirróticos hospitalizados, la que fue de 10%. La peritonitis bacteriana espontánea es una complicación grave de los enfermos con cirrosis hepática avanzada y se presenta generalmente asociada a hemorragia digestiva; insuficiencia renal y/o infecciones de otro origen